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THE
KE¥ YORK
MEDICAL JOUKNAL.
A
WIEEKLY REVIEW OF MEDICINE.
EDITED BY
FRANK P. FOSTER, M.D.
VOLUME LV.
JANUARY TO JUNE, 1892, INCLUSIVE.
NEW YORK:
I). APPLETON AND COMPANY,
1 8, and 5 BOND STKEJET.
1892.
Copyright, 1892,
BY D. APPLETON AND COMPANY.
LIST OF CONTRIBUTORS TO VOLUME LV.
{EXCLUSIVE OF ANONYMOUS CORRESPONDENTS.)
Those whose names are marked with an asterisk have contributed editorial articles.
ABBE, ROBERT, M. D.
ADLER, I., M. P.
ALLEMAN, L. A. W., M. P., Brooklyn.
ALLEN, CHARLES W., M. D.
ANGELL, EDWARD B., M.D., Roches-
ter N. Y
♦ARMST RONG, S. T., M. D., Ph. D.
ASCH, MORRIS J., M. D.
BALDWIN, J. F., M. D., Columbus, 0.
BARKER, P. 0., M. D.
BARKER, T. RIDGWAY, M. D., Phila-
delphia.
BARTLEY, E. H., M. P., Brooklyn.
BATES. W. II., M. D.
BEACH, WOOSTER, M. D.
BECK, CARL. M. D.
BECKER, P. G., M. D.
BENS EL, WALTER, M. D.
BEELY, F., M. P., Berlin, Prussia.
BIER WIRTH, J. C, M. D.. Brooklyn.
BIGELOW. II. A., M. D., Philadelphia.
BIRMINGHAM. H. P., M. D , U. S. Army.
BLACK, G. MELVILLE, M. P., Penver,
Col.
BLANC, HENRY WILLIAM, B. S., M. P.,
Sewanee, Tenn.
BLODGETT, A. N., M. D., Boston.
BOSWORTH. FRANCE E (I., M. D.
BRADLEY, ELIZABETH N.. M. D.
BRANNAN, JOHN WINTERS, M. D.
BREMNER. W. W., M. I).
♦BRICKNER, SAMUEL F., M. P.
♦BRYSON. LOUISE FISKE, M. P.
BULL, CHARLES STEDM AN. M. D.
BURNETT, S. GROVER, M. D., Kansas
City, Mo.
BDRRODGH, EDMUND Y., M. D., Cam-
den, N. J.
BURRS, PAWSON, P. P., London, Eng-
land.
BURWELL, J. PAGE, M. P., Washing-
ton, P. C.
CAILLE, AUGUSTUS, M. P.
CARR, W. P., M.P., Washington, P. C.
CIl ADDOCK, C. G., M. D., Traverse City,
Mich.
CHANDLER, RALPH, M. D., Milwaukee,
Wis.
CnAPPELL, WALLIS T., M. D., M. R.
G.S.
CLAIBORNE, J. HERBERT, M. D.
COLLES, CHRISTOPHER J., M. D.
COLLINS, JOSEPH, M. D.
CORNING, J. LEONARD, M. D.
♦CRANPALL, FLOYD M., M. P.
CURRIER, AN PRE W F., M. P.
CURRIER, CHARLES G., M.P.
PAN A, CHARLES L., M. P.
DANIELS, FRANK IL, M.P.
PAVIS, G. G., M.P., M.R.C.S.E., Phil-
adelphia.
PAVIS. S K., M. P., Libertvville, Towa.
PELATOUR, H. BEEKMAN, M. P.,
Brooklyn.
PESSAR, LEONARP A., M. P.
PUNN, JOHN. M. P., Richmond, Va.
PURANT, GHISLANI, M. D.
DURYEE, CHARLES C, M. P., Schenec-
tady, N. Y.
ELIOT. ELLSWORTH. Jr., M.P.
ELLIOT. GEORGE T., M. P.
ELLIS, H. BERT., M. D., Los Angeles, Cal.
ELSNER, HENRY L., M. D., Syracuse,
N. Y.
FARMER, M. H., Pecatur, 111.
FERGUSON, JOHN, M. A., M. P., Toron-
to, Canada.
♦FOSTER, FRANK P., M. P.
*FOSTER, MATTHIAS L., M. P.
FRENCH, THOMAS R., M. P., Brooklyn.
GERSTER, ARPAD G., M. P.
GLASS, J. H., M. P., Utica, N. Y.
GOLOENBERG, HERMANN, M. P.
GOTTHEIL. W. S., M. 0.
GOULP, GEORGE M., M. P., Philadel-
phia.
GOULEY, JOHN W. S., M. P.
♦GRANGER, REED B., M. P.
GRIFFIN, HENRY A., M. P.
GRUENING, EMIL, M.P.
HAGEN, HUGH. M.P., Atlanta, Ga.
HALSEY. F. SPENCER, M.P.
HARE, HOBART A., M. P., Philadel-
phia.
HARRIS, W. H., M.P., Augusta, Maine.
HARTLEY, FRANK, M. P.
HAWKES, WILLIAM H., M. P., Wash-
ington, P. C.
HAYES, J. M., M. P.. Washington, P. C.
HAYNES, IRVING S., M. P.
HEIMAN, HENRY, M. P.
HENROTIN, F., M. P., Chicago.
HENRY, FREPERICK P., M. P., Phila-
delphia.
HERTER, C. A., M. P.
HINKSON, JOHN R., M.P., Long Island
City, N. Y.
HODGMAN, W. IL, M. P., Saratoga,
N. Y. ,
HOLSTEN, GEORGE P., M. P., Brook-
lyn.
HOPKINS, F. E , M.P.
HOWARO, W. R., M. P., Fort Worth,
Texas.
HOWELL, P. IL, M. P., Atlanta Ga.
HUBBELL, ALVIN A., M. P., Buffalo,
N. Y.
INGALS, FLETCHER, M. P., Chicago.
JACOBI, A., M.P.
JAR VIS, WILLIAM C, M. P.
JENKS, W. J.
KAKELES, M. S , M. P.
KELLER, LESTER, M. P., Beury, W. Va.
KELSEY, CHARLES B., M.P.
KING, GEORGE W., M. P., Helena, Mon-
tana.
KIN GSLEY, W. J. P., M. P., Rome N. Y.,
KINNEAR, B. ()., M. 0.
KINNICUTT, FRANCIS P., M. P.
KNIGHT, CHARLES IL, M. I).
KUPFER, SOPHIE, M. D.
LANCASTER, T. A., M. D., North Man-
chester, Ind.
LAPLACE, ERNEST, M. P., Philadel-
phia.
LEARY, A. H.. M. P.
LEIGH, SOUTHGATE, M. P., Norfolk,
Va.
LEITCH, MARGARET W., Mount Ver-
non. N. Y.
LEITCH, MARY.
LESZYNSKY, WILLIAM M., M. P.
LEWIS, FRANK N., M.P.
LINK, W. IL. M.A., M.P., Petersburg,
Ind.
LOCKWOOD, C. E., M. D.
L< H'ERSON, FRANK, M. D., Colum-
bus, O.
LUDLOW, OGDEN C, M. P.
LDSTGARTEN, S., M. P.
MACPON ALP, BELLE J., M. P., Wood-
haven Junction, L. I.
MAC PONALD, CARLOS F., M. P.
McCOSH, A. J., M.P.
MoCURPY, STEWART LE ROY, M.P.,
Pennisou, O.
McGUIRE, FRANK A., M. P.
McINTOSH, W. PAGE, M. P., U. S. Ma-
rine-Hospital Service.
MoMURTRY. L S., M. P., Louisville, Ky.
MAJOR, GEORGE W., M. P., Montreal,
Canada.
MATTHEWS, II. E., M.P., Orange, N.J.
MAXSON, EPWIN R., M. P., LL.P.,
Syracuse, N. Y.
METTLER, J. HARRISON, M.P., Chi-
cago.
MEYER, WILLY, M. P.
MILLS, CHARLES K., M. P., Philadel-
phia.
MONTGOMERY, R. IL, M. P., Cleve-
land, O.
MORRIS, ROBERT T., M. P.
MORTON, WILLIAM J., M.P.
MUNOE, PAUL F., M. P.
MURPHEY, GEORGE N., M. P., Bowl-
ing Green, Ky.
MURRAY, F. W., M. P.
NEWTON, ROBERT SAFFORO. M.P.
NORTIIRUP, WILLIAM P., M. P.
OVERLOOK. S. B., M. P., Steuben, Me.
PAGE, EMMETT P., M. I).
PATON, STEWART, M. D.
PAYORS, C. A., M. D.
♦PETERSON, FREDERICK, M. D.
PFINGST, A. 0., M. D., Louisville. Ky.
PILCHER, LEWIS S., M. P., Brooklvn.
POMEROY, OREN P., M. P.
POOLEY. THOMAS R., M. P.
POORE, CHARLES T., M. P.
PORTER, P. BRYNBERG, M. P.
*POWERS, CHARLES A., M. D.
PRINCE, JOHN A., M. P., Springfield,
111.
PRUDPEN, T. MITCHELL, M. P.
RABINOVITCH. LOUISE G., B. S., M.P.
RANNEY, AMBROSE L., M.P.
RAF, LEONARD S., M.P.
RAYMONP, J. H., M. P., Brooklyn.
REEP, C. A. L., M. P., Cincinnati.
REEVE, J. C, Jr., M. P., Dayton, 0.
REEVE, J. C, M. I)., Dayton, O.
RHEIN, M. L., M. P.
RIPLON, JOHN, M.O., Chicago, 111.
RICE, CLARENCE C, M. D.
ROBINSON, A. L„ M. I)., Seattle, Wash.
ROBINSON, BEVERLEY, M. D.
ROCKWELL, A. P., M. P.
♦ROOSEVELT. J. WEST, M. P.
ROSS, ARTHUR G.. M. D., Albany, N. Y.
RUTHERFORD, CLARENDON, M. P.,
Chicago.
SACHS, B., M. D.
SAYRE, LEWIS A., M. P.
SCRIPTURE, E. W., Worcester, Mass.
SEABROOK, II. II.. M. D.
SHAFFER, NEWTON M., M. D.
SHANI), JOHN, M. D., Edinburgh. Scot-
land.
SHERMAN, B. F., M. D., Ogdensburgh,
N. Y.
SHIRLEY, I. A., M. I >., Winchester, Kv.
iv
LIST OF ILLUSTRATIONS IN VOLUME LV.
[N. Y. Med. Jodh.,
SIMPSON, W. K., M.D.
SKINNER, WINSLOW W., M. D., Las
Vegas, N. M.
SMITH, E. E„ Ph. D.
SOUS-COHEN, J., M. D., Philadelphia.
SQUIBB, E. II., M. D., Brooklyn.
SQUIER, A. 0., M. D., Springfield, Mass.
STARK, HENRY S., M. D.
STARR, ELMER, M. D., Buffalo, N. Y.
STEVENS, GEORGE T., M. D.
*STIMSON, LEWIS A., M. D.
TAGGART, H. D., M. D., Akron, O.
TAYLOR, GEORGE II., M. D.
*TAYLOR. ROBERT W., M. D.
THACHER, JOHN S., M. D.
TROUVE, G., Paris, France.
*TUTTLE, JAMES P., M.D.
TUTTLE, THEEON, M.D., Brooklyn.
VALK, FRANCIS, M. D.
VAN ALLEN, H. W., M. D., Springfield,
VAN COTT, JOSHUA M., Jr., M.D.,
Brooklyn.
VAUGHAN, B. E., M. D.
*VINEBERG, HIRAM N., M. D.
VON RUCK, KARL, M. D., Asheville,
N. C.
VOUGHT, WALTER, M. D.
WEED, CHARLES R., M. D., Utica, N. Y.
WELLS, BROOKS H., M. D.
WEIR, ROBERT F., M. D.
WERDER, X. 0., M. D., Pittsburgh, Pa.
WESSINGER, J. A., M. D., Ann Arbor
Mich.
WEY, W. C, M. D., Elraira, N. Y.
WHITMAN, ROYAL, M. D., M. R. ('. S
WILCOX, REYNOLD W., M. D., LL. D.
WILLARD, DE FOREST, M. D., Phila-
delphia.
WILLIAMS, L. L., M.D., U. S. Marine-
Hospital Service.
WILLIS, G., M.D., L. R. C. P. (Ed.,)
Greenville, Cal.
WOODWARD, J. H., M. D., Burlington,
Vt.
*WYCKOFF, RICHARD M., M. D.,
Brooklyn.
WYETII, JOHN A., M. D.
LIST OF ILLUSTRATIONS IN VOLUME LV.
PAGE
Genital Chancres in Women. Nine Figures Facing 1
Suture of the. Conjunctiva 15
Neuroglia Sclerosis. Two Illustrations 30
A New Needle Holder 52
Compound Depressed Fracture of the Skull 70
General Athetosis. Two Illustrations 71
An Instrument for the Determination of Heterophoria.
Three Illustrations 80
Edinger's Apparatus for Low Magnification 81
Hereditary Syphilis of the Bones. Eleven Illustrations. 85-87
Operating Cystoscopes. Two Illustrations 110
A Lingual Curette 162
Stone in the Kidney 172
A New Hypodermic-syringe Needle 194
Radical Cure of Confirmed Flat-foot. Seven Illustra-
tions 228-231
Intrinsic Epithelioma of the Larynx. Three Illustra-
tions 233,234
An Attachment for Aspirators or Syringes 248
A Laryngeal Forceps 276
Cyst of the Middle Turbinated Bone 310
Removal of Necrotic and Carious Bone. Two Illustra-
tions 312
Cancer of the Ovary 313
Papilloma of the Ovary 313
Intracranial Neurectomy 319
A Tooth-plate in the (Esophagus 320
A Case of Scleroderma. Two Illustrations 337-339
PAGE
A Sponge Holder 361
An Ether Inhaler 361
A Needle Holder 362
An Artery Forceps 362
Massage at Rapid and Vibratory Rates. Five Illustra-
tions 374, 375
A Urethral Irrigator 391
Enlargements of the Epiglottis. Five Illustrations. . . 393,394
Fracture of the Radius. Three Illustrations 396
An Instrument for Refractive Errors 405
Vicious Union following Pott's Fracture. Two Illustra-
tions 424
A Lateral-cutting Curette 444
Volkmann's Spoon 449
Iodide of Potassium Eruptions. Two Illustrations 453
The Nervous Origin of Asthma 459
Results in Cases of Hip-joint Disease. Eighteen Illustra-
tions Facing 477
Morvan's Disease. Two Illustrations 483
Compressible- tube Syringe 487
Amputation at the Hip Joint. Two Illustrations 521
Execution by Electricity. Seven Illustrations 542, 543
An Instrument for measuring the Resistance of Stricture. 553
Syringomyelia. Two Illustrations 648
Precocious Development 659
Pott's Fracture at the Ankle. Nine Illustrations. Facing 7<>1
Cerebral Tumor 71 1
Section of Spinal Cord 712
NEW YORK MEDICAL JOURNAL. JAN. 1892. GENITAL CHANCRES IN WOMEN.
THE NEW YORK MEDICAL JOURNAL, January 2, 1892.
(Original Commumt at ions .
GENITAL CHANCRES IN WOMEN*
By R. W. TAYLOR, M. D.,
CLINICAL PROFESSOR OF VENEREAL DISEASES
AT THE COLLEGE OF PHYSICIANS AND SURGEONS. NEW YORK .
Chancres of the genital organs are very common in
men and in women, but in the latter extra-genital chancres
occur much more frequently than they do in men.
Our knowledge of genital chancres in the female is far
from complete, and this essay is offered with the hope of
presenting a succinct and graphic description of these le-
sions, together with life-like pictures of them.
Chancres in women are far less regular in their course
than they are in men. In many women the chancre is so
small, benign, and ephemeral that it may never be seen, or,
if seen, its nature is usually not suspected. In very many
cases, even when the lesion is strikingly apparent, its nature
remains for a long time in doubt, owing to inflammatory
complications and to a want of striking individuality in the
lesion itself. Then, again, simple inflammatory processes
and chancroidal ulcers often become upon the female geni-
tals so complicated and obscure in appearance that they
may resemble specific lesions. In women, induration as a
symptom is not so generally observed as it is in men. In
some females it can scarcely be appreciated by careful ex-
amination, and it may be very transitory in its duration,
whereas in others it attains large proportions, lasts for in-
definite periods, and may lead to ultimate deformity. In
men the chancre is readily examined. In women this lesion,
owing to the nature and inaccessibility of the parts, is very
difficult of examination except on protruding portions of
the genitals.
The main reason why chancres in the female are so
little understood, are so frequently unrecognized, and gen-
erally offer so much difficulty in diagnosis, is that there is
very little cham.j for their study on a large scale, and faith-
ful pictures of them are not obtainable.
As in men so in women, the chancre is simply a local-
■d aggregation of a peculiar new specific cell growth. For
1 purposes we may divide genital chancres in women
in cellar. , ., . . *. P
ollowing varieties :
Is lrremcdiaw ^ . , ,
7superncia] or chancrous erosion,
polyuria, .. , ,
v „ scaling papule or tubercle.
i .. The elevated papule or tubercle (exulcerated), ulcus
^ atrm.
4. The incrusted chancre.
as
, ( 5. The indurated nodule.
DP
. 0. The diffuse exulcerated chancre.
The Superficial Erosion, also called the Chancrous Ero-
sion.— The most constant early appearance of the syphilitic
chancre in women is seen in the form of an erosion of the
mucous membrane. In its very early days this lesion pre-
sents no well-marked characteristics and is very liable to be
* Read before the American Association of Genitourinary Surgeons,
September 22, 1891.
mistaken for a ruptured herpetic vr lele, an abrasion, chafe,
or scratch. Such is its seemingly benign, superficial, and
aphleginasio character and small size that its nature is fre-
quently not determined at the first examination. Indeed,
as Fournier says, " nine times out of ten the nascent chan-
cre is not recognized as such."
The chancrous erosion is always found on the surface
of the mucous membrane. It begins as a red spot, some-
what deeper in color than the mucous surface on which it
is seated. It is very rarely, if ever, seen in women in the
first few days of its existence, for the reason that its pres-
ence is usually unknown to its bearer, or, if it is seen by
her, it appears so simple, mild, and harmless that its nature
is scarcely ever suspected. Thus it is that when first seen
by the physician the red spot has become, by desquama-
tion of its epithelium, an erosion. When seated on smooth
surfaces, such as presented by the internal surfaces of the
labia majora and the greater part of the labia minora, this
lesion, when somewhat advanced, presents certain well-de-
fined features, but when it is developed upon the anfractu-
ous surfaces of the fourchette, the introitus vagime, the ves-
tibule, and around the urethra, its app' irance is not strik-
ing, and, indeed, is often misleading to the eye, while its
exploration is difficult and unsatisfactory to the fingers. In
very many cases a catarrhal or blennorrhagic condition of
the parts conduces to further obscurity of the diagnosis.
When the erosion is quite well developed it presents
the appearance of a very superficially exi 'cerated lesion, of
a more or less deep-red color, resembling quite closely mus-
cular tissue. This color, however, varies in different cases
between certain extremes. In very cleanly and anaemic
women the redness may be scarcely deeper than normal,
while in uncleanly persons, in those suffering from simple
or blennorrhagic inflammation of the genital tract, in those
in whom the coaptation of the parts is close and tight, and
in pregnant women, the chancre may b< of an extremely
deep dull-red tint.
Upon smooth, tolerably flat surfaces the chancrous ero-
sion is usually round or oval in shape, though either of
these outlines may become irregular. On anfractuous sur-
faces the chancre presents corresponding irregularities. The
surface of the chancre is smooth, sometimes even glistening
and shining, and shows that the lesion is formed of tolera-
bly compact tissue. It usually presents a solidity of struct-
ure which is striking. When seated upon parts in which
the chancre is subjected to movement, or in clefts, the
smoothness of surface may be more or less lost.
The secretion of the chancre is usually serous in char-
acter, but it may aiso contain some leucocytes. It varies
in quantity considerably ; from some chancres we see very
little serous oozing, while from others it is quite copious.
When seated on an inflamed surface, or when the chancre
is irritated, it may secrete true pus. In some cases these
chancres become contaminated with chancroidal pus, and
they are then converted into ulcers whose nature it is very
difficult to determine.
The true chancrous erosion scarcely presents an ap-
preciable elevation, and the lesion may run its course and
2
TAYLOR: GENITAL CHANCRES IN WOMEN.
[N. Y. Med. Joue.,
disappear without ever becoming salient above the normal
plane.
While in general there is not a well-defined margination
of the chancrous erosion, the eye can plainly see where the
lesion ends and where sound tissue begins. In some cases,
however, the circumferential margin becomes hyperplastic
and the chancre is converted into a saucer-shaped lesion.
The size of this chancre varies considerably ; some reach
maturity, and have a diameter of a third or half an inch,
and it is not common to see one larger than an inch in
diameter.
In many cases, even when a satisfactory examination is
possible, no evidence of induration can be made out, and at
best soft, (Edematous hyperplasia may be felt. In other
cases, however, induration of a superficial, flat character —
parchment induration — can be felt. This form of chancre
is well depicted in Fig. 1.
As already stated, in many instances the chancrous
erosion runs its whole course as a non-salient lesion, but in
others the erosion lesion gradually develops into a papule
or tubercle, the description of which will soon follow.
While in general the chancrous erosion is with difficulty
diagnosticated in its early days, if it is protected from irri-
tation and dirt and carefully watched, its nature may be de-
termined in the course of ten days or two weeks, if not
sooner. Herpetic discs, chafes, and excoriations usually
show a tendency to become rapidly cicatrized by the simple
interposition of lint or of a mild astringent wash, and from
the first they show signs of healing. On the other handi
despite judicious aseptic measures, the chancrous erosion
keeps on its course without any early signs of healing-
With this lesion the implication of the ganglia can usually
be well made out in about two weeks, and this sign, with
the typical appearance of the lesion, will usually make the
diagnosis of syphilis clear.
Chancrous erosions, when seated upon the surfaces of the
labia, large and small, are very commonly multiple, varying
in number from two to four.
The chancrous erosion upon uneven and anfractuous
surfaces is even more difficult of recognition than the le-
sions just considered. Upon the carunculae myrtiformes,
about the urethra, at the fourchette, and around the vagi-
nal orifice the lesion rarely has a definite shape and out-
line. As Clerc says, the syphilitic neoplasm molds itself to
the parts it is seated upon, and when these parts are
uneven, nodular, fringed, and anfractuous, its shape, out-
line, and general configuration are vague and indetermin-
ate. The diagnosis at best being very difficult, it is often
rendered more obscure and even impossible by underlying
chronic and acute inflammatory conditions of the vagina
and vulva. I have many times seen this form of chancre
thus located pass wholly unrecognized by careful and
skilled men in the cases of women suffering from simple
and blennorrhagic inflammation of the genitals. In practice
the best course to pursue when one is consulted for or sees
a deep-red, superficially eroded patch, or even papule of ir-
regular outline on the parts just mentioned, is to keep them
free from all irritation and apply a bland lotion on cotton.
If the lesion is simple in character, it will soon become
pale and heal, but if it is composed of syphilitic cell-growth
it will keep on and become further developed. Time,
watchfulness, and the condition of the ganglia will within
three weeks certainly make the diagnosis clear. It follows,
therefore, that the physician should speak guardedly of
these lesions, and that he should never pass them over as
insignificant or pronounce them off-hand as being of no
moment.
A frequent and striking peculiarity of the chancrous
erosion is its short period of existence. It frequently
comes and goes without the knowledge of its bearer.
Physicians, young and old, are often much surprised that
on female subjects presenting early secondary lesions they
can find no trace of the chancre. Not only does this lesion
frequently undergo rapid involution, but it may also leave
after it no trace after the lapse of a few days. Fournier
watched a chancrous erosion run its course in fourteen days
and leave after it no trace. I recall the case of a woman
who had a pea-sized erosion in the cleft formed by the
labium majus and the labium minus which I watched care-
fully and in which the chancrous lesion lasted eighteen days
and disappeared without the slightest trace.
Sometimes on the involution of the chancre a reddened,
very slightly hyperplastic spot is left, and one can tell that
the affected tissue is slightly denser than normal. Then,
again, the only trace left is a circumscribed redness, at first
rather deep. This gradually pales and the mucous mem-
brane is left apparently healthy. While in many cases the
chancre is very ephemeral and leaves a trace which rapidlv
disappears, in other cases the red spot is very persistent
and it may be seen for several months.
The chancrous erosion leaves no evidence of a cicatrix ;
the reason of this is that the syphilitic new growth com-
posing it is not copious and condensed, consequently it does
not destroy or impair the tissue which it infiltrates, and is
absorbed without carrying away with it any normal cells.
This lesion, however, is sometimes accompanied with an
oedematous condition of the tissues under and around it.
This complicating condition consists in a slow, aphlegmasic
thickening of the tissues. It may be limited to a moder-
ately wide area around the sore, or it may be extensive anc^
involve much tissue. It is not at all uncommon to see tl
whole of a labium minus or majus the seat of this inc
ing oedema. Tissues thus affected present a dens
and somewhat elastic structure, but the indurai
early periods is not as hard as that of a typi!
sclerosis.
It not infrequently happens, particularly when the char
crous erosion is seated near the integument or upon tl,
fourchette or prepuce of the clitoris, that well-defined in
duration takes place under it and it becomes developed into*-
a typical indurated chancre. This condition is sometimes
strikingly well marked at the fourchette, and is well shown
in Fig. 2. This presents a V-shaped chancrous erosion,
with deep induration of the tissues of the parts. This
chancre, when seen here, frequently presents a raw-beef ap-
pearance, which is very characteristic.
The Scaling Papule or Tubercle. — This lesion is found
upon the outer surface of the labia majora ; upon the labia
Ban. 2, 1892. J
TAYLOR: GENITAL CHANCRES IN WOMEN.
3
■minora when they are long and their structure resemhles that
Ipf the integument ; upon the prepuce of the clitoris when it
as long and protrudes from the vulva ; upon the internal
■surface of the thighs, the inguinal folds, and the hypogas-
Irium. It begins in a very insignificant manner as a small,
(dull-red colored papule, which may or may not be scaly.
IfThis lesion increases circumferentially, but usually does not
Ibecome much elevated. As it grows it develops into a flat,
librownish-red and sometimes purplish-brown, perhaps scaly,
•elevation of the skin, with a sharply defined margin. It
limay be of the size of a silver five-cent piece, or as large as
a silver quarter or half dollar. Its shape is round or oval,
and sometimes, owing to the conformation of the parts, it
is of irregular outline. It may present well-marked indu-
ration, or this symptom may be scarcely recognized. In
general this lesion is unique, and exceptionally two are
found. Though it is cold and aphlegmasic in appearance,
it presents to the eye a compactness of structure giving
one the impression that it has come to stay. It runs an in-
dolent course, and may last several weeks or even months.
In most cases it leaves after it a deep-brown, even a purplish,
stain, and not uncommonly atrophy of the skin is produced
by it. When irritated, this lesion loses its epidermal cov-
ering and becomes raw and exuding. It then is developed
into what is called the ecthymatous chancre (a bad term),
and may be better classed as an incrusted chancre. This
form of chancre is far from uncommon in women.
In rare cases the scaling papule becomes very large in
area and very much elevated, so as to form what we may
call an elephantine chancre. I have seen one on the but-
tocks of a woman the diameter of which was two inches
and a half, and another on the upper portion of the thigh
which had an area of an inch and a half and a height of
I three quarters of an inch.
In rare cases the scaling papular chancre develops around
a hair, and forms a conical lesion of the color just described.
When this occurs it is not uncommon to see two or three or
ieven more of these chancres. They may run an uncompli-
cated course, or they may become attacked with ulceration,
j in which event the diagnosis is much obscured, and a lapse
|,of time is required before their nature is rendered clear and
isitive. The resulting ulcers have well-defined, elevated
■>'S and a saucer-shaped surface. They vary in size from
to half an inch. All chancres of this variety are
i&Vn disappearing,
polyuria, elevated Papule or Tubercle (Ulcus Elevatum). —
i chancre presents the appearance of a well-circum-
scribed, flat or elevated lesion, whose surface is similar to
that of the chancrous erosion. Indeed, it may be defined
as a chancrous erosion in which the hyperplastic process has
been very active and productive of much infiltration. Cases
not infrequently present themselves in which we can watch
the development of the ulcus elevatum from the chancrous
erosion.
The ulcus elevatum is seen upon the mucous surface of
the labia majora and minora in its most typical form. It is
well shown in Fig. in which the two elevated excoriations
are seen, one seated on each internal surface of a labium
majus. This form of chancre is round, oval, or slightly
irregular in outline, and varies in size from a third of an
inch to an inch and even an inch and a half. Its surface is
smooth and even velvety, and its color is of a deep red, like
muscular tissue. In some cases the smoothness of surface
is replaced by an uneven, slightly granular condition ; but
in uncomplicated cases nothing like a warty or strawberry
surface is seen. In old and irritated cases of the ulcus ele-
vatum a slightly warty appearance of the surface may be
present. In other cases, as the lesion grows old, it assumes
the appearances of condylomata lata. The surface may be
flat, slightly convex, or even decidedly concave. As a rule,
the margination of the ulcus elevatum is not sharp and
steep, but in some cases this feature is observed. The se-
cretion of this lesion is serous in character, and is mixed
with a few leucocytes. In consequence of the irritation of
catarrhal or blennorrhagic secretions, as a result of unclean-
liness and alcoholic and sexual excesses, and of prolonged
walking and fatigue, the ulcus elevatum may become much
hypertrophied, and around it may develop a greater or lesser
amount of indurating oedema ; or, from the same causes, it
may become more or less ulcerated, in which event its na-
ture is often rendered very obscure. A hypergemic condi-
tion of the parts around, due to pregnancy or any other
source of irritation, is very often a complication which ob-
scures and delays the diagnosis.
Careful palpation rarely shows very marked induration
in the ulcus elevatum. This symptom is usually difficult of
detection, and when found it is generally of the parchment-
like order, or it simply gives the impression of a rather
greater condensation of tissue than is normally found.
When this lesion is situated near the juncture of the mu-
cous membrane and the integument it may present marked
induration. As a rule, this form of chancre is chronic in
its course, lasts weeks and months and slowly resolves, leav-
ing a deep-red spot which may be very persistent and is
often very useful in diagnosis.
The Incrusted Chancre. — This chancre, as we have seen,
is not uncommonly found upon juxtapudendal cutaneous
surfaces, and indeed upon any portion of the integument.
It has been stated that incrusted chancres are not found
within the area of the mucous membrane of the vulva, but
that their habitat is the tegumentary structures. It is true
that in most instances vulvar chancres are of the erosive or
papulo-tubercular variety. This is largely due to the fact
that the coaptation of the parts and their moisture, aided
very often by pathological secretions, cause any surface
covering of the chancre to melt away and to disappear. But
it is not at all uncommon to find chancres at the fourchette
in an incrusted state, and I have twice seen this condition
in vaginal chancres. Further, in somewhat rare cases, I
have seen incrusted chancres of the clitoris, and also of the
labia minora, when these structures have been prominent in
the vulva and have come to look like integument.
At the fourchette, besides the raw-beef chancre — the
outcome of the chancrous erosion — we not uncommonly find
incrusted chancres.
This incrustation in women, as in men, forms upon an
eroded surface — namely, (lie chancrous erosion, the indu-
rated nodule, or the diffuse indurated plaque. It begins as
4
TAYLOR: (1 EX IT A L CHANCRES IS WOMEN.
[N. Y. Med. Jouk.,
a thin, white film, presenting a glistening appearance. This
film, which is formed of necrotic tissue elements and serous
secretion, increases in extent and thickness until a species
of false membrane is formed which is wrongly called diph-
theritic membrane. As this membrane increases it becomes
of a grayish-cream color, which in some instances is tinged
with a very light tint of green. In this state the membrane
of syphilitic chancre may be said to present its typical ap-
pearance. It may thus remain more commonly in men
than in women ; in general, however, we find that the gray-
ish color in some parts (if not the whole) of a chancre be-
comes brownish or even blackish, probably; from blood ad-
mixture or from dirt contamination. This condition is well
shown in Fig. 4, which portrays a chancre of the fourchette
in a pregnant woman (the vulva has a bluish-red hue).
Then again in women, as in men, the surface of the
chancre may be covered with a thin, brownish-red, necrotic-
looking film, which consists of the usual membrane dis-
colored with blood, which may be scattered in little masses
over the surface of the chancre, giving it a spotted appear-
ance. This necrotic chancre is well shown in Fig. 7.
Then again we find, though very rarely, the chancre
called by Fournier chancre multicolore, or the chancre en
cocarde, in which the surface of the chancre presents a series
of concentrated zones of different colors which are thought
to resemble a cockade. In Fig. 5 this chancre is beautifully
delineated, the colors being red in the center, green, then
red, and then gray. This play of color is due to some pe-
culiar changes in the typical syphilitic membrane of the
chancre.
The incrusted chancre may present a smooth surface or
it may be more or less uneven and undulating, owing to the
nature of the parts upon which it is seated.
In Fig. 6 an incrusted chancre of the mons Veneris is
well shown. It is developed among the hair, and the infil-
trating neoplasm has caused little elevations around the hair
follicles ; consequently the surface of the chancre is quite
uneven. This is the usual condition of chancres when de-
veloped upon hairy parts.
In the incrusted state the chancre may remain indolent
and aphlegmasic for a long time. As the lesion becomes
old it is not uncommon to find that it is complicated with a
greater or less amount of indurating oedema. In Fig. 6
this complication is shown very clearly in the great hyper-
trophy of the right labium majus. Under proper medica-
tion, the crust disappears and healing takes place in the
chancre.
The Indurated Nodule. — This chancre, so common in
men, is very rare in women. In men the syphilitic neo-
plasm or nodule, as a rule, circumscribes itself in compact
form into a little mass ; in women this new growth tends
to diffuse itself more loosely into the soft mucous tissues.
Thus it is that we rarely see the indurated nodule in the
female sex, except on parts where the skin and mucous
membrane fuse together.
The indurated nodule is seen as a sharply circumscribed
mass of indurated tissue which may be rather broad and
fiat, or it may have a rather narrow base, sloping edges,
and ilat surface. The color of the lesion is dull red, and its
surface may be smooth and glossy, or it may present the
grayish color of the incrusted chancre with all the variega-
tions found upon that. In Fig. 8 an indurated nodule is
admirably well shown at the lower part of the left labium
majus. This nodule, like most of its class, presented a
cartilaginous hardness, sharply limited to its margin. The
course of this lesion is very chronic, and on its disappear-
ance a pigmented spot may be left or atrophied skin may
be evident.
The Diffuse Exulcerated Chancre. — This lesion is ob-
served not infrequently in women of the lower order who
are uncleanly in their habits and given to debauches. It
presumably begins as the chancrous erosion develops into
the ulcus elevatum, and from this stage it further increases.
It is usually seen involving more or less of one lip, large or
small. The morbid area is much thickened, of a deep-red
color, and it is exulcerated over the greater part of its sur-
face. In these very large chancres we find a raw, uneven
surface, and very often small or large ulcerating spots.
Their course being very chronic and indolent, their appear-
ance varies. At some times they are raw, like beef, and at
others they look like elephantine incrusted chancres. They
are very often complicated with the development of hard
cedema.
As a rule, all chancres of the female genitals are unac-
companied with pain. In some cases itching and burning
are complained of, and in some chancres of the clitoris and
fourchette severe pain is felt.
On the labia majora we find the incrusted chancre, the
chancrous erosion, the ulcus elevatum, the diffuse exul-
cerated chancre, and the indurated nodule. In the tissues
of these parts indurating cedema is very often observed as
a complication involving large and small portions. This
complication is also found as a result of secondary lesions —
such as erosions and condylomata lata.
On the labia minora the chancrous erosion, the ulcus
elevatum, and the diffuse exulcerated chancre are commonly
found. All chancres on these parts may be accompanied
by mild or dense induration, which may involve part or
the wdiole of the structure.
Chancres of the fourchette are of the erosive, incrusted,
or diffusely indurated type.
Chancres of the introitus vagina?, meatus, and m,T" * .
form caruncles are commonly ill-defined masses of ;
tion which frequently present no characteristic a^|
and whose diagnosis is usually very difficult, and fr^P^U/
only possible after considerable delay and observation.
these parts it is very difficult, often impossible, to deter-
mine the extent and density of the induration.
Chancres of the vagina are very rare. Clerc never saw
one, and Fournier says he never saw one seated beyond the
vaginal ring. Bockhart reports a case of chancre of the
middle portion of the vagina which had developed upon an
excoriation produced by a tickler in ultra-libidinous coitus.
In Fig. 9 I present a very graphic picture of a chancre
of the vagina in the sulcus to the right of the neck of the
bladder. (In the left sulcus was a corresponding lesion.)
This chancre was of the incrusted variety, and it will be
seen that the false membrane is of a deep-green color, such
Jan. 2, 1892.]
as we sometimes see in this form of chancre. Near the
fourchette a well-marked chancrous erosion may he seen.
In the treatment of chancres in women too much atten-
tion can not he paid to the matter of cleanliness and to the
production of a dry state of the parts. In some mild cases
of chancre simple lotions only are necessary. "When the
lesion is well developed it should he constantly covered
with mercurial ointment.
DISEASES OF THE URINARY APPARATUS.
By JOHN W. S. GOULEY, M.D.,
SURGEON TO BELLE VUE HOSPITAL.
(Continued from vol. lii>, page 711.)
PART I. — PHLEGMASIC AFFECTIONS.
Skction n.— special considerations.
VI.
Cystitis; its Treatment.
The treatment of sufferers from cystitis should be con-
stitutional and local. The general indications are to re-
move the original cause, to relieve pain, to shorten the pe-
riod of resolution of the phlegmasia, and to prevent or to
combat complications. The special indications vary in ac-
cordance with the exigencies of individual cases. The
prime requisite to the rational management of a particular
case of cystitis is the proper interpretation of its phenome-
na. This is possible only after the history of the patient
is known and the cause of the phlegmasia ascertained, and
a close analysis is made of its subjective and objective
symptoms. An accurate diagnosis can have no other foun-
dation.
Constitutional Treatment. — When a subacute cystitis
is traced to supersecretion of urine of low specific gravity,
the cause of the polyuria is first'ascertained and, if possible,
removed ; then the cystitis is likely to cease. For instance,
when polyuria is due to temporarily disturbed innervation,
the re-establishment of the nervous equilibrium is sufficient
to effect the cessation of polyuria and thus to remove the
cause of the cystitis. This, however, is hopeless in some
cases of grave disease or injury of nervous centers, as it is
in certain serious lesions of the kidneys where the polyuria
is irremediable. In some cases of cystitis due to persistent
polyuria, opium in moderate doses has the double effect of
relieving pain and of lessening the urinary secretion. In
other cases it becomes necessary to add to the opium either
ergot extract or gallic acid.
In cases of cystitis caused by diminished secretion, the
urine being of high specific gravity and acrid, the treat-
ment should he such as to cause an increase in the quantity
of urine. By the judicious use of mild alkaline diuretics,
such as the citrate of soda or potash, largely diluted, or in-
fusion of uva ursi, decoction of triticum repens, etc., is ac-
complished the indication of rendering the urine bland, and
of thus causing a rapid subsidence of the cystitis.
The cases of cystitis arising indirectly from disturbance
in the cutaneous circulation ordinarily get well when this
5
circulation is re-established, and do not require other medi-
cation than such as may render the urine bland. When,
however, the cystitis persists, and vesical contracture ensues
in any of the varieties of the first group, a more active treat-
ment is necessaiy, as will be presently stated.
Cystitis from persistent hyperlithuria is of much more
frequent occurrence than any of the varieties of this first
group, and its management demands close attention. This
variety of cystitis is often miscalled irritability of the blad-
der, and this symptom is treated with opium, belladonna,
etc., and the phlegmasia is allowed to progress until perma-
nent contracture of the bladder is established. This cysti-
tis is as amenable to treatment and to cure in its incipiency
as it is refractory to either in its advanced stages, particu-
larly after contracture of the bladder is confirmed.
If, when the bladder is said to be irritable, the urine is
examined microscopically and found to contain an excess of
uric acid, and treatment for hyperlithuria is at once insti-
tuted, normal urination is soon restored and all symptoms
of beginning cystitis disappear. Patients affected with cys-
titis due to hyperlithuria are necessarily hyperlithaemicr
and this is consequent upon dyspepsia and hepatic engorge-
ment. In such cases there is habitual costiveness, and with
this headaches, muscular pains, and other symptoms of
ptomainal or leucomainal toxa?mia. The treatment should
therefore be directed to the restoration of the digestive
function and to the remedy of the consequences of its im-
pairment. For these ends the first desideratum is free
catharsis ; then daily aperient medicines and the so-called
hepatics, such as small doses of podophyllin, leptandrin,
irisin, colocynth, and nux vomica, combined. At the same
time should be prescribed alkaline waters, such as those of
Vichy, from the Celestins spring, six ounces four times
daily, between meals, for two weeks or, at most, three weeks.
When there is -a very abundant precipitate of uric acid,
causing greater distress than usual, nothing seems to act so
quickly as ten grains of salicylate of sodium, largely di-
luted, four times daily for two or three days onlyT ; as such
doses are not long tolerated by the stomachs of most pa-
tients, their continuance beyond that time is not wise. This
should precede the administration of the Vichy water.
Five-grain or even ten-grain doses of phenacetin sometimes
promptly relieve the muscular pains which so often accom-
pany hyperlithajmia.
During this treatment and for thrc 2 or four weeks there-
after the patient should abstain from eating starches and
sugars, or use them very sparingly, especially at the even-
ing meal. Abstention from all articles of food tending to
cause flatulency, and from malt liquors, cider, sweet wines,
etc., is essential, as they are known to be so often hurtful
to the process of digestion in the cases under considera-
tion. Sufficient bodily exercise, promotion of the cuta-
neous functions by frequent ablutions and frictions, and
clothing suited to the state of the weather, constitute the
remainder of the hygienic management.
A medication and hygienic precautions such as have
just been described are likely to nip in the bud a cystitis
which would otherwise become very distressing and lead to
| transitory, and finally to permanent, contracture with steno-
G0ULJ5Y: DISEASES OF TIIE URINARY APPARATUS.
6
GOULEY: DISEASES OF THE URINARY APR AR ATI'S.
[N. Y. Med. Jour.,
sis of the bladder. But contracture of the bladder, even of
many months' standing, is not necessarily hopeless and is
often cured ; but this requires the greatest patience on the
part of the physician and of the sufferer.
The local treatment consists in the use of medicinal
and mechanical means. When acute cystitis is accompanied
with transitory contracture, which is a state of rigidity of
the muscular coat of the bladder preceded by frequent and
painful spasmodic contractions especially at the close of
each act of urination, a brisk saline cathartic should first be
administered, then half a dozen leeches should be applied
to the perinaeum and as many to the hypogastrium. As
soon as the gorged leeches drop, hot fomentations should
be applied to the hypogastrium and continued for two or
three days. This local depletion is of much advantage in
young robust subjects, but should be omitted in those whose
health has already been impaired or those who are known
to be intolerant of bloodletting in any form. Two or three
liberal doses of opium may be necessary to relieve the pain
incident to the acute phlegmasia, and diluent drinks should
be given throughout the treatment. A hot hip bath, of five
minutes, every night is often very advantageous. No in-
strument should be introduced into the bladder except in
the case of retention of urine, which, however, is of ex-
tremely rare occurrence in these cases. After a few doses
of belladonna extract, a quarter of a grain four times daily
for two or three days, the sensitiveness of the bladder is
lessened and it allows itself to be distended by the urine
rendered bland by the diluent beverages. Resolution of the
phlegmasia begins and the tonic spasms of the bladder cease,
so that in the course of a few more days the patient is able
to retain his urine several hours, and is soon well.
In chronic cystitis with contracture, if there are not very
much thickening and induration of the bladder walls conse-
quent upon interstitial cystitis, mechanical as well as consti-
tutional treatment is required, the indications being to
remedy the phlegmasia and to restore to the bladder its
normal suppleness and capacity. The constitutional treat-
ment must be used as an indispensable adjuvant to the me-
chanical treatment, which would otherwise be fruitless.
The inordinate irritability of the bladder and the accom-
panying distressing and unduly frequent urination incident
to cystitis with contracture, react upon the nervous system
to the extent of seriously disturbing sleep and of rendering
the patient excessively fretful. lie is constantly on the
alert for the moment to arrive when it is time to urinate,
and ever ready to clutch any object that may serve as a ful-
crum for his straining efforts. His face then becomes livid
and intense suffering is thereon depicted. At the close of
the act of urination he throws himself upon his bed ex-
hausted, but not always to sleep, and even then often dreams
of his distress. This scene is renewed every hour, half-hour,
or even every quarter of an hour. His skin is harsh and
inactive, his digestion is soon impaired, his appetite van-
ishes, his intestinal dejecta are hard and scanty, and he is
in no slight degree under the influence of leucomainal in-
toxication. Such is a true picture of the worst cases. It
is therefore wise to endeavor to remedy these several
morbid states before they attain this high state of develop-
ment.
The first prescription should be for a cathartic. The
next, for a nightly dose of twenty or thirty grains of sodium
bromide, with the object of procuring sleep and of prolong-
ing the intervals of urination. Then thrice daily five min-
ims of tincture of the chloride of iron with a grain of qui-
nine. Other medicinal agents that may be indicated should
be used with due regard to the state of the digestive func-
tion, and not given beyond the point of tolerance. For in-
stance, diluents should not be continued more than four
days, to be replaced by balsamics, which in some cases act
so favorably as modifiers of the urine ; the balsamics in
their turn to be discontinued in favor of some diluent. Bel-
ladonna and opium, and, for a change, hyoscyamia, not more
than one two-hundredth of a grain thrice daily, are not
generally well tolerated longer than four days. Such are
the agents required for the constitutional treatment, but they
should be used with discretion and judgment, otherwise the
desired effect is not likely to be obtained.
Gradual Hydraulic Dilatation of the Contract-
ured Bladder. — The mechanical treatment consists in
slow, gradual, and progressive hydraulic dilatation of the
bladder, and is effected in the manner presently to be de-
scribed.
An eight-ounce, pear-shaped India-rubber bagwith noz-
zle and stop-cock is filled with a warm solution of mercuric
chloride (1 to 10,000), with the addition of thirty grains of
boric acid, ten minims of spirit of gaultheria, and half an
ounce of glycerin. A curved gum catheter, No. 9 English
scale, is introduced into the bladder and all the contained
urine is allowed to flow and is measured. Suppose the quan-
tity of urine thus drawn to be one ounce ; the nozzle of the
India-rubber bag is thrust into the distal end of the cathe-
ter, and, by very gently compressing the bag, as much of
the fluid is slowly throwm in as the bladder can tolerate w ith-
out too much pain. The fluid is then allowed to escape
through the catheter and is measured. In this manner the
capacity of the bladder is determined. It may be of an
ounce and a half or two ounces. A second injection at the
same sitting determines the degree of distensibility of the
bladder, for if, after a very slight increase — two or three
drachms over the amount of the first injection — the fluid
drawn is tinged with blood, the operator knows that the
bladder has been distended beyond its abnormally restricted
dimensions, that a slight violence has been inflicted upon
its mucous coat, and that he should desist from further at-
tempts at distending the bladder during the sitting, and
throw in only one ounce of fluid at a time, simply to soothe
and cleanse the bladder, until the eight ounces are exhausted.
On the next day, the patient being under the influence of
belladonna or of hy^oscyamine, the process of injection and
dilatation is repeated. It may be that no gain is made over
the maximum distention of the previous day, or even that
there is a loss, the bladder being less tolerant than before,
so that not over one ounce of fluid can be injected. This
often happens during the early part of the treatment, but
should not discourage the operator, for on the third day's
Jan. 2, 1892.]
6 OWLET: DISEASES OE THE URINARY APPARATUS.
7
sitting- there may be a gain sufficient to more than make up
for the loss. With the exception of such retrogressions and
the occasional occurrence of slight haemorrhages, the dila-
tation is progressive from day to day, though the increase
on some days can be measured only by the drop, while on
other days it is by the drachm, but later by the ounce, and
in the course of five or six weeks the bladder sometimes tol-
erates eight, ten, or twelve ounces of fluid. When this stage
is reached the injections are repeated every second day,
twice a week, and finally only once a week, until the cystitis
is cured.
A very important point to which the attention of the
physician should be directed is the habit that some pa-
tients, affected with cystitis and contracture, form of urinat-
ing, so to speak, by the clock. Unless this habit be soon
broken, the case may well be regarded as hopeless. The
example to be given is a fair illustration of this point. A
patient, for the relief of whose suffering cystotomy had
been proposed, said that he had also been advised to uri-
nate often so as to keep his bladder empty as long as pos-
sible. He therefore, for several months, employed most of
his time in watching a clock, and whether or not he had any
desire to urinate he did so regularly every fifteen minutes.
It was very difficult to convince him that he was commit-
ting a grave error, but as he was daily getting worse he
finally consented to pay no further attention to the minutes
by the clock or watch, and in a few days retained his urine
half an hour, three quarters, and one hour, and in the
course of three weeks the mechanical dilatation of the blad-
der was carried from two ounces to ten ounces. He was
then able to retain his urine four hours. This urine, from
being purulent, bloody, and offensive, became clear and
normal.
For vesical irrigation and dilatation in chronic cystitis
with contracture, sundry other solutions beside that already
mentioned may be employed, such as of phenol, permanga-
nate of potassium, permanganate of zinc, acetate of lead,
acidulated water, etc.
It may be interesting to note some of the many differ-
ent substances that have been employed for vesical injec-
tions during the past hundred years. Chopart seems to
have been among the first to resort to vesical irrigations
for the cure of cystitis, although the early lithotomists,
among them Franco, used warm vesical irrigations as part
of the after-treatment of lithotomy to cure any lingering
cystitis, and although in the beginning of the eighteenth
century Pierre Desault, of Bordeaux, had used, in calculous
cystitis, injections of the mineral water of Bareges. Cho-
part at first made use of simple warm water, then of barley
water, and afterward of acetate of lead dissolved in water.
Later, in England and France, others used flax-seed water,
soot water, tar water, calomel suspended in an emulsion of
acacia gum, wine, normal urine, etc. Still later, copaiba
balsam in emulsion, carbonic-acid gas, solutions of hypo-
sulphite of sodium, bromide of potassium, iodide of potas-
sium, tincture of iodine, corrosive chloride of mercury,
chloride of sodium, carbonate of sodium, nitrate of silver,
sulphate of zinc, alum, tannin, strychnine, morphine, qui-
nine, salicylic acid, resorcin, methylaniline, peroxide of
hydrogen, divers mineral waters, etc., with varying but
mostly bad results, partly because no attempt had been
made to gradually dilate the contractured bladder.
It is often advantageous to change, from time to time,
the formulas of the fluids to be injected, but the essential is
to bear in mind the indications of curing the phlegmasia
and of restoring to the bladder its normal suppleness and
capacity.
This method of gradual hydraulic dilatation of the blad-
der, employed by Civiale and others of his time, appears to
have been soon set aside by many who have been allured by
the quicker and seemingly more promising method of sudden
dilatation aided by artificially induced general anaesthesia.
The quick method, which does serious violence to the blad-
der, is generally unsafe, often dangerous, and seldom if ever
successful. The slight benefit it very exceptionally confers
is of short duration, and the old symptoms soon return in a
more aggravated form than before. The advocacy of sudden
distention of the bladder with a solution of nitrate of silver,
thirty grains to the ounce, is even more unwarrantable.
This rash procedure has been adopted by many who have
regretted it, for when the patients have survived the vio-
lence and cauterization, their bladders have become perma-
nently and incurably contractured, stenosed, and thickened
from the consequent interstitial phlegmasia.
Nitrate of Silver in Cystitis. — In obstinate cystitis
nitrate of silver is unquestionably a valuable therapeutic
agent when used at the right time and in solutions of suita-
ble strength, but very strong solutions not only fail to cure
but do serious mischief. After the bladder has been gradu-
ally dilated to eight or ten ounces and the same amount of
urine is retained without causing pain or hemorrhage, if
this urine is still purulent, a weak solution of nitrate of
silver may, with much advantage, be employed for irriga-
tion everyr four or five days. A grain of crystallized
nitrate of silver is dissolved in eight ounces of distilled
water, then, after having drawn off all the urine contained
in the bladder and washed it twice with pure water, two in-
jections of four ounces each are rapidly made with the
nitrate-of-silver solution. In four or rive days the process
is repeated, but the quantity of nitrate of silver is doubled.
After this the solution is gradually increased in strength to
three, four, eight, and sixteen grains of nitrate of silver to
the eight ounces of warm water, and it is very rarely neces-
sary to increase the strength of the solution to thirty-two
grains to the eight ounces, for, after eight or ten sittings, all
the good that maybe expected is accomplished. Guyon,
of Paris, uses the nitrate-of-silver solution by way of in-
stillations of ten, fifteen, twenty, or thirty drops of the
strength of from rive to sixty grains to the ounce, once and
sometimes twice daily, principally in trachelocystitis.
As far back as the latter part of the last century strong
solutions of nitrate of silver were used in the treatment of
cystitis, from fifteen to sixty grains to the ounce of distilled
water. In some instances, instead of the silver salt, corro-
sive chloride of mercury was used in the same strength and,
it is said, with the same effect. Long afterward Trousseau
began to use, for vesical injection, the mercuric chloride,
8
(ioULEY: DISEASES OF THE URINARY APPARATUS.
[N. Y. Med. Jock.,
but only at the rate of about a quarter of a grain to the
ounce. Bretonneau was a strong partisan of vesical injec-
tions, and finally employed nitrate of silver in cystitis, but
his solutions did not exceed a quarter of a grain to tlie
ounce. In L842 Mercier revived the use of strong solutions
of nitrate of silver, beginning with fifteen grains and gradu-
ally increasing to sixty grains to the ounce, and this treat-
ment was adopted by Ricord and others, and is to this day
employed.
The advocates of strong solutions declare the weak solu-
tions to be worthless because, they say, the urine decom-
poses the nitrate of silver, converting it into an inert
chloride, and they further say that thirty minims of urine
suffice to decompose a grain of nitrate of silver. When the
precaution is taken of carefully washing the bladder imme-
diately before making the injection, surely enough urine
does not enter by the ureters to decompose a grain or a
quarter of a grain of nitrate of silver rapidly thrown in, and
it should be remembered that two injections are made in
quick succession within a minute or before the sixteen
minims of urine which it receives per minute can possibly
act upon the silver salt. Even in the event of polyuria, if
the urine entering the bladder should be increased to thirty
minims or to sixty minims a minute, which would be half
a minim in the one case and one minim a second in the
other case, it would not be sufficient to decompose the
weakest of the proposed solutions, for to inject four ounces
of fluid in the bladder requires not more than ten or twelve
seconds of time, the increase in the saline not being neces-
sarily proportionate with the watery element. Besides, as
a proof that the weak solutions of nitrate of silver do act
upon the mucous membrane of the bladder before the salt
can be decomposed by the chlorides as well as by the acid
phosphates, the injections are almost invariably followed by
a burning pain, which lasts from twenty to thirty minutes,
and by frequent and urgent desire to urinate for two or
three hours. Without there being enough urine in the
bladder to decompose the nitrate of silver, the ejected solu-
tion has a milky appearance, indicating its conversion into
a chloride. The action of nitrate of silver is primarily
upon the epithelium. A solution of moderate strength co-
agulates the albumin of the superficial epithelial layer, and
in so doing is decomposed into an insoluble chloride. But
a very strong solution is likely to act upon all the epithelial
layers, and even to penetrate more deeply and coagulate the
albumin and gelatin of the fibrous layer of the mucous
membrane before it is decomposed, and the iiritation it
causes leads to interstitial cystitis. Here, then, lies the
main objection to the use of strong solutions.
The repeated application of strong solutions of nitrate
of silver to mucous membranes has been demonstrated to
cause induration not only of the mucous membranes them-
selves but of their underlying connective tissue. These
membranes soon lose their elasticity, being, as it were,
tanned, and often spoken of as leathery. This condition of
sclerosis has been observed on a large scale in the fauces
among patients that had been treated during the great craze
of thirty-live years ago for cauterizing the human fauces on
the most trivial complaint of " sore throat," and was com-
monly termed the nitrate-of-silver throat, from which they
never recovered. A similar condition has been observed
during life in the urethra, from frequent applications of
strong solutions of nitrate of silver and other irritants.
The bladder may recover from the effects of a single injec-
tion of a strong solution of nitrate of silver, but when the
strong injections are several times repeated in accordance
with the directions given by those who advocate their em-
ployment, the delicate mucous membrane of this organ must
suffer much more than other mucous membranes that are
not the recipients of such an irritating excrement as the
urine, and whose outlets are free and broad.
Cvstotomy, infrapubic AND suPRAPUiuc, has been
frequently performed during the past forty years for the
cure of obstinate cystitis with contracture of the muscular
coat of the bladder uncomplicated by the presence of a
tumor, stone, or foreign body, or by prostatic obstruction.
The alleged effect of this operation is that it affords com-
plete drainage of and rest to the bladder, and therefore
cures the cystitis and contracture.
The analysis of a considerable number of reported cys-
totomies for chronic cystitis uncomplicated with vesical
tumors, stones, or foreign bodies, shows that the relief af-
forded by the drainage was only temporary, and that they
had failed to cure the cystitis and contracture.
It is not desirable nor is it possible to keep open the
neck of the bladder more than three or four weeks. Cica-
trization takes place within that period, notwithstanding the
use of dilating instruments, and the natural action of the
vesical neck is restored and prevents the urine from escap-
ing involuntarily. The insertion through the external
wound and the long retention of a large tube does not pre-
vent cicatrization of the urethro-vesical wound, and this
tube acts injuriously as a foreign body. There is no cura-
tive power in rest and drainage of the bladder in the case
of cystitis and contracture. The temporary drainage, in
the most obstinate and distressing cases, may sometimes be
of advantage as preparatory and adjuvant to the hydraulic
dilatation of the bladder without which no permanent cure
need be expected, and this dilatation should be employed
a few days after the perineal cystotomy. The fluid for
irrigation is heated from 105° to 110° F., and thrown
in very slowly, one, two, or three ounces at a time, un-
til a pint is used. This process is repeated once each
day until eight, ten, or twelve ounces can be injected at
once, but before this is accomplished the wound will have
healed.
In the case of suprapubic cystotomy a fistula has been
kept patent for months, and in some instances for years,
but without curing the cystitis or the contracture.
The prescription of long rest to the bladder in these
cases does not seem rational, since it is well known that the
prolonged immobilization of any part so surely leads to its
permanent contracture. The muscular walls of the bladder
need to be exercised in cases of cystitis with contracture
which has not become permanent, and this exercise is at-
tainable by hydraulic expansion, w hich gradually restores to
the bladder its normal suppleness and capacity.
Jan. 2, 1892.]
GOULEY
DISEASES OF THE URINARY APPARATUS.
9
The treatment of acute trachelocystitis, due to the
extension of acute urethritis, consists in recumbency, a light
regimen, the administration of diluent drinks to render the
urine bland, the use of belladonna and opium by mouth or
rectum, of hot fomentations to the hypogastric region, and
of daily warm baths. For ordinary cases this treatment
suffices to induce resolution in the course of a week or ten
days. Balsamics are often prescribed, but only serve to
disturb digestion. Other cases attended with great pain
and dysuresis require local depletion, such as may be effect-
ed by leeching the perinseum, and the substitution of cold
for warm applications, the cold being applied within the
rectum by way of ice suppositories. No instruments should
be introduced into the urethra except in the event of reten-
tion of urine. In these severer cases it is necessary to give
free doses of alkalies, such as the bicarbonate of sodium,
thirty or forty grains, largely diluted, four times daily for
three or four days, and to increase the doses of belladonna
and opium. Though the pain and urgent and frequent uri-
nation diminish under this treatment, resolution is frequently
incomplete, and the affection becomes chronic. It is in
these chronic cases that Guyon's method of instillations of
nitrate-of-silver solution is of the greatest service ; but this
will be detailed in the discussion of chronic prostatitis.
The treatment of cystitis due to injuries of the bladder
will be stated in connection with the subject of traumatic
affections of the urinary organs.
Treatment of Calculous Cystitis. — When cystitis is
caused by the presence of a calculus or of a foreign body, it
is sometimes necessary to prepare the bladder for the removal
of either irritant. The bladder may be spasmodically con-
tracted around the calculus or the foreign body to such a de-
gree as to gravely interfere with the play of the instruments
introduced for the destruction or the removal of the in-
truder. In such a case the preparation begins with the ad-
ministration of a few free doses of belladonna and opium
for two or three days. During this time the bladder is
daily irrigated with a warm, soothing antiseptic solution,
dilating it gradually as much as necessary for the safe de-
struction of the calculus or the extraction of the foreign
body ; either operation being successfully performed, the
after-treatment consists in daily irrigations tending to cure
the phlegmasia and to restore the bladder to its normal
state.
In the management of cystitis due to obstruction
by local urethral stenosis the physician is guided by the
character and caliber of the stricture, by its complications,
and by the general physical state of the patient. If the
stricture, though very narrow, is free from complications
and susceptible of expansion, its gradual dilatation is at once
begun and practiced every third or fourth day. As soon as
the urethral canal is thus sufficiently enlarged at the strict-
Bred point to render urination moderately free, the acts are
less painful, less frequent, the bladder is soon emptied, and
the cystitis begins to subside, to be well, as a general rule,
when the urethra is dilated to its normal caliber. When,
however, the stricture is not dilatable beyond three or four
millimetres, it should be cut longitudinally from within, and
a catheter introduced to draw off the purulent urine and
to permit the thorough cleansing and disinfection of the
bladder. The catheter is afterward used for every act of
urination, and the bladder washed once each day until there
are no more signs of cystitis. If there happens to be vesical
contracture, gradual hydraulic dilatation becomes neces-
sary. When internal urethrotomy is contra-indicated by
reason of the extreme narrowness of a stricture seated in
the scrotal or perineal region, especially if there be a uri-
nary fistula or an abscess, the operation of external perineal
urethrotomy should be performed without delay, to give
free vent to the urine ; but this urine should be drawn off
by means of a large catheter passed through the wound,
and the bladder thoroughly cleansed once or twice daily.
If there is no serious complication toward the upper uri-
nary organs, the cystitis is likely to be cured, or nearly so,
before the external wound is fairly healed.
The cystitis of elderly men affected with prostatic
enlargement requires unremitting attention from the earliest
period of its development, because of the grave conse-
quences that arise from neglect to relieve the bladder of
the stagnant urine which so surely undergoes fermentation
with the conversion of its urea into carbonate of ammoni-
um, and the extension of the consequent phlegmasia to the
whole of the vesical mucous membrane and even to its under-
lying fibrous coat. This cystitis is generally of slow develop-
ment. At first the urine contains very little pus, only the
lower fundus of the bladder being affected. The amount of
residual urine may not exceed an ounce, but this residuum
gradually increases until the bladder is abnormally distended.
The urine is then ammoniacal, slimy, and fietid, and urination
is unduly frequent and very painful. If before the cystitis
reaches this state of development the catheter is used once
or twice daily and the bladder is properly cleansed, further
fermentation is prevented and the phlegmasia subsides.
But if the cystitis has already extended to the whole
vesical mucous membrane, proper measures should be taken
to check the ammoniacal conversion of the urea of the
urine and to counteract its ill effects. The amount of
urea metamorphosed into ammonium carbonate is not less
than two per cent., or nearly ten grains to the ounce of
urine. This percentage of ammonium carbonate is quite
sufficient to excite cystitis, to act upon the albumin of the
pus-corpuscles, and to saponify the fats of the pus, the
result of these changes being the slime, miscalled ropy
mucus, which is sometimes so tenacious that it can not be
extracted through an ordinary catheter. There are two
ways of relieving a bladder gorged with tenacious slime.
One is to convert the carbonate into an acetate of ammoni-
um bythrowingin largely diluted arctic acid, thus liberating
the fats and liquefying the slime, which then assumes a
milky appearance; the other is to remove the slime by as-
piration through a large-sized catheter.
The bladder is then to be emptied by means of an ordi-
nary catheter five or six times every twenty-four hours and
thoroughly cleansed with an antiseptic solution once and
sometimes twice daily, night and morning. About ten
10
GOULEY: DISEASES OF THE URINARY APPARATUS.
[N. Y. Med. Jonn.,
ounces of fluid at a temperature of 105° to 110° F. may be
employed for this purpose, one third to be injected and
three successive injections to be made at each sitting. The
substances dissolved may be varied from time to time —
boric acid with the corrosive chloride of mercury, phenol,
permanganate of potassium, etc. — and continued as long as
the urine is alkaline. When the urine resumes its normal
acidity the injections need not be used oftener than twice a
week, but the use of the catheter should not be abandoned.
When the urine contains phosphates in great abundance,
two grains of acetate of lead to the ounce of warm water,
with two minims of acetic acid, may be used with good
effect, there being a double decomposition and the forma-
tion of a soluble acetate of the bases, and of an insoluble
phosphate of lead. Water acidulated with nitric or hydro-
chloric acid, two or three minims to the ounce, may also be
used with advantage. These two means constitute the
prophylaxis of phosphatic stone.
One of the gravest of the consequences of the cystitis
of elderly men suffering from prostatic obstruction is con-
tracture with diminished capacity of the bladder; this, hap-
pily, is of comparatively rare occurrence, while contracture
with increased vesical capacity is the rule. These patients
are tormented by constantly" painful and unduly frequent
urination, and, if allowed, would introduce the catheter
every half-hour, for they suffer all the pangs of acute reten-
tion of urine, and their bladders bear very little if any arti-
ficial hydraulic distention. Though they are the most hope-
less of all cases, their suffering is often alleviated by free
doses of belladonna and opium, and byT one or two daily in-
jections of warm water rendered denser by the addition of
glycerin and some salt of sodium or potassium.
The physician is sometimes called upon to minister to
the suffering caused by complete retention of urine, another
grave complication of the cystitis arising from stagnation
of urine due to prostatic obstruction. His duty in such a
case is to ascertain the degree of enlargement of the pros-
tate and the exciting cause of the occlusion of the urethro-
vesical orifice. lie may learn, by patient cross-examination,
that the sufferer had been exposed to inclement weather, or
had committed some excess, or that his rectum had not
been relieved for several days, etc. He may also learn how
long since the bladder had been emptied, whether the pa-
tient or any one else had used a catheter, and if so what
kind of catheter; if catheterism had been unsuccessful, how
many times it had been tried ; whether haemorrhage had fol-
lowed the attempts made to enter the bladder, and whether
he had had any chills after the catheterisms. Then he should
make a general examination of the case to ascertain the
condition of the patient and the degree of distention of the
bladder. If he finds the patient suffering much constitu-
tionally from his ailment he should not at once resort to
catheterism, but first administer a broth, a stimulant, and
an opiate, and finally an enema to empty the rectum. In
an hour or two he may select a suitable catheter, introduce
it and draw off only a pint of urine, two hours after this
another pint, and so on every two or three hours until the
bladder is empty. The dangerous procedure of precipi-
tately evacuating the ovcrdistendcd bladder of elderly men
has already been pointed out, but an example will be given
later. The best instrument for ordinary use is a No. 9
English curved gum catheter. If on account of a longi-
tudinal rent in the prostate the point of the catheter is
arrested and by gentle manipulation can not be made to
enter the bladder, the instrument should be withdrawn and
armed with a properly curved metal stylet and reintro-
duced after the manner of William Hey, which consists in
carrying the instrument to the point of obstruction and in
then withdrawing the stylet, at the same time pushing in
the catheter seized with the left thumb and index. The
suddenly increased curve changes the direction of the vesi-
cal extremity of the instrument, and the bladder is thus en-
tered. If no urine flows it is probably because the eye of
the catheter is obstructed by a clot of blood which can be
driven out by injecting quickly through the instrument an
ounce or two of water. It sometimes happens that this
method of catheterism fails. Then the invaginated catheter
of Mercier may be substituted with the fairest prospect of
success. This ingenious contrivance has many times obvi-
ated the necessity for puncture of the bladder, which is to
be regarded as an evil and performed for temporary relief
only, in case suitable catheters can not be procured for
many hours. The invaginated catheter consists of two
catheters — one metallic, the other non-metallic. The first
or female part is a thin-walled No. 10 English silver cathe-
ter, eleven inches long, very slightly curved, and having in
its concavity, about half an inch from the point, an oval eye
five eighths of an inch in length and three sixteenths in
breadth. From the vesical extremity of the eye is an in-
clined plane, which is lost in the floor of the opening at a
distance of a quarter of an inch, serving to tilt up the point
of the male part. This male part is a flexible but firm
" gum " catheter, No. 7 English, eighteen inches long, fit-
ting loosely in the lumen of the female part, and having a
single eye an eighth of an inch from its point. The man-
ner of using the invaginated catheter is to introduce the
male into the female part as far as the eye of the female
part, then to pass the instrument as far as the obstacle and
engage the point of the metallic part in the false route, and
finally to project the male part, which will override the false
route thus blocked and enter the bladder. The female part
can then be withdrawn and the male part left in as long as
may be required ; this is the reason for the increased length
of the male part.
In case of multiple false routes in the prostatic region
and of failure of all methods of catheterism, the patient is
rendered insensible by ether, or, better, by nitrous-oxide gas,
and is placed in the lithotomy position. A grooved steel
staff is then introduced into the urethra as far as possible,
a median incision is made in the perinaeum, the membranous
urethra is laid open longitudinally with a bistoury, the left
index finger is passed as far as the bladder to serve as a
guide for a broadly grooved director; the finger is then
withdrawn, and, with the guidance of the director, a deep
downward cut is made with a long-bladed beaked bistoury
in the median line through the base of the prostate, includ-
ing the neck of the bladder. Before withdrawing the di-
rector a soft India-rubber tube of not less than ten milli-
Jan. 2, 18J»2.]
GRUENING: OPERATIONS UPON THE MASTOID PROCESS.
11
luetics in diameter is introduced and retained in position
for forty-eight hours. Meanwhile the bladder is initiated
twice or thrice daily. After the withdrawal of the tube,
the same, or one slightly smaller, is used once <>r twice
daily to cleanse the bladder, though the urine may be
flowing involuntarily. In the course of three or four weeks
the false routes and the external wound heal by granula-
tion, and ordinary eatheterism may be employed to empty
the bladder.
Vesical Hemorrhage. — When the overdistended blad-
der has been precipitately emptied and an abundant haemor-
rhage has ensued, this viscus should not again be allowed
to become distended, and means should be promptly taken
to arrest the haemorrhage. In such a case may be adminis-
tered twenty-minim doses of fluid extract of ergot every
two or three hours, or ten grains of gallic acid dissolved in
glycerin, or the same quantity of quinine dissolved in dilute
sulphuric acid. Vesical injections of cold water, slightly
acidulated with acetic acid, may be made after each evacuat-
ing eatheterism. Then it is essential that the bladder be
kept empty. So long as the urine is much in excess of the
effused blood, this blood retains its fluidity ; but when the
blood is in excess, coagulation rapidly takes place and the
bladder is soon distended with dense clots which can not
be extracted until they are broken up and removed by as-
piration through a large catheter.
A vigorous farmer, seventy years of age, was seen in
consultation at his home on the last day of June, 1891, on
account of profuse vesical haemorrhage due to his having
suddenly emptied his overdistended bladder five days be-
fore when he had ridden forty miles in a light carriage.
The bladder was filled with clots and distended to the level of
the umbilicus. Notwithstanding the existence of prostatic
obstruction, eatheterism was easy, but, after a little bloody
urine had escaped, a clot occluded the gum catheter. A
metallic catheter, ten millimetres in diameter, was substi-
tuted and moved in different directions to break up the
clots, several ounces of which were aspirated by means of
Bigelow's instrument. A lithotribe was then used to
further break up the clots, and these were likewise aspi-
rated. After this several injections of diluted vinegar were
made and the patient allowed to rest and sleep for three
hours, when eatheterism was again employed, but with a
smaller instrument, which was not this time obstructed,
and a pint of bloody urine drawn. After several cold irri-
gations with ten per cent, of vinegar the ejected fluid con-
tained very little blood and no more clots. The haemor-
rhage gradually lessened and ceased on the third day. It
had lasted eight days in all. Meanwhile evacuative eathe-
terism had been practiced every live hours. In a week the
family physician wrote that the patient was in good condi-
tion, though he had been troubled with polyuria, which
necessitated the more frequent use of the catheter, and that
the cystitis was under control, the bladder being daily irri-
gated. The patient is at this date in excellent condition.
treatment of cystitis will now be closed with some hints
respecting the management of the cystitis which arises from
stagnation and fermentation of urine due to disease or injury
of the great nerve centers. In patients who survive grave
lesions of the brain or of the spinal cord for weeks or months
it has long since been observed that frequently the im-
mediate cause of death is traceable to consecutive lesions
of the urinary organs, such as cystitis, ureteritis, pyelo-
nephritis, calculous formation, etc., all arising from stag-
nation of urine in the bladder, whose sensibility is blunted
or even destroyed, owing to the nerve-center lesion, and
that when early attention is given to the impaired urinarv
organs while the primary disease or injury is undergoing
treatment, the life of the patient is prolonged and his
suffering lessened. The needed treatment is simple and
effective, so far as the urinary organs are concerned.
Very soon after a patient becomes paraplegic his bladder
ceases to act and rapidly fills with urine ; therefore it
should be artificially emptied at once, if it is not over-
distended. So long as the urine is clear and of acid reac-
tion, simple evacuative eatheterism, practiced at regular
intervals, suffices to prevent stagnation and cystitis. But
when the urine is already turbid and alkaline the bladder
should be irrigated once or twice daily with suitable solu-
tions. This plan of treatment has been current in Bellevue
Hospital for the past twenty-six years, and it is believed
that the lives of many patients have thus been prolonged
for months and even for years. Experienced surgeons
know so well how commonly, in depressed fractures of the
skull, the bladder becomes distended with urine, that the
first direction they give to their aids is to empty the
patient's bladder, with the object of preventing overdis-
tension and cystitis.
( To lie continued.)
NOTES ON
OPERATIONS UPON THE MASTOID PROCESS*
By E. GRUENING, M. D.
At the Aural Department of the Mt. Sinai Hospital
forty-seven operations of opening the mastoid process have
been performed since January, 1889. This number exceeds
that of any previous triennial period, the increase being due
to the prevalence of influenza. The cases operated upon
may be classified as follows :
First. — Acute caries or empyema of the mastoid, with
profuse purulent discharge through the middle ear — thirty-
nine cases.
Second. — Caries of mastoid with cortex intact, without
purulent discharge through the middle ear — two cases.
Third. — Chronic otitis media purulenta, with presence
of cholesteatomatous masses in the antrum and tympanic
cavity — three cases.
Fourth. — Chronic otitis media purulenta, with sclerosis
of mastoid process, thrombosis of lateral sinus, and pyaemia
— two cases.
Treatment ok the Cystitis due to Disease or Injury
of the Great Nekve ('enters. — The discussion of (he
* Head before the American Otologieal Society at its twenty-fourth
annual meeting,
12
MATTHEWS: THE CLIMATE OF BERMUDA.
[N. Y. Med. Joue.,
Fifth. — Chronic otitis media purulenta, with sclerosis of
mastoid and abscess of brain — one case.
Of these forty-seven cases, in all the acute cases, forty-
one iu number, the patients recovered completely and were
discharged cured ; of the chronic cases, in the three com-
plicated with a formation of cholesteatomatous masses the
patients were improved, but not cured; while the remaining
three admitted to the hospital with thrombosis of the lateral
sinus and abscess of the brain, respectively, died.
The method of operation which T had employed in the
Mt. Sinai Hospital up to 1889 was strictly that of Schwartze-
Kiister and von Bergmann have criticised Schwartze's
method severely because the cases require a lengthy after-
treatment by frequent syringing. Kiister has proposed
another mode of procedure in which the opening of the
mastoid is systematically combined with the removal of the
posterior wall of the osseous portion of the external auditory
canal, and the introduction of a drainage-tube through the
mastoid opening and the canal. The strictures made by
these gentlemen are justifiable from a surgical, but not from
an otological, standpoint. My operations demonstrate that,
by an extension of Schwartze's method, the prolonged after-
treatment becomes unnecessary, and the function of the ear
is respected. This was particularly noticeable in the forty-
one acute cases mentioned in this series.
The modification of Schwartze's method as practiced by
me during the past three years consists in the systematic
removal of the whole external wall of the mastoid process.
I begin my operation through the soft parts with an in-
cision extending from a point situated two centimetres above
the linea temporalis and carry it to a point below the apex
of the mastoid. The periosteum is then lifted from the
whole extent of the mastoid process, and the tendinous at-
tachments of the sterno-cleido-mastoid muscle are severed.
The outer surface of the bone is thus completely exposed,
and, if found diseased and softened, opened with a sharp
spoon at the point affected. If the bone is found firm and
apparently healthy, the opening is made with chisel and
mallet on a level with the spina supra meatum. Thus far I
follow Schwartze's directions. The next step in my opera-
tion is the removal of the whole cortex by means of the
bone forceps or rongeur. I use for this purpose an instru-
ment specially constructed with a view to the dimensions of
the field of operation. Removal of the cortex brings into
view a number of cavities filled with granulation tissue, for
the dislodgment of which the sharp spoon is used. Tbese
small cavities are thus generally converted into one large
cavity, whose bony walls may be found softened in many
spots. Again the sharp spoon is used to clear away the
softened and diseased bone. Now the large cavity thus
made can be fully explored, and the site of the lateral sinus
and its relation to the antrum determined. The importance
of this localization was shown in one of my cases, where the
sinus covered the path to the antrum into which I intended
to penetrate. In some cases the sinus was found behind
this path; in others, below that level. It is evident, tben,
from my experience in this series of operations, that locali-
zation of the sinus is generally possible, and thereby the
subsequent step of entering the antrum rendered absolutely
safe. After the operation the cavity is packed with iodo-
form gauze and a bandage applied.
Of the forty-one acute cases, forty remained aseptic
during the entire process of healing, which, on an average,
lasted four weeks. Throughout that time neither the wound
nor the ear was syringed. The packing was removed every
fourth day and replaced by fresh gauze. The profuse dis-
charge from the middle ear ceased immediately after the
operation in every case. It is obvious, then, that in these
cases we have not to deal with a disease of the osseous walls
nor ossicles of the middle ear, but that the pus formed in
the mastoid is only discharged through that channel. Fur-
thermore, I have learned from these operations that the
large incision over the mastoid may be immediately closed
after the operation. This I intend to do in the future.
The fact that very extensive disease may exist in the in-
terior of the mastoid process without the presence of any of
the outward signs demanded by our text-books is shown by
the two cases of central caries without apparent disease of
the middle ear. Tenderness of the mastoid was the only
symptom present at the time of operation. In fact, this
local tenderness is the only symptom common to all cases
of mastoid disease. Redness and swelling of the soft parts,
local pain, headache, and high temperature may or may not
be present. Tenderness, however, is a constant factor in
this variety of local possibilities, and if, in spite of the em-
ployment of the ordinary means to combat it, this symptom
persists, it is an indication for operative interference.
THE CLIMATE OF BERMUDA.
By H. E. MATTHEWS, M. D.,
ORANGE, N. J.
The object of this paper is to present to the profession
a short study of the climate of Bermuda from a physician's
point of view. This is the season when people begin to
flock to Bermuda for their health ; many of these return bene-
fited, but to many others it is the worst place they could
have chosen, because they lacked knowledge of the place.
The Bermudas are a group of small islands situated in
lat. 32° 14' 45" N., and long. 64° 49' 55" W. They are
said to number about three hundred and sixty-five, but only
a few are habitable, the remainder being mere points of
rock unfit for habitation. Geographically, these islands
form a lagoon, being surrounded by a barrier reef contain-
ing a central inclosure of water which is subdivided by the
various islands into two fine harbors. To this formation
they owe their importance as a military and naval strong-
hold. They are of coral formation, and consist of a basis
of coral limestone, with a topsoil of fine coral sand and ani-
mal and vegetable detritus.
The largest of these numerous islands is Long Island, or
Great Bermuda, which is twelve miles in length and about
two miles in average breadth. The capital, Hamilton, is
situated on this island.
The other principal islands are St. George, on which is
tlu' town of the same name; David's Island; Ireland Isl-
and, noted for its famous dockyard ; and Somerset Island.
Jan. 2, 1892.]
MATTHEWS: THE CLIMATE OE BERMUDA.
13
These islands are about seven hundred miles from New
York, and are reached by the steamers of the Quebec Steam-
ship Company, sailing from Pier 47 North River, every
Thursday between January 1st and May 1st, and fort-
nightly during the remainder of the year. The steamers
are well fitted, the table is good, and the officers and men
are kind and courteous to all. The agents of the line
arc A. E. Outerbridge & Company, 39 Broadway, New
York.
Mv. Stark, in his book on Bermuda, says:
It certainly was a striking change in the scene that our
voyage of sixty-five hours brought to us. We left New York
at 3 p. m. on Thursday. The ground was white with snow and
a raw northeast wind blowing, and on Sunday morning at sun-
rise we were floating on a glassy tropic sea, close to the isl-
ands. . . . Tropic, indeed, in one sense, these islands are. No
frost ever visits them. The palm, banana, orange, lemon, paw-
paw, India-rubber tree, with a profusion of flowers and vines,
only seen in our northern greenhouses, flourish here.
The population of these isles is about sixteen thousand
souls.
In a consideration of the climate of Bermuda the first
point to be noticed is the temperature. The Bermudas,
from their situation in mid-ocean and from the proximity
of the Gulf Stream, enjoy a very uniform temperature
throughout the year — the annual average being between
60° and 70° F. This compares most favorably with New
York, where we habitually meet with extremes of the tem-
perature within a few hours. It is indeed rare in Bermuda
to find the temperature below 50° F. The observations of
the British army, made at Prospect, give the range of tem-
perature as follows for 1889 :
Chart A. — Bermuda Temperature Chart, 1889.
Month.
Mean maxi-
mum shade
temperature.
Mean mini-
mum shade
temperature.
Actual maxi-
mum shade
temperature.
Actual mini-
mum shade
temperature.
Date.
Date.
69-6°
55-4°
74- 8"
10
48-0°
30, 31
68-0
53 6
74-2
19
47 5
27
71 4
56-1
76-0
16
46 8
1
77-0
61 4
84-0
23
57-5
13
80-2
63-0
84 4
1
58-0
11
84-1
65 3
89-0
15
61-0
8
July
85-7
69-6
89-2
4
67-0
2, 8, 23
88-3
70 5
93 5
28
65-0
9
86-6
71-3
91-2
13
65-4
27
81-7
66-7
87-0
2
63-8
11
78-7
64-1
83 5
10
59-4
26
74-2
59-3
80-2
21
54-2
29
a mean shade temperature of 79-4° F. The variations of
the temperature are insignificant when compared with many
of our health resorts, and to show this I have inserted tables
containing the winter temperatures of several places for
comparison with that of Bermuda. A glance will show the
uniformity of the temperature of Bermuda.
The tables in this article are compiled from the record's
of the United States Signal Service and the British Army,
and cover observations extending from seven to thirteen
years.
CHART C. — Comparative Table of Absolute Winter Temperature — Win-
ter rneaninff November, December, January, February, March, and
April.
Place.
Bermuda . . .
San Diego. . .
Jacksonville.
Nice, France
New York . .
Chicago
Boston
Yearly i Winter
average, average.
absolute
MAXIMUM
TEMPERATURE.
Highest, Lowest.
78-7c
85-6
84-5
70- 6
71- 0
70- 6
71- 9
73-r
66-6
76-8
51-5
50-3
50-6
ABSOLUTE
MINIMUM
TEMPERATURE.
Highest Lowest
58 -3C
47-0
45-6
25-6
25-6
18-6
52 -2C
34-3
28-8
35 5
2-3
-8-5
-5-0
Pos-
sible
winter
range in
degrees.
76-9
The coldest month is February, with a mean shade tem-
perature of 60-3° F. The warmest month is August, with
Chart B. — Comparative Table of Mean Winter Temperatures.
A careful examination of the tables will show that Ber-
muda enjoys a most equable temperature — even more so
than San Diego. Bermuda, with its shade temperature
rarely below 50° F. and never above 86° F., never hot or
never cold, possesses, perhaps, a more uniform temperature
than an)' other point on the globe.
Humidity. — Many authorities consider humidity of
more importance than the temperature in the consideration
of climate. It is certainly true that, in order to form a
correct estimate of the effects of a climate upon our pa-
tients, the amount of moisture in the air must be taken into
consideration, for it is well known that moist cold or
moist heat is not so well borne as dry heat or dry cold. In
Tab/e of Mean Humidity, Perccntar/e.
Place.
Annual.
Nov.
Dec.
Jan.
Feb.
March.
April.
73 4
72-2
72-0
750
76-5
77-0
77-1
San Diego
72-9
66-4
67 2
71-2
74-3
75-5
72-4
Jacksonville.. . .
72-0
74-8
73-7
74-6
70-6
65-4
67-2
62-4
63-0
65-9
59-9
55-7
60-4
New York
69-7
69-6
72 4
72-4
72-0
67-6
64-8
70-8
70-8
73-9
76-0
72-5
715
66-5
Boston
69-6
70-5
72-7
71-8
69-6
69-4
64-8
common with most islands and sea-coast towns, the air of
Bermuda contains a relatively high proportion of moisture.
The situation of these islands in mid-ocean and their small
November.
December.
January.
February.
March
April,
Place.
Max.
Min.
Av.
Max.
Min.
Av.
Max.
Min.
Av.
Max.
Min.
Av.
Max.
Min.
Av.
Max.
Min.
Av.
74-2°
60-3°
67-7°
72-
3°
57-0°
64
6°
69
5°
54-0°
66-7°
69"
0°
51-0°
60-
0°
69"
2°
51-7°
60-4°
72
0°
57-0°
64
0°
66-8
48-7
58-2
64
5
49-0
55
6
61
8
44 5
53 • 6
61
6
46-3
54
3
62
8
49-4
55-6
65
3
51-2
57
7
Jacksonville
70-4
55-3
61-7
66
4
49-4
55
8
64
9
48-2
55-8
68
5
52-1
58
1
73
6
56-2
62-7
78
4
61-5
69
0
68-0
30-0
49-5
66
0
26-3
46
6
65
6
25-6
45-6
67
3
25-7
46
5
75
0
26-5
50-7
75
0
35 6
55
3
New York
50-9
37-3
42 1
41
7
28-6
32
9
36
7
23-1
30-1
40
1
25-9
31
3
45
9
31-3
36 8
56
3
40-5
46
9
47-2
33 6
38-5
37
5
24-7
29
6
32
6
17-7
25 • 8
37
5
23-3
28
9
44
3
30 7
34-7
54
0
39-7
45
4
49-2
32-8
38-2
40
3
23-8
29
•5
35
3
17-0
26-4
38
6
20-1
28
1
43
2
26-7
34-2
53
2
36" 1
43
9
14
MATTHEWS: THE CLIMATE OE BERMUDA.
|N. Y. Med. Jouk.,
area are the causes of the high degree of humidity, for the
vapors constantly rising from the encircling sea are driven
over the islands by every wind that blows.
Rainfall. — The presence of such a high degree of moist-
ure is considered by many to predispose to rainfall ; but,
perhaps, the chief cause <>f rain in Bermuda is the prox-
imity of the Gulf Stream. The cold blasts rush down from
the north and strike the moist humid air in the vicinity
of the Gulf Stream, condensing its vapors and causing the
precipitation of rain.
From the preceding remarks the inference will be that
considerable rain falls in Bermuda ; a glance at the accom-
panying table will show this to be the case :
Table of (he Average Rain fall in Inches.
Place
Nov.
Dec.
Jan.
Feb.
March.
April.
Annual.
1-35
4-18
7-40
6-75
4-12
11-20
54-00
•70
2-12
1-85
2-07
•97
•68
9-49
Jacksonville. . . .
2-95
2-89
3-28
3-45
3-13
3-55
54-68
3-34
2-97
3-50
3-23
4-07
3-25
42-52
2-96
2-07
2-04
2 28
2-79
3-69
37-58
5-20
3-57
4-03
3-52
4-97
4-01
48-16
During the year 1889 there were 161 clear days, 57 over-
cast days, and 153 days on which rain fell. Although, as
shown by the table, considerable rain falls in Bermuda,
yet it is worthy of notice that a settled rain is the excep-
tion rather than the rule. The rain falls often, but in short
showers or "squalls," between which will be intervals of
sunshine. Moreover, from the porous nature of the soil,
the rain does not lie long on the surface, but percolation
and evaporation soon dispose of it. The large amount of
rainfall is a factor of importance to Bermudians. There
are no wells in the islands, and the inhabitants depend upon
the rain-water for drinking purposes. The rain is collected
in stone tanks, which are kept scrupulously clean — compar-
ing most favorably with such contrivances in our own
country.
Wind. — The prevailing direction of the wind is from the
southwest ; it also frequently blows from the northeast and
southeast. The wind is usually of a gentlec haracter and
not squally, but the liability of sudden gales in southern lati-
tudes must be borne in mind. In 1889 there were two gales.
I have made no study of the atmospheric pressure, as
this, at sea-level, is of more interest to the meteorologist
than to the physician.
Not among the least important points to be noticed in
studying a health-resort are the accommodations, food,
water, and society.
The accommodations are excellent. There are two fine,
well-managed hotels — the Hamilton and the Princess —
and also a number of smaller houses, where the visitor will
be well housed and fed. Those who do not care for the
bustle of hotel life will find many comfortable and home-
like boarding houses. The subject of water has been men-
tioned l>efore.
The air is remarkable for its purity and wholesomeness.
It is pure sea air, unadulterated by the dust and odors of
«»ur cities.
The roads are excellent and are unexcelled for driving
or bicycling; they wind about through nooks and crannies,
every now and then running out along the seashore, and
giving the traveler a glimpse of the azure-hued sea — the
beauty of which defies description.
The Bermudians are a refined, hospitable, and cheerful
people, and any visitor equipped with a few introductory
letters may be sure of receiving every attention.
To sum up, then, the climate of Bermuda is one of very
uniform and moderately warm temperature, of high humid-
ity, and frequent rainfall. From careful inquiry and per*
sonal study, I have made the following conclusions concern-
ing the effect of a visit to Bermuda upon patients suffering
from various illnesses.
Phthisis. — The death-rate (total) of Bermuda is from
\x to 21 per 1,000. The death-rate from phthisis and al-
lied tubercular complaints is about 2'."i per 1,000, and these
diseases occur for the most part in the colored population.
The greater proportion of deaths are due to diseases inci-
dental to old age, these being mentioned in the government
reports as "old age," "senile debility," "general debility,"
and other indefinite diagnoses. The general opinion con-
cerning the climatic treatment of phthisis appears to be
that these patients do not do well in low, moist climates.
It is so in Bermuda ; phthisis, as a rule, does not do well
there ; but some patients with incipient phthisis — with
slight consolidation of the apex, with little or no expectora-
tion, and with a tendency to haemorrhage — are often greatly
benefited by a residence in Bermuda. But all patients with
phthisis which has progressed to any extent, and more par-
ticularly those in whom the lung tissue has begun to break
down, will receive more harm than benefit from a visit to
Bermuda.
Bronchitis and Asthma. — On the other hand, cases of
bronchitis and asthma, with or without cardiac complica-
tions and emphysema, do well in Bermuda, particularly if
the expectoration is scanty.
Patients with pleurisy in which the effusion remains
unabsorbed are very much benefited, and go on to complete
recovery in Bermuda.
Rheumatism, Gout, and Neuralgias. — These complaints
will not, as a rule, be benefited by a visit to Bermuda.
These patients will do better in a climate not so humid as
that of Bermuda.
Cystitis and Nephritis. — Patients suffering with cystitis,
stone, and the various forms of nephritis, may receive con-
siderable benefit as regards their general health. They gain
tiesh and strength, sleep well, and very often receive perma-
nent relief.
Patients troubled with stomach disorders do well, as a
rule ; but those with intestinal disorders will do better in a
colder climate.
But it is in Bermuda especially that convalescents,
hypochondriacs, overworked business men, and victims of
neurasthenia ami mental depression, will find a haven for
rest and health. They are shut off from the rest of the
world, and have nothing to do but to eat, sleep, and partake
of the various outdoor sports. These people, relieved of
their cares, soon become cured, and to them, above all, Ber-
muda proves a true Bimini — a veritable fountain of health.
Jan. 2, 1892.]
SHIRLEY: FATAL HEMORRHAGE AFTER SCARIFICATION.
15
FATAL B^EMOKEHAGE IN AN INFANT
AFTER SCARIFICATION OF THE CONJUNCTIVA.
By I. A. SHIRLEY, M. IX,
WINCHESTER. KY.
Alice B., mulatto, priuripara, aged eighteen, was delivered
September !>, 1890, of a well-developed girl baby, weighing
eight pounds. Labor normal in every respect, save an occipito
posterior position of vertex presentation which naturally pro-
longed it. Puerperal convalescence was uneventful. Within a
few days of birth the babe exhibited characteristic "snuffles,"
which it came by honestly, as both parents were known to be
syphilitic. When about two weeks old I prescribed a weak
zinc and morphine collyrium for what I supposed, from descrip-
tion given me, was acute conjunctivitis. After being reported
better I heard nothing more of it until called a month later to
prescribe for its bad sore throat, which, however, did not exist.
The eyelids were closed, and I was informed were seldom opened
at all, and then to a degree scarcely perceptible. The exterior
of the upper lids was putted up, resembling very much the condi-
tion frequently seen and occasionally experienced by some of us
country chaps when approximating too closely our optics to t lie
abode of the bumble-bee. On separating the lids, quite a quan-
tity of pus was discharged and the mucous membranes were
enormously swollen. Palpebral conjunctiva? were freely scari-
fied, and sulphate of copper in substance applied. The flow of
blood at this time was pretty free, but not too much, and it was
directed to be let alone for a while, as a tolerably thorough
evacuation was desired. This was about 9 a. m. At 12.:i0 p. m.
the mother informed me that she believed her babe would bleed
to death; I accompanied her to her home at once, and found
her fears well grounded. Blood was flowing freely, terrifically
from the conjunctival incisions; blood in clots, fluid blood came
in a free, continuous, steady stream The lids were thoroughly
everted, and sponges, wrung out of water as hot as could be
borne, forcibly applied to the bleeding surfaces; this availing
nothing, ice was similarly tried, with a like result. Persulphate
of iron, in powder and solution, were each in turn given a thor-
ough trial, only to prove disappointing. The bleeding could be
plainly seen issuing from
transverse incisions near
the superior palpebral
fold. The everted mu-
cous membranes were
approximated in such a
way that a needle, curved
at the point and armed
with a stout silk thread,
could be passed well be-
neath the bleeding areas,
and the upper and lower
conjunctiva1 were firmly
united by four inter-
rupted sutures in either eye. There was but little haem-
orrhage from the lower lids, but it was considered best to
stop every possible leak, however insignificant, and as a means
to an end, and to expedite matters, the needle was made
to traverse both lids and unite them. As the needle transfixed,
as it were, not more than a quarter of an inch of each con-
junctiva, the lids remained everted after sutures were tied.
Haamorrhage was now effectually and permanently stopped.
My friend Dr. MeKinley, who at this time kindly saw the
case with me, and I thought, from the fair condition of the
heart's action, that the little one would recover, barring a recur-
rence of the haemorrhage. It was given a small dose of ergot
and a stimulant, with an opiate to quiet it, and a light water
dressing applied to rather hideous-looking eyes. The stimulant
and ergot were to be repeated at regular intervals. I was re-
quested, tv.'O hours later, to remove the stitches from the dead
babe's eyes, who at this time showed the blanched, pale color
characteristic of great loss of blood.
The query with me is, Was it of the family of bleeders \
Could not the lids in persons of the non-hamiophilic type
be entirely removed without fatal or even severe loss of
blood \ Haemorrhage after scarification for purulent or
granular conjunctivitis is not mentioned by any authority to
whom I have access or been referred. Noyes, Wells, Mc-
Namara, DeWccker, Swanzy, and George JBerry, while men-
tioning' the procedure, say nothing of hemorrhage. Dr. C,.
E. De Schweinitz, of Philadelphia, in a recent number of the
Medical Record, reported a case of dangerous and alarming
haemorrhage from the application of nitrate of silver to
purulent conjunctivae in an infant of six weeks. Darnier,
in the St. Louis Medical Review, advises deep incisions and
scraping with sharp spoon in granular conjunctivitis, but
says not a word about haemorrhage. Dr. Robert Sattler, of
Cincinnati, has observed persistent haemorrhage after en-
tropium and trichiasis operations, but not after simple scarifi-
cation. Therefore, from what I have been able to glean, I
believe the case to be unique, and shall henceforth keep a
watchful and suspicious eye, for some hours at least, on
every conjunctiva that I scarify.
A CASE OF PTYAL1SM BY COLCIJICUM.
By JOHN SHANE), M. D.,
EDINBURGH, SCOTLAND.
" Colchicum occasionally acts as a diuretic and
expectorant, and a case is on record of violent sali-
vation supposed to have resulted from its use." —
Dnited States Dispensatory, 1887, page 886.
The following case bears out the confirmation of the
conjecture expressed in the above-given quotation. This
conjecture has been extremely interesting to me, as it is the
only instance, in the human subject, of such a probability
that I can find recorded in our huge library of the College
of Physicians. I say in the human subject advisedly, for
there is a record in the last century of two dogs being pro-
fusely salivated by colchicum. This, as I consider it,
valuable suggestion appears never to have been acted upon.
My case occurred over twenty years ago, while engaged
in a very large general practice in the south of Scotland.
I was called to see a lady a little past middle life who was a
patient sufferer from an acute pain in the left hypochondriura,
with oedema of the ankles. The oedema soon became general
dropsy and the pain continued. So acute was this pain that its
increase on movement of any sort terrified her into refusing to
go to bed, as she preferred resting her body on one easy chair
and her feet on another. This had been the case lor over two
months before I saw her.
Careful examination revealed no organic lesion or affection,
and, as the dropsy had become alarming, I prescribed all the
usual diuretics with but partial and passing effect. I felt a crisis
threatened soon, and spent a little time in industriously listening
to an account of all the ailments of her past life, and I could
It')
BUR WELL: DIABETES MELLITUS, AND TREATMENT.
[N. Y. Med. Joue.,
not but remark that there was a thread or trace of rheumatism
or gouty rheumatism indicated in all. An anxious considera-
tion and reflection decided me to treat this recognizable thread
alone for a little, and I selected colchicum as my remedial agent,
and resolved to use it with every care and justice alike to pa-
tient and medicine, which I have learned as an apprentice to my
father to regard with a degree of veneration in cases of that
character, if wisely prescribed. In addition, from my long ex-
perience of Fleming's strong tincture of aconite, I considered it
best to use the tincture of colchicum seed in a similar way.
I began with one minim every eight hours, guarded by a
triple multiple of aromatic spirit of ammonia (with respect to
cardiac action). This went on with regularity and precision till
the twelfth day, when a wonderful improvement was apparent
in the dropsy, and the patient invited my attention to the con-
temporaneous profuse salivation.
On the sixteenth day dropsy and pain had alike totally dis-
appeared.
I should mention that by the eightirday the pain was so re-
lieved that she voluntarily took to bed at night, reserving her
chairs for day.
In conclusion, she survived eight or nine years without any
return of her old ailment, and her death seemed occasioned by
a gradual decline of strength after a slight chill. She knew me
three hours before her death, when I happened accidentally to
be in the South and passing that way.
Since those days I have had many cases in which,
though not so urgent as this, I have prescribed colchicum in
the same way — beginning with one minim and going on till
some physiological effect was produced, whether pain in the
epigastrium, nausea, a diarrhoea, or, best of all, total allevia-
tion of pain.
It is important to annotate that I tested the ptyalism
more than once by diminishing the dose of colchicum, or
increasing it, and I each time found a corresponding re-
sponse.
The above-given case appears to me a good text for
further treatment by colchicum in rheumatic gout, especially
if accompanied with dropsy, though it need not be with-
held till dropsy is ushered in.
REPORT OF A CASE OF
DIABETES MELLITUS, AND TREATMENT.
By J. PAGE BUR WELL, M. I).,
WASHINGTON, D. C.
Mks. L., widow, aged fifty-five, was in March, 1890, confined
to bed, complaining of severe pains in all of her limbs and in her
back. Her tongue was red and glazed, and micturition was
frequent. Upon examining the urine, I found the specific
gravity 1-0-48, and the reaction acid. A test with Fehling's
solution showed a large quantity of sugar.
1 prescribed three grains of gallic acid and one grain of
aqueous extract of opium in capsules three times a day; also
two grains of ergotine night and morning.- The diet consisted
of milk, beef-tea, and gluten bread. Under this treatment the
sugar gradually disappeared until September, 1890, when the
specific gravity was found normal, and there has not been a
trace of sugar since, although 1 have made frequent tests. All
treatment has been discontinued since November, 1890, and she
has not been restricted in diet since January, 1891. She sleeps
well, is free from pain, and has a very healthy appearance.
THE
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by Edited by
t) Appleton & Co. Frank P. Foster, M. D.
NEW YORK, SATURDAY, JANUARY 2, 1892
UNSUSPECTED GALL-STONES.
Dr. Joseph M. Price, of Philadelphia, presented at a recent
meeting of the Philadelphia County Medical Society several cases
of abdominal section. His paper, with the discussion, has been
published in the Medical and Surgical Reporter for December
12th. His most striking case was one of obstinate obstruction
of the bowels the true cause of which was a large biliary calcu-
lus which was not suspected until the operation was well
under way. The patient was a woman of forty-five years, hav-
ing pain and some extension of the normal area of dullness over
the hepatic region. There was no jaundice, fever, vomiting, or
tympanites, but there was slight weakening of the heart's
action. Large and frequent doses of cathartics had been given
without avail. The patient's general condition was good, but a
very anxious facial expression began to assert itself. The
patient desired that something radical be undertaken for her
relief. An abdominal section was done in the hepatic region.
The incision, two inches long, almost immediately disclosed a
greatly distended gall-bladder. This was tapped, and the con-
tents proved to be a clear gelatinous fluid, without any of the
characteristics of bile. The gall-bladder was examined and two
large stones and one small one were removed. The direct
cause of the intestinal obstruction was the pressure of this en-
larged bladder, with its gall-stones, over and upon the trans-
verse colon, the anterior abdominal wall yielding but slightly
and causing all or nearly all of the effects of overdistention, as
the gall-bladder gradually enlarged, to be expended on the
colon, thus creating as complete an obstruction as had ever
been met with by Dr. Price.
Dr. Price speculates regarding the possible outcome of the
case if the operation had not been resorted to and if the pa-
tient had survived long enough for protective adhesion to take
place between the gall-bladder and the bowel. The transverse
colon was in contact with the gall-bladder, and was therefore
favorably located for that form of " Nature's cure " which is
obtained through inflammatory adhesion, ulceration, and dis-
charge of the calculus it. to the adjacent or underlying intestine.
In not a few such cases the adhesion does not take place at the
" point of election," so to call it, and a leakage of bile into the
peritoneal cavity may cause disastrous results. Or the ulcera-
tive process may be excessive, and a defective coaptation of the
organs in question may permit of an escape of the stone or
stones into the peritoneal cavity. Or, again, both the adhesive
and the ulcerative processes may be conducted safely and the
stone be lodged in the intestine — the ileum, for example —
and there cause complete obstruction and a fatal result. Two
cases of this last-named accident have been observed by Dr.
Jan. 2, 1892.)
LEADING ARTICLES.— MINOR PARAGRAPHS.
17
James Collins, of Philadelphia, within the last ten years, and lie
believes that deaths from similar conditions are not infrequent.
These are the instructive points to be gleaned from the
paper and discussion given in the Reporter. One other point,
bearing upon the remedial influence of operative interference,
is the proposition of Riedel, in the Centralblatt far Chintrgie,
No. 21. He refers to those attacks of pain and digestive dis-
turbances that depend upon old adhesions, bands, etc., on and
about the gall bladder. In thirty-six abdominal sections for
diseases of the gall-bladder and gall-ducts he has found no
fewer than fifteen cases of adhesion, of which nine existed be-
tween these organs and the omentum, four with the bowel,
and two with the abdominal wall. These adhesions are not of
necessity connected with severe inflammatory processes — far
less with suppurative changes — but may have been produced by
a catarrh of the gall-bladder, with or without the existence of
calculi. Riedel advocates a more frequent employment of
laparotomy in cases of obscure abdominal diseases, in the belief
that many of them are due to bands thus surreptitiously
formed, and thinks that a degree of relief out of all proportion
to the apparent structural disturbances can be accomplished by
discovering and breaking up these adhesions.
SO-CALLED " HYDRARGYRUM LACTATUM."
A casualty from the misuse of drugs is reported from Bay
City, Michigan. Somebody blundered, and somebody else lost
his life ; so says the Western Jiruggist. A physician of that
town fell into the habit of prescribing "hydrargyrum lacta-
tum," meaning thereby a preparation furnished by a Chicago
dealer in drugs which is said to contain one part each of calo-
mel and of bismuth subnitrate and eight parts of milk sugar.
This did no harm so long as the prescriptions were taken to the
shops where the Chicago specialty was known. But the day
came when a change in pharmacists was made by the patient.
The new pharmacist , ordered through his wholesale dealer a
bottle of " hydrargyrum lactatum," and received a supply of
Merck's " lactate of mercury." Merck's catalogue contains that
item, with the price marked at $1.00 an ounce. Chemistry rec-
ognizes "hydrargyri lactas," or mercurous lactate, and, although
it is not often heard of in medicine, Watts's Dictionary of
Chemistry describes its composition and properties. This prep-
aration was dispensed three times before any injurious effects
were noticed, but the fourth dispensing of it was followed by
the death of the patient. An analysis of the drug is said to,
have shown the presence of mercuric lactate as well as of the
mercurous salt, and it is suggested that a reduction had been
going on in the bottle after it left the wholesaler's hands. If
this is the fact, and can be proved, it will tend to lighten the
condemnation launched by the Western Drvggist against the
conductors of the Chicago drug house for its " criminally reck-
less terminology," in that they adopted a harmful name to cover
a comparatively mild " specialty." It will also tend to lighten
the feeling of responsibility for this particular "accident" in
the mind of the physician, against whom the Druggist alleges
that his conduct was "little less than criminal," because he pre-
scribed a substance about which he really knew nothing. There
seems to be a fatality about nearly all these " specialties, or
combinations made by some know n-to-us-alone process"; sooner
or later, they become the occasion of loss of life, or they get
everybody into trouble who has anything to do with them. The
remedy of known composition is not always safe, but it com-
ports more thoroughly with the dignity of the profession to em-
ploy it, so that even if perchance a casualty should follow its
legitimate use. it will not be necessary to resort to that most
idiotic of excuses, " I did not know it was loaded " — the plea
of those who point pistols at their best friends and kill them !
MINOR PA RA GRA PUS.
INFLUENZA AND THE BIRTH-RATE.
Thk year 1890 did but little to arrest the impending depopu-
lation of France. Four months of it were signalized in Paris
by a lower birth-rate than at any period during the five preced-
ing years. There are, on an average, a thousand children born
in Paris every week, and sometimes eleven or twelve hundred.
The forty-first week of 1890 told a different story. There were
only seven hundred and eighty-seven births. One author con-
siders this due in great measure to losses of men in the Franco-
Prussian war, affirming that, about twenty-five years after war,
pestilence, and famine, there is always a deficiency in the birth-
rate, owing to the absence of children of the fallen, who would
in one generation themselves become fathers. To this Dr.
Roeser fails to agree, and in the Revue generate de clinique et de
therapeutique for December 9, 1891, gives an interesting dia-
gram illustrating the falling off in the birth-rate, which he as-
cribes to the influenza that reigned in Paris from the 26th of
November, 1889, to the early days of February, 1890. His ob-
servations form an interesting contribution to the statistics of
epidemics and natality.
PILOCARPINE AS A REMEDY FOR RABIES.
In the November number of the Indian Medical Gazette
Assistant Surgeon Troylucko Nath Ghose gives an account of a
case of supposed rabies in which recovery followed the use of
eleven subcutaneous injections of pilocarpine hydrochloride, of
a fifth of a grain each, in the course of seven days. The author
remarks that in the course of his twenty-five years' practice he
has seen probably not fewer than twenty cases of rabies, but
has never before succeeded in curing one, and lie adds that he
has never known of a recovery from the disease in India. He
was led to use the drug in this case by seeing it mentioned in
Martindale's Extra Pharmacopceia as having effected a cure in
two cases out of four. Before resorting to it, and before the
spasms had come on, he excised the cicatrix that had formed as
the result of the bite, and kept the sore open for two weeks,
with the effect of stopping a shooting pain that had been felt in
the scar.
THE NEW JERSEY STATE BOARD OF MEDICAL EXAMINERS.
Tins board has just reported to the Governor on the opera-
tion of the medical-practice law of 1890. It is stated that over
a hundred physicians have been allowed to register in the old
way, because the county clerks were unable or unwilling to dis-
criminate between fraudulent and legal diplomas, though BUoh
registration does not entitle the person registered to practice
18
MINOR PA RA GRA PUS. — ITEMS.
[N. Y. Med. Jctoh.,
medicine. Of the 2,500 legalized physicians in the State, ten
per cent, are registered on bogus or fraudulent diplomas. The
board examined 101 candidates, issued 82 licenses to practice
medicine in the State, and 3 licenses in the preliminary
brandies, and rejected 16 candidates. It is to be hoped that
public sentiment will support the board in it* efforts to protect
the community from quacks and incompetent men.
THE MEDICAL CORPS OF THE NAVY.
The Report of the Chief of the Bureau of Medicine a ml .Sur-
gery for the year 1890, dated October 7, 1891, is a pamphlet of
rather mure than a hundred pages. It contains the usual tabu-
lar matter, an account of the health of the force, and interest-
ing reports from the medical officers in charge of various sta-
tions and individual vessels. It seems that during: the year
1,422 persons were on the sick list with influenza, among whom
there was only one death. On the average, the men were off
duty on account of this disease between five and six days, mak-
ing a total of 7,719 days lost to the service.
MERITORIOUS SERVICES BY ARMY MEDICAL OFFICERS.
In a recent list issued by the Major- General commanding
the Army, giving the names of officers and enlisted men who
distinguished themselves by specially meritorious acts or con-
duct in service in 1890 and in the more recent Indian campaign
in South Dakota, are mentioned the names of Lieutenant-Colo-
nel Dallas Bache and Major J. Van R. Hoff, surgeons, and Cap-
tain H. P. Birmingham and Captain W. L. Kneedler, assistant
surgeons.
ITEMS, ETC.
The Sloane Maternity Hospital. — It is announced that five sum-
mer courses, each lasting four weeks, will he open to physicians and
advanced students. Each class is positively limited to six. The five
courses will be the same, so the only choice is in regard to the time.
The courses begin on May 2, June 1, July 1, August 1, and September
1,1892. Each course offers the following advantages: I. Twenty les-
sons in operative obstetrics (live each week). Each student in turn will
practice upon the phantom all the common and most of the rarer ob-
stetric operations. Special endeavor will be made to render these ex-
ercises of the greatest practical value. II. Attendance at all birth* in
tin hospital (about fifty may be expected in four weeks). Clinical in-
struction and every facility for observation of births, normal and ab-
normal, will be given. III. Instruction in the treatment of puerperae
and infants. Students in turn will make rounds daily with the house
staff. IV. Instruction in abdominal palpation and auscultation and
vaginal touch. Examination of gravidas will be practiced daily by
each student in turn. For further information application may he
made in person or by letter to Dr. E. A. Tucker, at the hospital.
The Metropolitan Medical Society. — This society, which meets fort-
nightly, is limited to a membership of eighty. Officers for the ensuing
year were recently elected as follows : Dr. F. A. McGuire, president ;
Dr. William Cowen, vice-president ; Dr. F F. Marshall, recording sec-
retary ; Dr. Henry S. Stark, corresponding secretary ; and Dr. H. N.
Vineherg, treasurer.
The Alumni Association of Mt. Sinai Hospital held its first annual
dinner at the Arena on December 7th. About thirty gentlemen were
present. Dr. Alfred Meyer presided.
The Obstetrical Society of Leipsic. — At the four hundredth meeting
of the society, held on October 19, 1891, Dr. Paul F. Munde, of New
York, was elected a corresponding fellow.
The Death of Dr. Robert A. Kinloch, of Charleston, took place on
December 23d. He was in the sixty-sixth year of his age. He had
been the professor of surgery at the South Carolina Medical College and
surgeon-in-chief of the Roper Hospital so long that he occupied without
dispute the leading surgical position in his State. He was at one time
president of the State Medical Society. During the late war he was
medical director of the South Atlantic Division in the Confederate
service.
The Death of Dr. Simon T. Clark, of Lockport, N. Y., took place on ■
Thursday, December 24, 1891. He was fifty-five years old, was born
in Canton, Mass., and was graduated from the Berkshire Medical Col-
lege in 1861.
The Death of Dr. Buckminster Brown, of Boston, occurred at Au-
burndale, Mass., on Thursday, December 24, 1891. He was seventy-
two years old, was born in Boston, and was graduated from the Hai vard
Medical School in 1844.
The Death of Sir James Risdon Bennett, M. D., F. R. S., is an-
nounced in the British Mnliral .Journal as having taken place recently.
The deceased, who was an ex-president of the Royal College of Physi-
cians, was eighty-two years old.
Army Intelligence. — Official List of Change* m th< Stations and
Duties of Officer* serving in t/te Medical Department, United Stale*
Army, from December 13 to December 26, 1891:
By direction of the Acting Secretary of War, a Board of Medical Offi-
cers is constituted, to consist of —
Ikwin, Bernard J. D., Colonel and Surgeon; Alden, Chari.es L.,
Lieutenant-Colonel and Surgeon; Girard, Alfred C, Major and
Surgeon ; and Bradley, Alfred E.. First Lieutenant and Assistant
Surgeon — to meet at Headquarters Department of the Missouri,
Chicago, III., on February 1, 1892, for the examination of candi-
dates for admission to the Medical Corns of the Army, and for such
other business as the Surgeon-General may desire to bring before it.
Mearns, Edgar A., Captain and Assistant Surgeon. By direction of
the Acting Secretary of War, so much of Par. 1, S. O. 265, A. G. O.,
November 13, 1891, as directs him to report to the commanding
officer, Fort Mackinac, Mich., is revoked; he will proceed to El
Paso, Texas, and on arrival there report for duty to Lieutenant-
Colonel John W. Barlow, Corps of Engineers, member of the com-
mission appointed for the location and marking of the boundary be-
tween Mexico and the United States.
Wales, Philip G., First Lieutenant and Assistant Surgeon, is granted
leave of absence for one month, with permission to apply for an
extension of one month.
Gardner, Edwin F., Captain and Assistant Surgeon, is, by direction of
the Secretary of War, relieved from further duty at Fort Porter,
N. Y., and also from temporary duty at Fort Columbus, N. Y., to
take effect upon the arrival at that post of Fisher, Walter W. R.,
Captain and Assistant Surgeon, and will then proceed to Fort Mack-
inac, Mich., for duty.
Robinson, Samuel A., Captain and Assistant Surgeon, is granted leave
of absence for twenty days, to take effect on or about January 2,
1892.
Society Meetings for the Coming Week :
Monday, January jfth : German Medical Society of the City of New
York ; New York Academy of Sciences (Section in Biology) ; Mor-
risania Medical Society (private) ; Brooklyn Anatomical and Sur-
gical Society (private); Utica, N. Y., Medical Library Association;
Corning, N. Y., Academy of Medicine; Boston Society for Medical
Observation ; St. Albans, Vt., Medical Association ; Providence,
R. I., Medical Association ; Hartford, Conn., Medical Society ; Chi-
cago Medical Society.
Tuesday, January 5th : New York Obstetrical Society (private) ; New
York Neurological Society ; Elmira, N. Y., Academy of Medicine ;
Buffalo Medical and Surgical Association; Ogdensburgh, N. Y.,
Medical Association ; Medical Societies of the Counties of Broome
(quarterly) and Niagara (semi-annual — Lockport), N. Y. ; Hudson
(Jersey City) and Union (quarterly), N. J., County Medical Societies
Chittenden, Vt., County Medical Society ; Androscoggin, Me., County
Medical Association ; Baltimore Academy of Medicine.
Jan. -2, 1892.]
PROCEEDINGS OF SOCIETIES.
L9
Wkdnksday, January Glh : Society of the Alumni of Bellevue Hospital ;
Harlem Medical Association of the City of New York; Medical
Microscopical Society of Brooklyn; Medical Society of the County
of Richmond (Stapleton), N. Y. ; Bridgeport, Conn., Medical Asso-
ciation; Penobscot, Me., County Medical Society (B.mgort.
Thursday, January 7th: New York Academy of Medicine; Society of
Physicians of (lie Village of Canandaigua, X. Y. ; Brooklyn Surgical
Society; Bo ton Medico-psychological Association ; Obstetrical So-
ciety of Philadelphia; United States Naval Medical Society (Wash-
ington); Washington, Vt., County Medical Society (annual — Mont-
pelier).
Friday, January 8th: New York Academy of Medicine (Section in
Neurology); Yorkville Me lical Association (private); German Medi-
cal Society of Brooklyn ; Medical Society of the Town of Sauger-
ties, N. Y.
Saturday, January 9th: Obstetrical Society of Boston (private);
Worcester, Mass., North District Medical Society.
jproccebings of Societies.
SOUTHERN STTKGICAL AND GYNAECOLOGICAL
ASSOCIATION.
Fourth Annual Meeting, held in Richmond, Va., November 10,
11, and 12, 1891.
The President, Dr. L. S. MoMurtry, of Louisville, Ky., in the
Chair.
(Concluded from vol. Uv, page 723.)
The Pedicle in Hysterectomy.— Dr. I. S. Stone, of Wash-
ington, D. G, read a paper on this subject, in which the three
principal methods were described and illustrated by colored
drawings, showing the arrangement of the pedicle in the ab.
dominal wound. The author alleged a revival of interest in the
operation and said that there was need for its frequent perform-
ance. The statistics were far better now than those of ovari-
otomy after it had become an operation of election and was
firmly planted in public favor. Particular attention was given
by the author to tying off the broad ligaments and the use of
the elastic ligature. Sewing the parietal peritonasum to that of
the pedicle in the extraperitoneal cases was also dwelt upon.
The method by ventrofixation had given good results in the au-
thor's hands and served to accomplish two important purposes
— viz., a speedy convalescence and avoidance of the disagreeable
sloughing which f jllowed the use of the wire clamp. It might
also be used in some cases of short pedicle where the wire
might not easily be applied. The methods were compared and
statistics furnished, showing that the extraperitoneal method
with wire and pin gave better results than either of the others,
and that ventrofixation came next and the intraperitoneal method
last, with a large mortality. A method of closing the capsule
over the stump was described, which the author stated would
answer for either dropping it or sewing it into the wound —
ventrofixation. In the latter case the suspensory sutures were
placed and the pedicle was sewed in, and under the lower end
of the abdominal incision. Great care was required in closing
the capsule over the raw surface of the stump so that separation
might not occur. Owing to the peculiar contractile nature of
the capsule, car" must he taken to leave sufficient length for ap-
proximation of the peritoneal surfaces.
The uterine arteries were to be tied in any case when heem-
orrhage was likely to occur and drainage might be required,
besides reference to methods, the author described the process
through which the wound passed after supravaginal hyster-
ectomy. All myomatous tissue should be removed, which
could only be effected in some cases by a process of reduction
of the pedicle. This was very important, as in the operations
where a large amount id' myoma was left more time was re-
quired for atrophy and absorption to reduce the pedicle to its
proper size. Great danger to the patient was apt to follow
where a broad base of the tumor was left in either method of
treatment, because this mass must he disposed of before the
patient could entirely recover. The author had observed a suf-
ficient number of cases to declare that permanent fixation of the
stump to the abdominal wall was the rule where the extra-ab-
dominal methods were used, and especially when the broad
ligaments were cut away to prevent traction.
A Plea for Progressive Surgery was the subject of the
President's address. Dr. McMurtry said that within fifteen
years the entire practice of surgery had been revolutionized.
New methods had been introduced and new regions invaded ;
comparatively recent teachings had become obsolete in prac-
tice and modern treatises had been recast. The science and art
of gynaecology, which a few years since had been limited to a
small and narrow field, had grown into a great branch of medi-
cal science and practice. Formerly divided between midwifery
and surgery, as a minor branch of one or both, gynaecology had
become an independent and essential department of the heal-
ing art.
When Marion Sims announced through the columns of the
British Medical Journal that he believed the proper course of
treatment in every case of gunshot wound of the abdomen
was to open the stomach, search for the bleeding points and
secure them, and suture intestinal perforations, he had been pro-
nounced by many eminent surgeons to be a dreamer. The sug-
gestion of Sims had been most timely, and shortly afterward Bull
had successfully executed the operation. For years the treat-
ment by opium in full doses had been pursued, with death in
waiting. Now there was scarcely a State in the Union in which
one or more patients had not been rescued from certain death
by prompt resort to operative treatment. He mentioned these
circumstances to illustrate and emphasize the point that surgery
was advanced more by the aggressiveness of the surgeon than
by timidity. In the face of desperate conditions of disease and
injury, where there could be no safety whatever in delay and
palliation, the only treatment worthy of consideration was the
aggressive course which promised success. Under such condi-
tions the most heroic surgery was conservative and any other
course was not conservative.
The Growth of Fibroid Tumors of the Uterus after the
Menopause. — Dr. Joseph Taber Johnson, of Washington, D.
C, followed with a paper on this subject, in which he said that
the object of the paper was to put on record cases and opinions
in opposition to this view of this important subject and to aid
in recasting our views and in modifying our practice. He had
within the past five years seen at least a dozen women with
large growing and troublesome fibroid tumors of the uterus
who were over fifty years of age, some of them over sixty.
These women had been assured by their physicians that if they
could get along somehow until after the change of life their
tumors would not only stop growing, but that they would lessen
in size, and probably go away altogether, at least the trouble-
some and dangerous symptoms would disappear. They had
been advised against any radical operation, and encouraged to
believe that as they grew older they would get entirely well.
In perhaps the majority of cases this might prove to be very
good advice, but the point which the author wished to make
was that, as we were now better acquainted with the history
and behavior of these tumors, this was no longer safe advice to
2()
PROCEEDINGS OF SOCIETIES.
[N. Y. Med. Jouk.,
give. We could assure any woman that her tumor might not
prove to be one of the exceptional cases, and that it might not
grow more rapidly even after the menopause than it had before,
or that it might not present complications equally distressing or
disastrous. When from forty to fifty per cent, of women sub-
jected to supravaginal hysterectomy died from the effects of the
operation this was very safe and conservative counsel to follow.
The possible dangers of the tumor were not equal to the proba-
ble dangers of the operation.
The author drew the following conclusions:
1. That the "rule" stated in the text-books, that uterine
fibromata ceased to grow after the menopause, had many more
exceptions than was generally supposed.
2. That when they continued to grow after the menopause
they pursued a more disastrous course than before.
3. They more frequently became cystic, calcareous, or had
abscesses develop in them.
4. These conditions requiring operation according to well-
known rules of surgery, the patients were in a less favorable
condition for recovery than before the menopause.
5 If the above-given conclusions were admitted to be true,
it must follow that they furnished additional indications for
more frequent and earlier resort to the radical operation.
In the hands of the best operators in cases where a pedicle
could be secured the mortality of supravaginal hysterectomy
was rapidly approaching that of ovariotomy.
The Surgical Treatment of Anterior Displacements of
the Uterus. — Dr. 0. A. L. Rekd, of Cincinnati, read a paper
on this subject. He said anterior displacements of the uterus,
when they existed to the pathological degree, were the oppro-
bria of gynaecology. It was indeed true that many wombs
leaned far forward without inducing symptoms, but it was
likewise true that many of them that were thus malposed did
entail symptoms, objective and subjective, that frequently
baffled our resources. It was a misfortune, too, that of all
the displacements to which the wound was liable, those in
which the organ deviated anteriorly to the normal axis were
vastly the more prevalent. Thus, in an aggregate of four hun-
dred and ninety-four cases by Nonat, Meadows, Scanzoni, Val-
leix, and Hewitt, quoted by Thomas and Mund6, there were
two hundred and ninety-four antefiexions and one hundred and
eighty retroflexions, while Munde himself reported two hun-
dred and ninety-four antefiexions, thirty-three retroflexions, and
ten lateroflexions in a total of three hundred and thirty-seven
cases. As the latter authority was disposed to look upon ante-
fiexions in minor stages as a physiological (even congenital) con-
dition, it was legitimate to infer that his statistics had been
based upon observations of displacements in the pathological
degree. The conclusion was forced upon us, then, that of all
the displacements of the uterus, those of the anterior variety
were the more frequent ; while the records of practice would
force us likewise to the conclusion that of all the womb dis-
placements those of the anterior variety were less amenable to
treatment than any of the others.
In the treatment the term surgical was employed in contra-
distinction to any method of treatment by pessaries, tampon-
nade, or electricity. It might be premised that all surgical
methods devised for the relief of these conditions should be
directed, first, to the removal, when practicable, of the causes
of the diseased conditions proper, and, finally, to the readjust-
ment of the diseased organs to the normal physical forces of
the pelvis.
In conclusion, the author desired the association to con-
sider—
I. The etiological relationship of contracture of the utero-
sacral ligaments to anteflexion.
2. The possibility of overcoming this condition by such con-
servative measures as rest, pelvic depletion, and appropriate
manipulations.
3. The feasibility of removing the obstructive dysmenorrhea
and the sterility usually incident to these cases by the plastic
operation which he bad described.
4. The inexpediency of forcible dilatation for the relief of
these cases and its inability to effect a permanent cure.
The Part the Shoulders play in producing Laceration
of the Perinaeum, with Suggestions for its Prevention.—
This was the title of a paper read by Dr. W. D. Haggard, of
Nashville, Term., in which he made the following suggestions:
1. The patient should occupy the left lateral decubitus, at
least during the second stage of labor.
2. Overcome rigidity of the vulvar outlet by the judicious
use of chloroform.
3. The presenting part of the child should be supported, and
not the periiueum, daring the passage of the head and shoulders.
4. Support the head by pressing it well up under the sym-
physis pubis by placing the right thumb in the rectum and fin-
gers of right hand expanded over the occiput.
5. To retard the exit of the shoulders, pressure should be
applied to the trunk and shoulder by placing the index and
middle fingers of the left hand in the rectum with the thumb in
the vagina to restrain its exit.
6. Support the head and neck by pressure well over the
symphysis pubis.
Abdominal Section in a Case of Cyst of the Mesentery.
— Dr. James A. Goggans, of Alexander City, Ala., read a paper
with this title, in which he stated that he had been induced to
write a paper on the case by the fact that cysts of the mesen-
tery were extremely rare, and that operations for their removal
were most generally fatal. He said that he had been able to
find the record of one case of cyst of the mesentery removed
by enucleation by Guyon. The patient had died on the seventh
day after the operation. One patient had been operated upon
by Sir Spencer Wells; the operator in that case had incised and
drained the cyst, but the patient had died within a few weeks.
Three patients had been operated upon by Pean, only one of
whom had recovered. One patient had been operated upon by
Watts, but he did not know the result in the case. One had
been operated upon by Cortes, who had incised and drained the
cyst, but the patient had died from septicaemia and haemor-
rhage. One had been operated upon by Bantock, who bad
removed the cyst by enucleation, and the patient had recov-
ered. The conclusion arrived at as to the origin of the cyst in
that case, both by Dr. Bantock and by the pathologist who
had examined the specimen, had been that it originated from
some foetal structure, possibly some of the rudiments of the
permanent kidney. Dr. Greig Smith had said that he knew
of two cases of mesenteric cyst removed by operation by a
friend, but that he could not relate them to him, as they bad
not yet been published. The patient upon whom the author
had operated for a cyst of the mesentery was a young woman,
twenty-one years of age, daughter of a physician of Columbus,
Ga. She had not been well for two years, but did not know
that her abdomen was becoming larger until three months before
the operation. During those three months she had been treated
for abdominal dropsy, and bad suffered much uneasiness and
pain in the abdomen, and at the time of the operation her pulse
had been 120 and her temperature 100° F. The cyst- had been
quite large, had occupied mostly the left side of the abdomen, had
extended from under the ribs into the left lumbar region, bad
dipped downward into the pelvis, and had extended three or
four inches beyond the median line of the abdomen into the
right side. He said that lie had first removed about a quart of
Jan. 2, 1892.1
PROCEEDINGS OF SOCIETIES.
21
the fluid by aspiration on February 7, 1891. The fluid had been
thin and of a dark color, and had contained albumin, phosphates,
and chlorides. The patient had not been benefited by the op-
eration, and the abdominal section for the removal of the cyst
had been made on February 24, 1891.
The cyst had heen covered with omentum and mesentery,
and loops of small intestine had been imbedded in its walls. An
attempt bad been made to enucleate it, hut ha3morrhag3 had
been so free that the idea of enucleation had soon been aban-
doned. A point as remote as possible from blood-vessels and
intestines had been selected, and the cyst incised and drained-
More than a gallon of a thin, dark-colored fluid had been evacu-
ated, the sac irrigated with hot water, the lips of the incised
sac stitched to the upper angle of the abdominal incision, and a
glass drainage-tuhe introduced to the bottom of the cyst. The
abdominal incision had then been closed with silkworm-gut
sutures. The author was confident that the cyst had been retro-
peritoneal. The time consumed in the operation had been
twenty-five minutes. The sac had been irrigated three or four
times in the twenty-four hours and the drainage-tube gradually
withdrawn. The patient had suffered much from nausea and
vomiting, which he had attributed to the close connection be-
tween the walls of the sac and the loops of small intestine
The patient had made a good recovery within thirty days. He
presented a picture of the patient which was taken on Novem-
ber 1, 1891, which showed her to be in perfect health.
Thinness of the Uterine Walls simulating Extra-uterine
Pregnancy was the title of a paper by Dr. George J. Engel-
mann, of St. Louis. The author said there were many diffi
culties in the way of a positive diagnosis of early pregnancy,
even in cases surrounded by conditions less unusual, but they
assumed alarming proportions when aggravated by the curious
complications which might arise in individual cases, and, above
all, when conditions were simulated in which delay was danger-
ous and operative interference seemed called for, when a decision
was urgently demanded — a decision upon which a life, and per-
haps two, might depend. While the auditor might criticise at
his leisure and readily distinguish the conditions depicted, it was
only he who was to pronounce and to act who could realize the
difficulties of this entangling and so knotty a problem.
Case. — A patient, thirty-two years of age, had borne three
children in the six years and a half of her married life, the
youngest twenty months ago, which she was still nursing, and
the menstrual flow had not as yet reappeared since the birth of
this child. The patient had come to his clinic for relief from a
variety of discomforts from which she had been suffering more
or less for the past three months. She had complained of sick
headache, vomiting spells, fullness of the stomach, be'ching
after meals, an intermittent swelling of the abdomen, a pain
in the groin, appearing before such swelling, and a small tumor
above the right groin, which she had first noticed three weeks
ago, and, as she had stated, bad then suddenly made its ap-
pearance. An examination had revealed large varicose veins
over the lower limbs; a solid, round, movable tumor above the
symphysis and right groin, the cervix low and large, the uterine
body thickened, lying low in the pelvis, with a certain mobility
independent of the superimposed tumor, an applicator entering
three inches and a half slightly forward. Notwithstanding the
wine color of I lie pronounced cystocele and the cervix, preg-
nancy had seemed out of the question, and the tumor hail been
diagnosticated as most probably a dermoid of the right ovary,
hardly one connected with the uterine wall. In the course of
an examination two weeks later a very different condition of
affairs had been revealed. The tumor had disappeared, and a
foetus had been found in the utero-vesical space, freely mova-
ble, apparently floating about, the small parts being distinctly
felt as if underneath a wet towel both through the vagina and
abdominal walls. So distinct had the small parts appeared to
the examining finger that it had seemed impossible to realize
that even as much as a thickness of the vaginal tissues should
intervene, and the abdominal walls must certainly have been
very much attenuated to disclose the foetal parts with such dis-
tinctness. The probe had shown the uterine cavity free, six
inches and a half in length, still running slightly forward, but
never curving forward in the direction of the previous tumor.
The treatment for the supposed subinvolution had been discon-
tinued, the patient had been warned to keep quiet and to notify
the reader upon the occurrence of any abnormal symptoms. He
believed the case to be one of ectopic gestation either within
the broad ligament or in the abdominal cavity after tubal rupt-
ure marked by the sudden appearance of the tumor five weeks
ago, yet he was not sufficiently positive to warrant the imme-
diate resort to the knife, and it was well that he did not do so,
as persistent treatment and repeated examinations had resulted
in labor pains and the birth of a five-months foetus in the most
correct and natural manner.
The Removal of Necrotic and Carious Bone with Hy-
drochloric Acid and Pepsin.— Dr. Robert T. Morris, of New
York, contributed a paper on this subject (to be published).
The Present Status of Cerebral Surgery.— Dr. Landon
Carter Gray, of New York, in a paper thus entitled, touched
upon the modern aspect of intracranial surgery. The author
first passed in review our present knowledge of localization of
functions of the brain, stating that we were well acquainted
with the functions of the motor area, of the third frontal con-
volution, the frontal lobe, the island of Eeil, the two upper
temporal convolutions, the cuneus, certain portions of the basal
ganglia, the base of the brain, and the cerebellum, and that we
knew nothing, or had still under discussion, the question of the
localization of the centers for the sensations of touch, pain,
muscular sense, temperature sense, most of the parietal lobe,
and most of the temporo-sphenoidal lobe with the exception of
the olfactory lobe. He stated that operations for fracture of
the skull with or without haemorrhage, for abscess, and for
tumors that were removable and localizable were usually suc-
cessful ; those for so-called idiopathic epilepsy were utterly val-
ueless, as were also those for epilepsy supposed to be due to
genital or ovarian irritations, while those done for epilepsy due
to removable and localizable lesions of the intracranial contents
were usually successful so far as the lesion was concerned, al-
though it was a grave question as to whether the epileptic habit
was ever cured ; the latest operation for idiocy supposed to be
due to premature ossification of the fontauelles was still under
discussion and consideration, the cases being too few and too
recent to permit of any conclusion, while the operations for
hydrocephalus and for epilepsy due to such early infantile and
fcetal lesions as porencephalia, haemorrhage, and meningitis were
indefensible. He further impressed upon surgeons the great
difficulty that there often was in finding a subcortical lesion of
the centrum ovale that was deep-seated or small, and the fact
should be borne in mind that there might be no decussation of
the motor fibers from the hemispheres, so that a lesion would
be found upon the same side as the paralysis.
A Case of Induced Abortion for Relief of Nausea and
Vomiting, with Remarks. Dr. Christopher Tompkins, of
Richmond Va., followed with a paper thus entitled, in which
he said that on August 1, 1885, be bad been called to see Mrs.
•I.. aged twenty-four, and, as nearly as could be ascertained,
three months and a half pregnant with her first child. The pa-
tient had been born in the mountainous part of Virginia; she
bad had an active outdoor life and had grown up to be a woman
of good height and of round, full figure. On January 14, 1884,
22
BOOK NOTICES.
[N. Y. Med. Joor.,
she had been married. While in the city of Sew Orleans, in
stepping from the platform of a car, she had sprained her
ankle. This, although treated immediately by a physician of
that place and subsequently in this cily, had caused her great
suffering. Finally, as the umimI treatment proved ineffectual:
the part had been put in a plaster cast; she had gone about on
crutches, and after many months had recovered. In the mean
time she had become pregnant, and from the first had been
attacked with nausea and vomiting. Mild in the beginning, it
had gradually increased in gravity, until she had sent for him
on August 1, 1885.
Her hushand had stated that she had had fever tor two
weeks. The author had found her in bed and had learned that
she had been there for days; her figure was not robust and her
face thin and attenuated. What little she had eaten in the past
ten days or two weeks had been apparently rejected, her tem-
perature was a degree above normal, her tongue was foul, there
were sordes on the teeth, and the breath was of a sour and
bilious odor. The pulse was fairly good considering her condi-
tion. Even the mention of food was distressing to her. and the
sound of the dinner hell, though far off from her, caused such
distress that its ringing had been discontinued by the family.
The bowels had throughout her pregnancy been constipated,
only moving once in two or three days Although she was con-
tinuously retching, very little or no blood had been seen in the
material vomited, except on two occasions, and then not a great
deal, and such as there had been was of a florid, scarlet color
No medicine had been given and no treatment taken, except the
occasional use of lime water, which she had said ''did no good."
The patient had not improved up to August 7th, when the
author, thinking the case one of the greatest gravity and that
the question of abortion could no longer be deferred, had in-
vited Dr. J. B. McCaw and Dr. Aaron Jeffrey to meet him in
the afternoon in consultation. All had agreed that abortion
must be produced in order to give the patient a last chance for
her life, and it had been done.
The case was reported principally because it was an unsuc-
cessful one and because he wished to disabuse the minds of
those who were not experienced in such operations of the no-
tion, commonly entertained and o'ten expressed, that the induc-
tion of abortion for the nausea and vomiting of pregnancy was
in skillful hands an undertaking devoid of danger and neces-
sarily attended by success. In this case he was of the opinion
that death had been the result of the protracted debility and
enfeebled constitution, due to her long confinement and suffer-
ing— first, from the injury to her ankle, from which she had
not recovered when she had become pregnant and had been
attacked by nausea and vomiting, this last continuing till her
death. Under such circumstances the outlook had indeed been
very unfavorable, for to the shock of the operation and to the
depression incident to the use of chloroform there had been ad-
ded, fever and protracted prostration, both from injury to the
ankle and from want of nutrition, the result of the long existing
nausea and vomiting. He had before and since operated on
women for the nausea and vomiting of pregnancy, and with
success, in those whose apparent condition was much worse
than that described in this case, but without the history of a
previous injury or disease.
The prognosis, always unfavorable, ought, when the case
was so complicated, to be of the most guarded kind. The prac-
titioner should not, however, hold his hands on this account,
for the operation afforded the poor sufferer the only opportu-
nity of relief. The author used metal dilators instead of tents
and completed the operation at one sitting. He was likewise
convinced that the least possible chloroform used, the better the
result.
Officers for the Ensuing Year.— The following officers
were elected : President, Dr. McFadden Gaston, of Atlanta, Ga. ;
first vice-president, Dr. Cornelius Kollock. of Cheraw. 8. C. ;
second vice president, Dr. George Ben Johnston, of Richmond.
Va. : secretary. Dr. W. E. B. Davis, of Birmingham, Ala. Place
of next meeting, Louisville, Ky., beginning on the second Tues-
day in November. 1892. Chairman of Committee of Arrange-
ments Dr. L. S McMurtry, of Louisville.
$ook llotiecs.
Artificial Anmsthesia and Anaesthetics. By De Forest Willakd,
M. D., Ph.D., etc. Detroit: George S. Davis, 1891. Pp.
144.
Ix this little book will be found all the more essential points
connected with the administration of general and local anaes-
thetics Unlike many similar publications, the book before us
is thoroughly practical in spirit and devoid of purely speculative
discussion; so that little time need be wasted in arriving at es-
sential facts. The chapter on local anaesthesia is particularly
good, the author having had extensive opportunities of employ-
ing Dr. J. Leonard Coming's system of anaesthetization.
Several judicious recommendations on the preparation of the
patient for the administration of the anaesthetic are contained
in one of the earlier chapters. This is notably true of the ad-
vice concerning the preliminary use of morphine, which the
author maintains should always be given with atropine, with a
view to stimulating the heart and respiratory centers.
The Neuroses of Development, being the Morrison Lectures for
1890. By T. S. Clouston, M. D., F. R. C. P. E., Physician-
Superintendent, Royal Edinburgh Asylum for the Insane;
Lecturer on Mental Diseases, Edinburgh University. With
Illustrations. Edinburgh : Oliver and Boyd, 1891. Pp.
viii-138.
During the period of brain growth and development there
is a liability to certain failures in nervous action which result in
defects and diseases that are termed by the author neuroses of
development. He attempts to treat of such conditions from the
developmental and relational point of view. As a study of the
relationship of disease the work is unique and of great interest.
It presents numerous pathological conditions of childhood and
adolescence in an entirely new light, rendering the possibility of
prevention greater and the treatment more rational and scien-
tific. The book is crowded with facts, with the comments of
an unusually acute observer and original thinker, and is replete,
also, with that peculiar form of suggestion that is certain to in-
spire thought in the reader. It is a book well worthy not
only of reading but of careful study.
A Compend of Human Physiology, arranged in the Form of
Questions and Answers. Prepared and especially adapted
for the Use of Medical Students. By W. J. Watkins, M. D.,
Graduate of Kentucky Medical College, Louisville, Ky.
Louisville: W.J. Watkins, 1891. Pp. 10-11 to 244.
Tins is one of the latest of the class of objectionable books
concerniug which we had a word to say in the issue of the Jour-
nal for March 7, 1891, in an editorial entitled Short Cuts to
Knowledge. We said that the objection to such books was that
they simply presented a multitude of disconnected facts to be
memorized. They ignored the relationship of these facts to each
Jan. 2, 1892.1
BOOK NOTICES.— REPORTS ON
TJIE PROGRESS OF MEDICINE.
23
other and paid no regard to the interdependence and relation-
ship of diseases. The book under consideration is no exception
to the rule ; in fact, it seems to us that in the answers less re-
gard than usual is given to the meaning of the questions. Iso-
late the answers and they convey absolutely no meaning. The
author, in his preface, acknowledges his obligations to his " old
friend and teacher, Dr. Sam. Cochran," but he does not say that
the questions contained in the book, and the arrangement of
subjects, are practically those adopted by Dr. Cochran in a
pamphlet containing questions only, got up by the latter for the
use of his classes. As a matter of fact, the questions in the
book bear so striking a similarity to those in the pamphlet that
plagiarism is unavoidably suggested. This statement is made
after a comparison of the book with the pamphlet. The book
may "fill a want," but it is the want of those who prefer the
short cut to the " strait and narrow road."
BOOKS, ETC., RECEIVED.
On the Simulation of Hysteria by Organic Disease of the Nervous
System. By Thomas Buzzard, M. D. Lond., Fellow of the Royal Col-
lege of Physicians in London, etc. London : J. & A. Churchill, 1891.
Pp. vii-113.
The Physician as a Business Man ; or, how to obtain the Best Prac-
tical Results in the Practice of Medicine. By J. J. Taylor, M. D.
Philadelphia: The Medical World, 1891. Pp. 4-5 to 143.
Transactions of the Ophthulmological Section of the American Medi-
cal Association, at the Forty-second Meeting, held at Washington, D. C,
May 5-8, 1891.
Proceedings of the New York Pathological Society for the Year
1891.
Special Report on the Cause and Prevention of Swine Plague. Re-
sults of Experiments conducted under the Direction of Dr. D. E. Salmon,
Chief of the Bureau of Animal Industry. By Theobald Smith, Ph. B.,
M. D. Published by authority of the Secretary of Agriculture. Wash-
ington : Government Printing Office, 1891.
The Physicians' Visiting List for 1892. Philadelphia: P. Blakis-
ton, Son, & Co., 1892.
The Voice and its Treatment. By Arthur G. Hobbs, M. D. [Re-
printed from the Journal of Laryngology and Kkinology.]
Intubation of the Larynx. By Carl H. von Klein, M. D. [Re-
printed from the Cleveland Medical Gazette.]
The Arrangement of the Supraeerebral Veins in Man, as bearing
on Hill's Theory of a Developmental Rotation of the Brain. By William
Browning, M. D., Brooklyn, N. Y. [Reprinted from the Journal of
Nervous and Menial Disease.]
The Bilateial Pareses and Pseudoplegias of Childhood, with Special
Reference to a Type of Malarial Origin. By William Browning, M. D.
[Reprinted from the American Journal of the Medical Science*.]
Is a Child Viable at Six and a Half Months ? By Llewellyn Eliot,
M. D., Washington, D. C. [Reprinted from the Virginia Medical
Monthly.]
A Combined Laparotomy and Gynaecological Operating Table. By
George M. Edebohls, M. D., New York. [Repiinted fiom the Medical
Record. ]
Pathological Conditions of the Ethmoid Bone resulting from Dental
Lesion. By I. P. Wilson, D. D. S., Burlington, Iowa. (Head before
the Iowa State Dental Society.)
Trop de mutilations inutiles, pas assez de gynecologie conservatrice.
Par le Docteur A. Doleris. [Extrait des Nouvclles archives d'obste-
trique el dc gynecologic]
A B C of the Swedish System of Educational Gymnastics. A
Practical Hand-book for School Teachers and the Home. By Hartvig
Nissen, Instructor of Physical Training in the Public Schools of Bos-
ton, Mass. With Seventy. seven Illustrations. Philadelphia and Lon-
don: F, A. Davis, 1891. Pp. vii-107.
Massage and the Original Swedish Movements : their Application to
Various Diseases of the Body. Lectures before the Training School
for Nurses connected with the Hospital of the University of Pennsyl-
vania, German Hospital, Woman's Hospital, Philadelphia Lying-in
Charity Hospital, and the Kensington Hospital for Women, Philadel-
phia. By Kurre W. Ostrom, from the Royal University of Upsala,
Sweden. Second Edition, enlarged. With Eighty-seven Illustrations.
Philadelphia: P. Blakiston, Son, & Co., 1891. Pp. viii-9 to 143.
Age of the Domestic Animals : being a Complete Treatise on the
Dentition of the Horse, Ox, Sheep, Hog, and Dog, and on the Various
other Means of determining the Age of these Animals. By Rush
Shippen Huidekoper, M. D., Veterinary (Alfort, France); Professor of
Sanitary Science and Veterinary Jurisprudence, American Veterinary
College, New York, etc. Illustrated with Two Hundred Engravings.
Philadelphia and London: F. A. Davis, 1891. Pp. viii-217.
Lessons in t he Diagnosis and Treatment of Eye Diseases. By Casey
A. Wood, C. M., M. D., formerly Clinical Assistant, Royal London Oph-
thalmic Hospital (Moorfields), etc. With numerous Woodcuts. De-
troit: George S. Davis, 1891. [The Physicians' Library.]
A Volumetric Study of the Red and White Corpuscles of the Hu-
man Blood in Health and Disease, by the Aid of the Hamiatokrit. By
Judson Daland, M. D. [Reprinted from the University Medical Maga-
zine.]
Studies from the Pathological Laboratory of the College of Physi-
cians and Surgeons, Columbia College, New York. For the Collegiate
Year 1890-'91.
The Twenty-seventh Annual Report of the S. R. Smith Infirmary,
for the Year ending May 31, 1891.
Etude sur l'exalgine d'apres des observations prises a l'hopital Lari-
boisiere. Par M. le Dr. Emile Desire.
Reports on tin progress of ItUbtciru.
GENERAL MEDICINE.
By JOHN WINTERS BRANNAN, M. D.
The Significance of Cheyne-Stokes Respiration as a Symptom in
Cardiac Disease. — Dr. M. A. Boyd contributes an interesting study of
the phenomena of Cheyne-Stokes respiration to the Dublin Journal of
Medical Science for July. Hayden has said, in his work on Diseases of
the Heart and Aorta, that there is no change in the pulse or cardiac
rhythm during the ascending, descending, and apnoeal periods of the
respiratoiy act. Boyd believes this statement to be an error, and cites
illustrative cases to support his opinion. The phases of the respiratory
phenomenon, as he has observed them, are as follows :
1. An apnosal period characterized by deep sleep, lividity of face,
quick pulse, feeble contractions of the heart, and perfect rest from all
agitation, mental and bodily.
2. An inspiratory period, with rousing of all the patient's faculties,
extreme restlessness, slowing and strengthening of the pulse, appar-
ently stronger contractions of the heart, less lividity of the face, and
then a final deep inspiration.
3. An expiratory period, with inspirations gradually getting shorter
and expirations longer, pulse getting quicker and heart feebler in its
contractions till expirations cease, the chest is empty, and restlessness
gives place to sleep, which continues through the apncea following.
The cardiac conditions necessary for the production of this form of
breathing are, according to his experience, not alone dilatation of the
aorta, but also dilatation of the right ventricle, with beginning degen-
eration or weakness of its walls, also hypertrophy of the left ventricle
with or without dilatation, but with degeneration of its muscle or its
dynamic contractile power enfeebled from any cause whereby it is unable
to empty its contents into a dilated and inelastic aorta. He admits
that this condition of the heart is often met with in many cases of
valvular disease accompanied by atheroma of the arteries, and oi ly
produces dyspmea. But the difference, he holds, is only one of degree.
Any attack of cardiac dyspnoea produced by such alterations in the
heart and aorta may become Cheyne-Stokes dyspnoea when any addi-
tional strain is put on it, so as to still further enfeeble its action and
cause interference with the supply of arterialized blood to the reBpira-
24
REPORTS ON THE PROGRESS OF MEDICINE.
\N. Y. Med. Jouk.,
tory center. The affection i-, in t';u t , cardiac dyspnoea plus poisonin?,
or starvation of the respiratory center. Poisoning of this center or in-
terference with its blond supply may, of course, occur without cardiac
disease, and give rise to Cheyne-Stokes respiration. Apoplexy, menin-
gitis, and ursemic coma may be mentioned as conditions in which the
phenomenon has been observed. Its occurrence, however, is undoubt-
edly favored by the changes in the heart substance described above by
the author.
The iEtiology of Diabetes. — The iEtiology of Diabetes is the title
of an article by Dr. Schmitz in the Berliner klinisehe Wnehensehrift for
July 6th. He has had the unusual opportunity of observing 2,500
cases of the disease during his long residence at the German resort,
Neuenahr.
He makes a distinction between idiopathic diabetes and mellituria
or mellitucmia occurring as a complication of other affections. Of his
cases, 2,115 were instances of true diabetes.
It is his opinion that the development of idiopathic diabetes is
always dependent upon the presence of a diabetic predisposition.
Men are oftener affected than women ; of his patients, 1,206 were
male and 909 female. Idiopathic diabetes occurs very rarely in child-
hood, seldom in youth, but after the age of twenty increases steadily
with each decade.
It is rare among the inhabitants of certain regions — as, for instance,
Westphalia, the Rhine provinces, and Bavaria. On the other hand, ac-
cording to Cantani, it is as common among the people of Malta and
South Italy as tuberculosis is in Germany. It is frequently observed in
Sweden, and a strikingly large number of cases is found among the
Jews. Cantani attributes the frequency of the disease in Malta and
Italy to the excessive consumption of sugar by the inhabitants of those
countries. In opposition to this view, Schmitz refers to the fact that
diabetes is not often met with in the populations of East Germany and
of the United States in spite of their free use of sugar.
This diabetic tendency, which must be assumed to exist in certain
nations and races, is usually congenital, often, also, directly inherited.
In 998 cases, or almost one half of his patients, Schmitz was able to
establish that near relatives had suffered from diabetes. In one family
twelve cases had occurred. In 428 cases hereditary psychical dis-
turbances were noted. Insanity, especially melancholia, was observed
in the families of 263 patients.
Diabetes occurs also quite often in individuals affected with the
gouty or tubercular diathesis.
Schmitz admits that an excessive consumption of sugar undoubt-
edly is inju.ious to diabetics, and that the amount of sugar in the urine
varies directly with the amount eaten. In 641 of his cases the occur-
rence of the diabetes was preceded by a free use of sugar extending
over a considerable period of time. But he insists that in each case
the diabetic tendency must have been present, otherwise the disease
would not have developed. He lived for several years in the United
States and was struck by the very large amount of sweets eaten by the
inhabitants of this country. And yet diabetes is not often observed
here, though dyspepsia is a common ailment. Schmitz concludes fiom
this fact that the Americans must be free from any tendency to the
disease.
Grief, violent emotions, and nervous shocks are usually accepted as
important factors in the causation of diabetes. The experience of the
author leads him to oppose this view. He believes that in many of
the cases in which the origin of the disease is attributed to such causes
the diabetes has existed long before the shock to the nervous system
has taken place.
On the other hand, he does not doubt that diabetes can be commu-
nicated from one individual to another. In seven different instances
he has observed the disease in man and wife. He gives also the names
of several other German physicians who have written him of similar
observations on their part.
The aetiology of diabetes bears, in his opinion, a considerable re-
semblance to that of tuberculosis. In both affections a predisposition,
usually congenital and inherited, is a necessary condition for the de-
velopment of the disease. Carrying the comparison further, he sug-
gests that perhaps diabetes, like tuberculosis, may be due to micro-
organisms.
Schmitz, as we have said, distinguishes between idiopathic diabetes
and mellitiemia or symptomatic diabetes. This distinction applies,
however, only to the pathogenesis of the two affections. The latter
disease, when of long standing, exerts the same injurious effect upon
the body and calls forth the same symptoms as idiopathic diabetes.
Of his cases of mellitiemia 155 occurred as a complication of the uric-
acid diathesis. This form of gouty mellitiemia has usually a good
prognosis. Many cases recover after a sojourn at Carlsbad, Neuenahr,
or Vichy, the cure being due to the influence of the alkaline waters up-
on the primary affection. In 128 other cases there was pronounced
polysarcia.
Mellitiemia was also observed in the course of the following dis-
eases: Cancer, general tuberculosis, valvular disease of the heart,
cerebral syphilis, morphinomania, disease of the spinal cord, cirrhosis
of the liver, amyloid disease of the liver, and Addison's disease. It
also occurred six times after a fall on the head, four times after a
blow upon it, once after a violent cerebral concussion in a railroad
accident, and three times during convalescence from typhus fever.
Schmitz is convinced that disease of the pancreas is a cause of
mellita?mia, but he has never been able to diagnosticate this condition
with certainty.
Intestinal Perforation in Typhoid Fever. — Intestinal perforation
in typhoid fever was the subject of a lecture recently delivered by
Professor Potain and published in the Gazette des hopitaux for
June 9th. This accident, he says, is one of the most serious compli-
cations of typhoid fever. The possibility of its occurrence should
make us always very reserved in our prognosis in this disease, as it
may happen in cases which are apparently of the mildest character.
He refers, in illustration, to a case which had just been under observa-
tion in the wards of the Charity Hospital. It was that of a young
woman, twenty-five years of age, of strong frame and robust appear-
ance. She had never had any illness with the exception of a recent
attack of scarlet fever. She was in the third week of her convales-
cence from this disease when she was suddenly taken with a violent
chill, with severe headache, and pain in the left side. The headache
persisted, and four days later she had several attacks of epistaxis. On
the following day she entered the hospital. The diagnosis remained
in doubt for several days, because of the absence of positive signs.
The temperature was 100 9° F.. the facies was normal without lethargy,
the abdomen was relaxed, with no tenderness, and there was no diar-
rhoea. She coughed slightly, but there was no expectoration. The
only pulmonary sign was a slight diminution of resonance and vesicular
murmur at the left apex. Five days after her entrance into the hos-
pital she complained of pain and tenderness in the right iliac fossa.
Her temperature began to rise, and the next day rose-spots were ob-
served on the abdomen. The slight pulmonary signs disappeared in
the mean time. The diagnosis of typhoid fever was scarcely made
when all the symptoms suddenly grew much more marked. This was
on the thirteenth day of the disease. The patient had a severe chill,
and the pain in the right iliac fossa became intense. There was re-
peated vomiting and the temperature curve became very irregular and
some blood was observed in the stools. Six days later the patient
died in collapse.
At the autopsy, in addition to the signs of a purulent peritonitis, a
large mass of faecal matter was found in the right iliac fossa. On ex-
amining the bowel, a linear perforation, two inches long, was found
about two inches above the ileo-cajcal valve. Only six Peyer's patches
were affected, but the ulceration was very deep. The whole thickness
of the intestine was destroyed down to the serous coat. The bottom of
the ulcers was smooth, composed simply of the peritonaeum, in place
of being ragged and uneven, as is usual in ulcerations of slow develop-
ment. The gangrenous process had taken place en Woe, instead of
gradually, involving one follicle after another. The other organs do not
call for special mention.
In seeking the cause of the profound alterations of Peyer's patches
and the early occurrence of the perforation in this apparently mild case
of typhoid fever, Potain is inclined to attribute it to the preceding
scarlet fever. He refers to the injurious influence exerted on the vi-
tality of the tissues by scarlet fever, and the frequency with which it
is followed by suppuration. It is rare to see scarlet fever thus followed
Jan. 2, 1892.]
REPORTS ON THE PROGRESS OF MEDICINE.
25
by typhoid fever, but one other ease was reported by Rilliet and Bar-
thez, in which very deep ulceration was also observed on the eighth day
of the enteric disease.
Potain believes that in both cases the scarlet fever had favored the
destructive process.
Intestinal perforation is observed in about two per cent, of all cases
of typhoid fever, the proportion varying from one per cent, in women
to three per cent, in men.
The seat of the perforation is usually at the lower end of the ileum,
but it may be found in the large intestine and even in the rectum. The
form may be rounded or linear; it is rarely larger than the head of a
pin.
There may be certain premonitory symptoms. Profuse diarrhoea,
intestinal haemorrhage, or excessive tendernes in the iliac fossa should
all put us on our guard against it.
Sometimes sudden constipation, following diarrhoea, is the first in-
dication of the lesion of the peritonaeum.
The most usual time for its occurrence is from the third to the fifth
"week. It is more apt to be delayed than to occur early. It has even
taken place when the patient was apparently convalescent. Deep
pressure in the iliac region has occasionally caused the accident. An
error in diet is a more frequent cause.
The symptoms of the perforation itself are usually very abrupt.
Pain, chill, vomiting, coldness of the extremities, announce only too
surely peritonitis. Sometimes, however, it is of insidious de\ elop-
ment ; in such eases marked variations of temperature are of diagnos-
tic value.
Death is unfortunately the usual termination, occurring sometimes
in a few hours, more frequently at the end of two or three days. A
few cases of recovery have been observed. In these favorable cases
inflammatory adhesions form, limiting the f»cal effusion and prevent-
ing its escape into the peritona?um.
As to treatment, opium is of most service. Wet cups are useful
in relieving the pain. Surgical intervention gives but little hope in
this form of peritonitis. The perforation would be difficult to find
and more difficult to suture, because of the lesions of the adjacent tis-
sues. Resection of the intestine would be no less difficult, as Peyer's
patches are often affected over a very extensive area.
The Use of Drugs in the Treatment of Early Phthisis. — Dr. J. C.
Thorowgood read a paper with this title at the last annual meeting of
the British Medical Association. It is published in full in the British
Medical Journal for October 17th.
Dr. Thorowgood says that the discovery of the tubercle bacillus
and the wav in which it appears to be associated yvith the progress of
the more serious forms of tuberculous disease has tended to cast drug
treatment rather into the background. But in hospital practice, espe-
cially among out-patients, one is forced to do the most one can with
drugs. The patients are poor and hard-worked, and can not obtain the
advantages of change of air and rest. Among them phthisis is often
brought about in the first instance by some neglected inflammatory
mischief, such as bronchitis, pleurisy, and sometimes pneumonia. In
such cases drug treatment appears to advantage. That peculiar catar-
rhal state of the apex which has been described as pulmonary cachexia
and which is close on the borders of tubercle, and is due to a degener-
ated condition of the epithelium from constant respiration of bail air,
improves rapidly when the patient is removed to a pure air. Where,
however, we can not give the patient the advantage of removal, we
have to do our best with drugs. The author lays special stress upon
the good results that may be obtained in such cases from the use of the
hypophosphites. Hospital out patients who come with cough and ex-
pectoration, perhaps blood-stained at times, and who present rales at
the lung apex, improve in a surprising way on taking five grains of
hypophosphite of soda three times a day. The remedy may be given
n plain water or infusion of calumba. In cases of persistent consoli-
dation of lung after pneumonia, the effused products are rapidly ab-
sorbed under this treatment ; and this, too, in cases in which ordi-
nary treatment has been followed to no purpose for some time. In
cases of pleurisy yvith effusion, the hypophosphites seem to have no
effect whatever. But, when the pleura appears to have been rough-
ened by deposits so that friction sounds of loud anil coarse character
are very Audible, the author has seen all these sounds vanish and the
patient do well under the hypophosphite of sodium.
Dr. Thorowgood believes that a process of fatty change and lique-
faction of effused product is set up and absorption follows. Some-
times the process seems to be for a time attended yvith some increase
in temperature, and when this is the case it is yvell to reduce the dese
of the drug or give it at longer intervals. In recurring haemoptysis,
too, the hypophosphite must be used with care. The most active in
liquefacient power is the hypophosphite of potassium. The calcium
hypophosphite often acts remarkably well in cases in Which secretion is
profuse. It checks excessive sweating and also diarrhoea.
Occasionally, but very rarely, when the hypophosphite fails to re-
move an apex catarrh or inflammatory deposit, something may be gained
by changing to such medicines as tartrate of antimony in very small
doses, or iodide of potassium, or some form of mercury.
Dr. Thorowgood passes rapidly over such drugs as the mineral acids,
creasote, and guaiacol, though he has found them useful as tonics in
some cases. He has much to say in favor of the inhaling respirator.
He recommends its use with iodoform in ether, alcohol, or eucalyptus
oil. This is soothing and excites no cough. Next to this comes the
best German creasote, with or without ethylic alcohol. Thymol, car-
bolic acid, and iodine are all inferior to these. The patient should,
after clearing his lungs as much as possible in the morning by cough,
wear the perforated zinc respirator and keep it on for an hour ; again
in the middle of the day, and a short time at night.
Next to these inhalations Dr. Thorowgood places persistent and even
severe counter-irritation. He has seen a remarkable arrest by croton
liniment of phthisis of an active kind in a young woman. He thinks
that linimentum terebinthinae is also deserving of a high place, espe-
cially in chronic disease of the base of the lung.
Acute General Miliary Tuberculosis without Fever. — Dr. J.
Joseph, of Professor Fiirbringer's clinic, discusses this subject in the
Deutsche medicinische Woehenschrift for July 9th. It is universally
agreed, he says, that the diagnosis of acute general miliary tuberculosis
is often extremely difficult, and even impossible in some cases. The
widespread belief that the disease never occurs without fever is re-
sponsible for many errors in diagnosis. He therefore considers it of
interest to report three cases of undoubted acute general miliary tuber-
culosis, which ran their course entirely without fever. Two of the cases
were under observation for the period of seventeen days, so that the
absence of fever was evidently not simply a temporary condition.
The diagnosis in all three cases was somewhat uncertain because of
the apyrexia, but the autopsy showed in each case numerous gray mili-
ary tubercles in the lungs, liver, spleen, and kidneys.
The brain and meninges were unaffected.
Dr. Joseph adds that these cases furnish fresh testimony to the fact
that acute general miliary tuberculosis may occur without any elevation
of temperature whatever. The absence of fever, therefore, is no ground
for rejecting the diagnosis in doubtful cases when the other symptoms
point to this disease.
Dr. 0. Leichtenstern, commenting upon Dr. Joseph's paper, writes
in the same journal for August 6th that he has often observed cases
of afebrile and even subfebrile acute general miliary tuberculosis. He
thinks that it is generally recognized that there is an afebrile form of
the disease. He finds it especially frequent in old people. The symp-
toms often resemble those of cardiac degeneration with general dropsy,
or in other cases they suggest marasmus or diffuse capillary bronchitis
or pulmonary oedema. He also relates the histories of two-children who
died with progressive general emaciation, and in whose cases the diag-
nosis wavered between p;ediatrophy, rhachitN, and enteritis. The dis-
ease ran its course in both cases entirely without fever, and to his sur-
prise he found post mortem an acute general miliary tuberculosis, yvith
cheesy degeneration of the lymph glands.
He has also occasionally seen the disease begin with all the typical
symptoms of croupous pneumonia, such as sudden onset with chill, acute
lobar infiltration, pneumonic sputum, etc. Such cases are to be ex-
plained by assuming a simultaneous development of pneumonia and the
acute tubercular process.
The JEtiology of Nephritis. — In our report of May 2d yve referred
to the researches of Dr. Agnes Iiluhiu on this subject, based on the
26
REPORTS ON THE PROGRESS OF MEDICINE.
[N. Y. Med. Jouk.,
study of two hundred and seventy cases of Bright's disease. Dr. Bluhm
denied the importance of cold as a factor in the causation of nephritis,
and showed that the disease of the kidney was due in almost every case
to some form of infectious disease.
Dr. Viguerot (Arch. gen. dc med., October, 1891) has investigated
the same question, and agrees entirely with the views given above. He
believes that cold acting upon a kidney already diseased may give a new
impulse to the pre-existing affection and render acute symptoms which
up to that time had remained latent, just as it may excite an acute pul-
monary process in an individual suffering from tuberculosis.
Those persons who live in unwholesome and damp lodgings and
whose skin is defective in its action, and those whose occupation ex-
poses them to abrupt changes from a warm to a cold atmosphere, are
probably predisposed to renal affections, but unless there is previous
structural alteration of the kidney, even prolonged cold can not cause
the lesions of chronic nephritis.
It is often very difficult to ascertain the past history of a patient.
He may have had an infectious disease at some time, but he is not like-
ly to remember the symptoms, still less to know the condition of his
urine. He may since have enjoyed a long period of apparent health,
his symptoms not being such as to attract his attention or to interrupt
his work. When he afterward enters the hospital with the signs of
acute nephritic, the renal affection is called primary, or nephritis a
frigorc.
Dr. Viguerot's conclusions are based upon his own extensive patho-
logical and clinical observations and also upon the opinions expressed
by other writers. He has seen the alterations caused in the renal tissue
by the micro-organisms pass away without leaving any trace, but he has
also seen them pass into the chronic state in consequence of the fatty
degeneration of the epithelial elements and of the proliferation of the
connective tissue.
Among the infectious diseases in question, scarlet fever holds the
first place. Then follow variola and measles, also typhoid fever and
diphtheria. Pneumonia, erysipelas, rheumatism, infectious amygdalitis,
cholera, and septicemia have all been mentioned by various writers as
giving rise to persistent albuminuria. The author has seen chronic
nephritis follow mumps in one case. Tuberculosis, syphilis, and ma-
larial fever have also been added to the list of maladies capable of caus-
ing permanent lesions in the kidneys. In some cases the change into a
chronic affection is progressive and continuous ; in others it occurs
after an alternation of improvement and relapse, so that one might
easily be deceived and diagnosticate a primary nephritis, when in reality
the process was secondary to a series of intermittent exacerbations.
Sometimes cold is not alone the exciting cause, but there is some
intercurrent malady which stimulates the renal affection and helps to
render it chronic. As an illustration of this, Dr. Viguerot cites a ease
of diphtheria with intense and prolonged albuminuria which subse-
quently came under treatment for typhoid fever with marked renal
symptoms. It is evident in this case that the lesions in the kidneys
caused by the diphtheria and which were still in process of evolution
were accentuated under the influence of the typhoid fever and favored
in their tendency to become chronic.
The Local Treatment of Chronic Rheumatic Arthritis. — Dr. A. Sy-
mons Eccles describes in the Practitioner for August the measures which
he has found most useful in the local treatment of chronic rheumatic
arthritis. He employs the term rheumatic arthritis in its widest sense
to include all affections of the joints which present the clinical features
of pain, swelling, and impairment of function, unaccompanied by red-
raws and increased temperature, and in which no signs of suppuration
or advanced destruction of tissue can be discovered.
Most cases of chronic arthritis afford evidence of inflammatory de-
posits in the librous and muscular tissues in connection with the joint,
so that after one attack of rheumatism the fihro-serous tissues are
peculiarly liable to a recurrence of inflammation should they be exposed
to a repetition of the predisposing and exciting causes. Given a case of
chronic rheumatism, the indications are to relieve pain, to hasten the
removal of inflammatory products in and about the joint, and thus to
restore it to use, while at, the same time muscular atrophy is to be
an -t'-'l or cuivd. Meanwhile constitutional re die-, dietetic anil
medicinal, must be employed.
Dr. Eccles's local treatment consists of a combination of massage,
galvanism, and active and passive exercises. In severe cases, in w hich
there is much pain and thickening in and around the joint, with atrophy
of muscles, massage is best employed for a few minutes several times
daily; centripetal friction gradually increasing in firmness, and subse-
quently combined with kneading of the proximal muscles connected
with the joint, being applied at first as far from the forms of mischief
as possible, the lightest friction of the whole limb alone being permissi-
ble at the beginning of treatment. Cautiously the firmness and near
approach of manipulation to the joint may be increased, till the joint
itself is, in the course of a few days, submitted to thorough manipula-
tion, having for its object the dispersion and mechanical moving on-
ward of the accumulated waste products, the improvement of circula-
tion, and the stimulation of lymphatic resorption.
At the same time a stabile galvanic current is applied to the joint
itself, two electrodes of known dimensions being placed on opposite
sides of the articulation. A current of from ten to fifteen milliamperes
is used for ten to twenty minutes daily by voltaic alternation.
Dr. Eccles believes that the efficacy of the treatment by the stabile
constant current depends upon the density of the current, and he has
found the present form of dectrodes in use to be the best for the dif-
ferent joints affected.
In the case of the finger joints he applies the current in a different
manner, placing one electrode over the joint and the other in the palm
of the hand, the same density being employed as in the larger articula-
tions. Massage of the parts over which the electrodes are to be placed,
when practiced directly before the employment of galvanism, reduces
very considerably the resistance to the passage of the current. This is
evidently the result of increasing the volume of fluid in the skin and
subjacent structures. A striking proof of the therapeutic value of the
treatment is the gradually diminishing resistance opposed by the dis-
eased joint to the passage of the current from time to time as the ab-
sorption and removal of waste and inflammatory products proceed.
In the earlier days of treatment, while as yet the patient can not
bear vigorous manipulation, the labile application of the ascending
current to the muscles of the limb is attended by diminution of pain
and stiffness.
The passive exercise of the joint is gently practiced as early as pos-
sible, care being taken not to produce too much suffering. One or two
movements at each visit, gradually increasing the range of attempted
motion, till finally the patient is told to aid and independently to per-
form the exercises most suitable to the particular condition of the
joint, will slowly but surely overcome the tendency to muscular
spasm, which is almost always produced by the initial movements;
and, finally, after a period varying with the severity of the case, there
will follow the return of power to use the limb and move the joint
without pain.
The Elimination of Toxic Products in Typhoid Fever according to
the Different Methods of Treatment. — Dr. Roque and Dr. Weill pub-
lish in the September number of the Revue de medecine an interesting
experimental study of the above subject. They show that in typhoid
fever abandoned to itself the toxines produced in the body are elimi-
nated in part during the continuance of the disease. The urotoxic co-
efficient is double that of the normal : but this elimination is incom-
plete, so that it continues during convalescence, during which the hy-
pertoxic quality of the urine exists for four or five weeks after the
cessation of the fever.
In typhoid fever treated by cold baths the elimination of toxic
products is enormous during the illness. The urotoxic coefficient be-
comes five or six times greater than in the normal condition. This
hypertoxicity diminishes as the general symptoms decline and the tem-
perature falls, so that with the establishment of convalescence the
elimination of the toxines is ended and the coefficient descends to
normal.
The cold bath is therefore an eliminative treatment; it has no spe-
cific action, inasmuch as it does not at all prevent the formation of the
toxines, but it assures their expulsion as fast as they are produced.
On the other' hand, when the fever is treated by antipyrine the
elimination of the toxic products ceases entirely during the malady so
long as the remedy is used — the coefficient descends sometimes even
Jan. 2, 181,2.]
below the normal. But during convalescence the discharge of the
toxines takes place en masse for the space of five or six days. Anti-
] pyrine is therefore not an antiseptic. It does not prevent the forma-
j tion of the toxic substances, but does prevent their elimination in the
I urine.
The authors add that since the completion of their experiments
! Professor Teissier has reported some observations on the effect of
i naphthol in the treatment of typhoid fever. His conclusions are that
naphthol is a real antiseptic in this disease, inasmuch as it prevents
the formation of toxic matters both during the course of the fever and
during convalescence.
The Therapeutics of the Senile Heart. — Dr. George W. Balfour
contributes an interesting and instructive paper on this subject to the
June number of the Edinburgh Medical Journal. Senile diseases are
always degenerative and tend to precipitate the natural termination of
life. In them the object of treatment is not quite the same as it is in
the diseases of earlier life ; we no longer hope for complete restoration,
but we expect to be able to remove suffering and to check decadency,
and, so far as the heart is concerned, we are often successful in attain-
ing both of these objects.
Simple irritability, says Balfour, is the earliest indication of what
he calls advancing senility in the heart. The patient complains of un-
easiness in the cardiac region, sometimes amounting to actual pain.
Along with this there may be fits of palpitation, in the form of rapid
but not usually forcible action, which come on after exertion — such as
running up stairs, upon any excitement or sudden emotion, or during
the night from reflex causes, mostly of gastric origin ; or there may be
fits of tremor cordis coming on suddenly, without warning and appar-
ently without cause. The pulse is occasionally irregular in force and
frequency, or it may simply intermit at regular or irregular intervals.
These phenomena are always indicative of cardiac debility, which, left
to itself, sooner or later leads to dilatation of the heart as well as to
the other serious symptoms which we find associated with senile de-
generation of that organ. These symptoms depend upon structural
alterations in the heart itself, in its vascular and nervous connections,
as well as in the nutritive fluid, the blood. There is no regular se-
quence of events in any case. Not infrequently it may terminate in a
fatal attack of angina of the ordinary form, or occasionally in that form
of cardiac failure which may be called angina sine dolore. Other pa-
tients may suffer for years from irregularity or intermission of the
pulse or fluttering — tremor cordis — without any apparent detriment.
But, in Dr. Balfour's experience, such cases, unless remedied by treat-
ment, always ultimately develop serious cardiac symptoms, though this
may be delayed even to extreme old age.
The senile heart is a term which comprehends many symptoms and
a variety of signs, but which is at bottom a cardiac failure based upon
malnutrition. It is therefore most important to determine the cause
of this failure and to ascertain the source of the malnutrition upon
which it depends. In examining such a case with a view to treatment,
the pulse is one of those factors which require careful consideration.
When the blood-pressure is low we must inquire into any drains upon the
system and see that these are remedied ; we must inquire into the
amount and nature of the work done, and the exercise usually taken.
Exercise is a useful tonic for a muscle, including the heart, yet with all
muscles rest is often the best recuperative, and with a failing heart this
is often markedly the case. The need for exercise and the capacity
for taking it safely and with advantage is often a point to be carefully
considered before a decision is arrived at.
The question of diet is even more important than that of exercise.
In patients with weak hearts and feeble circulations the digestion is
slow and the intervals between meals should not be less than five
hours. As little fluid as possible should be taken with the meals, and
no solid food of any kind between them. The most important meal
should be in the middle of the day. The quantity of food should be
restricted, but the patient may choose pretty freely as to the kind and
the method of preparation.
Dr. Balfour never advises alcohol in any form for such cases. To-
bacco also must be used in great moderation or given up altogether.
The drugs useful in the senile heart are few in number, but of ex-
treme value. Digitalis is the chief and the most thoroughly reliable
27
cardiac tonic. It acts by improving the elasticity of the heart muscle
and restoring its tone. If the dose of digitalis is moderate, this in-
crease of tone, accompanied by an improvement in nutrition, may be
kept up and continued indefinitely for months or years without fear of
its action going farther. Ten minims of the tincture once or twice a
day is sufficient.
Strychnine is a very valuable remedy. In many cases its continu-
ous use is sufficient of itself to promote a cure. Arsenic is extremely
useful at times, especially in cases of angina.
Next to strengthening the heart and improving the blood, lowering
the blood-pressure is the most important object of our treatment.
All the nitrites are available for relieving spasm and lowering blood-
pressure, but nitroglycerin seems to act most rapidly and effectively.
When the high intra-arterial blood-pressure is more persistent and
more distinctly gouty in its character, the iodide of potassium is to be
preferred, as its action, though less rapid, is more permanent. Two or
three grains may be given every eight or twelve hours, and its use con-
tinued for some time. A mild course of anti-arthritic treatment is
often of much service, and for this purpose there is no better drug
than colehicum. The bowels should be kept moving regularly. In
case of flatulence the compound galbanum pill often gives relief.
Salicylate of Sodium in the Treatment of Pleurisy with Effusion. —
Dr. Charles Talamon calls attention (La Medecine moderne, June 18th) to
the prompt and efficient action of salicylate of sodium in the treatment
of pleurisy with serous effusion. He gives the histories of five cases,
in all of which the administration of the drug was followed by the rapid
absorption of the fluid. In three of the cases thoracentesis had al-
ready been twice performed, but the liquid had accumulated as abun-
dantly as before. Salicylate of sodium was then given, and at the end
of a week the effusion had entirely disappeared. A marked diminution
of the fluid was appreciable as early as the second or third day of the
treatment.
In discussing the mode of action of the salicylate, Talamon is not
inclined to agree with Stiller, who believes that it acts simply as a
diuretic. It is true that in two of his cases the amount of urine was
increased rapidly from two to four and six pints a day. But, as he ob-
serves, diuresis can be provoked by other drugs, and yet the pleural
effusion remains unaffected. Besides, in the three other cases the ab-
sorption of the fluid was affected just as rapidly, though there was no
polyuria.
The author thinks that the experiments of Rosenbach and Pohl
have a very important bearing on this question. They have proved
that the salicylates, when introduced into the digestive tract, are to be
found later in all the serous cavities of the body, those that are normal
as well as those in a morbid condition. Hence they even advise the
direct injection of the drug into the pleural cavity after the evacuation
of the liquid by aspiration. The salicylate would then have a direct
action upon the inflamed pleura and the remaining exudation.
Whatever its mode of action, Talamon holds that the therapeutic
value of salicylate of sodium in these cases is undoubted. It should be
given for a week, the dose being fifteen grains four to six times a day.
The more recent the pleurisy, the more prompt the action of the drug.
But it is of service at any time during the couise of the disease and is
especially indicated after thoracentesis, to complete the absorption of
the fluid and prevent its re-accumulation.
IP i s r c 1 1 \\\\\) .
The Action of Tuberculin upon the Experimental Eye Tubercu-
losis of the Babbit. — The following abstract of a report from the In-
stitute for Infectious Diseases, in Berlin, by Professor W. Doenitz, is
from the Deutsche mcdicinische Wochenschrift for November I '.1th :
Contrary to the negative results ;>f Haumgarten, the author said, in his
report before the Society of Charite Physicians, that he was now in a
position to demonstrate healed tubercular processes accomplished with
tuberculin, which had before been considered impossible. The author
MISCELLANY.
28
MISCELLANY.
|N. Y. Med. Jour.
then demonstrated in the eyes of a number of rabbits tubercular pro-
cesses established by inoculation, both with pure cultures and \\itli
tubercular tissues in various stages from that of the first irritative re-
action occurring about the middle of the third week after inoculation to
that of the complete cure, the latter resulting in from three to four
months, the eye retaining its function as a visual organ.
In the early part of the treatment with tuberculin the tubercular pro-
cess was hastened, cloudiness of the cornea and pannus developing rapid-
ly, whereas in the eye in the test animal the process was slower, with,
however, early necrotic processes at the seat of puncture and perforation,
this necrosis not occurring when tuberculin in gradually increasing doses
was administered. It was immaterial whether the treatment was be-
gun immediately after inoculation or at a time when true tubercle had
been formed. The administration of the product obtained from Koch's
tuberculin by Klebs was attended with only temporary improvement ;
the eyes were eventually lost. The same dose of the unmodified tu-
berculin, continued without increase, failed to produce good results.
The conclusions were:
1. Tuberculin is a sure curative agent for t he experimental tubercu-
losis of the eye of the rabbit.
2. Tuberculin shows its curative effect only after true tubercle can
be demonstrated.
3. The first effect of tuberculin is a transient but severe irritation
of the eye.
4. Under the continuous action of tuberculin, all irritation in the
eye subsides.
5. When, before the beginning of the treatment, deep-reaching de-
structive processes have not occurred, the cure results in retention of
the visual functions of the eye; otherwise, atrophy results.
ti. To a cure, it is necessary that the tuberculin be given in increas-
ing doses, and the continued maintenance of a not too slight reaction is
essential.
The Ohio Medical Colleges. — Pursuant to call issued by the Cincin-
nati College of Medicine and Surgery for a delegated convention of the
medical colleges of the State of Ohio, to be held at Columbus on De-
cember 3, 1891, representatives of the following faculties were present,
viz. : Starling Medical College, Toledo Medical College, Pulte Medical
College, Columbus Medical College, Medical Department of the National
Normal University, College of Physicians and Surgeons of Columbus,
Woman's Medical College of Cincinnati, and Cincinnati College of Medi-
cine and Surgery. On motion, Dr. Starling Loving was elected chair-
man and Dr. Charles A. L. Reed secretary. On motion of Dr. C. E.
Walton, representatives of the Physio-Medical Society of Ohio were ad-
mitted to a vote in the convention.
Dr. Charles A. L. Reed presented the following:
Resolved, By the medical colleges of Ohio, in convention assembled,
that the Legislature be and is hereby requested to enact a law which
shall embody the following features, viz. :
1. The creation of a board or boards of medical examiners in the
composition of which equitable and just representation shall be accorded
to the various recognized denominations of medical practice.
2. The examination of all candidates for the practice of medicine
holding diplomas hereafter issued by medical colleges which shall be
deemed in good standing by the board.
3. Exemptions from examination to extend only to those who at the
time of the enactment of this law shall be recognized as legal practi-
tioners within the meaning of existing statutes ; but all legal practi-
tioners shall be required to register.
4. A penal clause which shall secure the enforcement of the forego-
ing provisions.
Dr. C. E. Walton, on behalf of the Legislative Committee of Cin-
cinnati, presented the registration law approved and promulgated by
that committee. On motion by Dr. Shockey, the resolutions presented
by Dr. Reed were approved. On motion by Dr. Kinsman, the secretary
was directed to forward transi ripts of these proceedings to each local
me lieal society in Ohio, and to the medical press. On motion by Dr.
S -oviHc a committee was appointed to confer with the Legislative Com-
mittee of Cincinnati for the purpose of securing such changes in the bill
proposed by that committee as to make it conform to the resolutions
adopted by this convention. The chair appointed as such committee
Dr. S. S. Scoville, Dr.T.C. Hoover, Dr. G. W. Mayhugh.and Dr. Charles
A. L Reed.
An Army Medical Board will be in session in Chicago, 111., din-
ing February, 1802, for the examination of candidates for appointment
in the Medical Corps of the United States Army, to (ill existing vacan-
cies. Persons desiring to present themselves for examination by the
board will make application to the Secretary of War, before January
15, 1892, for the necessary invitation, stating the date and [dace of
birth, the place and State of permanent residence, the fact of American
citizenship, the name of the medical college from whence they were
graduated, and a record of service in hospital, if any, from the au-
thorities thereof. The application should be accompanied by certifi-
cates, based on personal knowledge, from at least two physicians of
repute, as to professional standing, character, and moral habits. The
candidate must be between twenty-one and twenty-eight years of age,
and a graduate from a regular medical college, evidence of which, his
diploma, must be submitted to the board. Further information regard-
ing the examinations may be obtained by addressing the Surgeon-Gen-
eral, United States Army, Washington, D. C.
To Contributors and Correspondents. — The attention of all who purpose
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THE NEW YORK MEDICAL
#riofmai Communications.
THE NATURE AND CAUSE OF
;the scleroses of teie spinal coed*
By CHARLES L. DANA, M. D.,
VISITING PHYSICIAN TO BELLEVTJE HOSPITAL.
The subject of the pathology of the chronic fibroid
t processes of the nervous system is so large a one that I
propose to limit myself to a consideration of only certain
points of it. I shall take up only the fibroid processes as they
affect the spinal cord, and I shall furthermore discuss the
question of pathology, dwelling only incidentally upon aeti-
ology or therapeutics. I shall further exclude chronic men-
ingitis and arterial sclerosis, because, so far as the nervous
system is concerned, there is nothing in these different
from similar processes occurring elsewhere.
The chronic fibroid processes of the spinal-cord sub-
stance are known as scleroses, those of the nerves as de-
generative (or parenchymatous) and interstitial neuritis.
The spinal scleroses are easily divided into four classes :
L The 'primary degenerations, in which the sclerosis is
preceded by a destruction and atrophy of the nerve fibers
and cells.
II. The secondary degenerations, in which the sclerosis
is preceded and due to a cutting off of certain nerve strands
from their trophic centers.
III. The inflammatory and reparative scleroses, in which
the process is the result of a destruction of nerve tissue by
inflammation, injury, pressure, or obliteration of vessels.
IV. The mixed forms.
Of these three forms of sclerosis it is the first about
which the most obscurity prevails, and it is about these
forms that the greatest interest centers. These primary
scleroses are :
1. Locomotor ataxia.
2. Lateral sclerosis (if it exists).
3. The combined scleroses.
4. Multiple sclerosis.
5. Progressive muscular atrophy and its modified type,
amyotrophic lateral sclerosis. \
The Nature and Cause of the Primary Scleroses. — Mod
ern ideas regarding these scleroses have undergone consid-
erable change. It has been and still is taught by some
that the process is a parenchymatous inflammation with
secondary growth of connective tissue. But such an idea
is no longer held by the majority of neurologists and pa-
thologists. The modern conception of inflammation, that it
is a process dealing with connective tissue and blood-ves-
sels only, renders the idea of an inflammation of parynchy-
matous tissue and specialized cells quite untenable. The
term parenchymatous inflammation is likely to be dropped
from our nomenclature therefore.
If not an inflammation, what is the process ?
* Read in the discussion on Chronic Fibroid Processes before the
Congress of American Physicians and Surgeons, September 24, 1891.
\ Ependymal and annular scleroses are mentioned by some authors,
but they belong to class iii.
JOURNAL, January 9, 1892.
So far as the microscope shows us, it is gradual decay
and death of the nerve fiber and cell. In some fibroid
processes, like locomotor ataxia, this decay is accompanied
with the development of irritating products, leucomaines,
or toxalbumins, which may produce so active a change in
the connective tissue as to lead to something resembling a
secondary or reactive inflammation. This is never of high
grade, however, and in some forms of tabes is very slight.
In progressive muscular atrophy the decay and death
produce few irritating products, though enough perhaps to
account for the fibrillary twitchings and occasional hyper-
tonic condition of the muscles.
The ultimate cause of these degenerative processes is
not known. This is just now the opprobrium of neuropa-
thology and the problem that most needs working out.
They are not due to any known "diathesis."
The T oxine Theory. — The progressive character of the
diseases like locomotor ataxia and progressive muscular
atrophy would lead one to think that there is a poison
constantly present in the body and constantly acting on the
diseased tissue. How otherwise can we explain why an in-
flammatory process in nervous tissue tends on the whole to
repair, to limit itself, and to recover, while a degenerative
process steadily and often speedily tends to progress ?
So far all bacteriological examinations have failed to
discover any microbe, but the fact that many degenerative
processes follow infectious fevers or syphilis has led to the
suggestion that pathogenic germs have poured into the
system a poison, or have so modified the cellular nutrition
that there is a poison constantly thrown out which irritates
and destroys certain areas of nerve tissue.
The Senility Theory. — Another view which may be held
is that, by the presence of the poisons of certain infectious
organisms, the nerve cell is stunned and its growth stunted.
Its nutritional equilibrium is destroyed, and premature se-
nility and death are brought about. Just as a man in the
full tide of life is made prematurely old by a severe illness
or shock, and begins to go down hill at the age of forty
instead of at a later age, so the nerve cell and fiber are
made unequal to their task and slowly die.
This explanation is undoubtedly the true one for the
hereditary scleroses like Friedreich's ataxia. In this dis-
ease certain strands in the spinal cord were never endowed
with vitality enough to carry on their functions for more
than a decade or two.
The theory of a steadily secreted poison, which may be
called the toxine theory, is the more hopeful one.
It is interesting in connection therewith to note that
degenerative diseases do not follow those infections which
do not confer long immunity — such as diphtheria, sepsis,
erysipelas, tuberculosis; while diseases that do confer long
immunity — like typhoid fever, measles, scarlatina, small-
pox, syphilis, etc. — are most likely to set up degenerative
changes. Now, as immunity is secured through the modi
fication of cell nutrition and through the continued presence
of some antitoxine in the liquor sanguinis,* it seems not
* J. Bunion Sanderson, Croonian Lectures on the Progress of Dis-
coveries in Relation to Infectious Diseases. Brit, Med. Jour., 1891.
30
DANA: SCLEROSES OF THE SPINAL CORD.
[N. Y. Med. Joub.,
unlikely that the very thing which protects against recur-
rence of infection may be the cause of some internal degen-
erative change.
The theory, however, of a premature and artificial se-
nility is, I am rather sorry to believe, more plausible, for it
is supported by the fact that in certain cases primary de-
generations are started by poisons, like lead or ergot, and
continue after the lead and ergot have been eliminated from
the system. Also by the fact that an inflammatory process
may set up a degenerative one, as when a chronic poliomye-
litis develops into a progressive muscular atrophy.
■M:
Via. a.
Fig. 1.
Neuroglia Sclerosis.— Fig. 1. Giay matter of the brain cortex in epilepsy.
same, much magnified. (Chaslin.)
Is So-called Sclerosis a Gliosis? — A further point of
great interest is the nature of the sclerosis in the primary
degenerative processes. It has until lately been held that
the sclerosis of locomotor ataxia, lateral sclerosis, etc., was
composed of connective tissue. Some facts have been
brought forward of late which threaten to revolutionize
this view completely.
It must be remembered that, while the matrix and sup-
porting structure of all other organs is connective tissue,
the matrix of the nervous centers is partly connective tis-
sue and partly neuroglia tissue. This neuroglia tissue, it is
admitted now, is of epiblastic origin, and allied more to
nervous than connective tissue. There is, to be sure, a
connective-tissue membrane, the pia mater, surrounding the
nervous mass, and sending saepta into it and following the
blood-vessels. But the neuroglia much more thoroughly
and completely surrounds and imbeds the fibers and cells.
In 1889 Chaslin (Journal des connuissances med.), study-
ing the brains of five epileptics, found a microscopical in-
crease in the neuroglial tissue. This, which would have
been called before a diffuse sclerosis, he believes is rather a
diffuse gliosis. He bases his view on a histo-chemical pro-
cess suggested by Malassez. The sections are placed for
ten minutes in a forty-per-cent. solution of caustic potash,
then washed, stained in carmin, placed in crystallized acetic
acid, washed, and mounted in acid glycerin. The connect-
ive tissue is softened and partly dissolved, and does not take
up the carmine stain, while the glia tissue is not injured
and is stained.
Achard and (xuinon (Arch, de med. exper., 1889, p. 701),
and Achard alone (Bull, de la Societ. anat., 1890, p. 200),
found a similar neuroglia proliferation in multiple sclerosis,
compression myelitis, tabes — in fine, in all the spinal scle-
roses, which they assert are in the main composed of neu-
Fig. 2. Tin-
roglia, not fibroid tissue. These scleroses differ somewhat
in the arrangement and relative amount of cells and fibrillse.
In true neoplasmic gliosis, or tumor formation, the cell pre-
dominates, hut in the ordinary sclerosis a fibrillary net-
work forms the most of the morbid structure.
Neuroglia sclerosis does not occur in the peripheral
nerves, except the optic, since they possess no neuroglia
matrix.
In April, 1890, Dejerine and Latulle announced (Bull,
de biol., March 8, 1890; La med. moderne, April 17, 1890)
that the sclerosis in Friedreich's ataxia was in reality a
gliosis, and in this respect differed from the
' ' ordinary scleroses.
Finally, Chaslin reviews the subject again
(Arch, de med. exper., 1891, No. 3) and reasserts
his views as to the dominance of the neuroglia
change in the primary scleroses and in certain de-
generative diseases, like idiopathic epilepsy.
The validity of the revolutionary views thus
put forward by French pathologists depends a
good deal on the Malassez stain. I have carefully
used this on cords from two cases of tabes and
on several other cords with primary and secondary
degenerations, and it does not give me satisfaction.
Nor, as I am informed, is Malassez himself sat-
isfied with it. Nevertheless, the conclusions based on its
use accord with probabilities, and even with the ordinary
and older descriptions of general pathologists, that those
chronic fibroid processes affecting the nervous system of
primary origin, at least, are largely gliomatous. And we
may yet have to speak of a posterior spinal fibrogliosis and
multiple fibrogliosis rather than of sclerosis.
The views here suggested that the scleroses are really
glioses may have some value in therapeutics. It is at least
somewhat curious that arsenic and silver, which have a dis-
tinct value in the treatment of these conditions, have no
value in fibroid processes elsewhere and are known to affect
epiblastic tissue rather than mesoblastic.
II. Regarding the secondary degenerations and the chronic
fibroid processes that are produced thereby, no facts of very
great or general interest have been brought out in recent
years. I refer more particularly to their pathology and a?ti-
ology.
Homen has brought evidence to show that the process
affects first the axis cylinder in its whole length; this swells
and undergoes granular decomposition. The myeline sheath
is affected later (Contribut. exper. a la path, et a Vanat. path,
de la moelle Spinier e).
The view that secondary degenerations are due to a
cutting off of the fiber from its trophic cell is no longer
doubted.
III. As to the inflammatory changes that lead to sclerosis,
I believe that much misconception still exists and that be-
fore a great many years there will be a reconstruction of the
views concerning what is now often called chronic myelitis,
transverse myelitis, compression myelitis, etc.
I take it that the neurologist can accept some such classi-
fication of inflammations as is given by the general patholo-
gist— e. g., that of Senn :
Jan. 9, 1802.]
QOULEY: DISEASES OF THE URINARY APPARATUS.
31
T. The simple and plastic inflammations.
II. The infective inflammations.
Then, as the simple and plastic inflammations' are mainly
reparative processes, and not inflammations, we may be
obliged, as Senn states, to admit some day that all true
primary inflammations of the cord are due to an infective
process.
This being- the case, we should find few cases of either
acute or chronic myelitis of primary origin, and, as a matter
of fact, this is the case. Thus, in my opinion, chronic mye-
litis, so called, is really the result, as a rule, of some injury
or focal softening, with resulting slow destruction of the
cord. Following and accompanying this is a reparative
process which may be called inflammatory, together with
secondary degenerations. Hence chronic myelitis is ordi-
narily a combination of —
1. A necrotic and destructive process.
2. A reparative inflammatory process.
A secondary degenerative process.
In what is usually called compression myelitis the pro-
Bess is one not of inflammation at all, but almost exclusively
of— ~
1. Destruction of tissue from pressure and eedema.
•2. Secondary degeneration.
To resume, I wish to point out that the term chronic
myelitis is used loosely and incorrectly for mixed processes
that have little or no inflammatory element in them, hut are
a mixture of necrotic, degenerative, and reparative processes.
I do not wish to deny, however, that true primary chronic
myelitis does not occur.
I have only been able to show, gentlemen, that there are
problems in neuropathology of enormous interest and prac-
tical importance. And I can only hope that my presenta-
tion of some of them here may give some further impetus
to their study and to efforts which will end in their final and
triumphant solution.
I append here a tabular view of the various scleroses of
the spinal cord, assuming yet that the processes are fibroid
and not general :
I. Primary Deyenerath'e Scleroses.
1. Posterior spinal sclerosis, locomotor ataxia.
2. Lateral sclerosis ? spastic paraplegia.
The combined scleroses, Friedreich's ataxia, ataxic
paraplegia, irregular forms.
4. Multiple sclerosis.
5. Progressive muscular atrophy and amyotrophic lat-
eral sclerosis.
II. Secondary Deyenerative Scleroses.
Of cerebral origin, lateral descending.
Of spinal origin, ascending and descending.
Of posterior root origin, posterior ascending.
III. Inflammatory Scleroses — so called.
Acute primary myelitis, | ^ ^
Chronic primary myelitis, \
Acute secondary .myelitis, )
Chronic secondary myelitis, - the common forms.
Chronic compressionjnyelitis,
These are mixed processes of softening, inflammation,
anil degeneration.
DISEASES OF THE URINARY APPARATUS.
By JOHN W. S. GOULEY, M. D.,
SURGEON TO BELLEVTJE HOSPITAL.
(Continued from page 11.)
PART I. — PHLEGMASIC AFFECTIONS.
Section- II. — SPECIAL CONSIDERATIONS.
VII.
PROSTATITIS AND UULIiO-URETHRAL ADENITIS.
Prostatitis — phlegmasia of the vesical prostatic body —
may begin and end in the glandular part (parenchymatous
prostatitis) ; it may thence extend to the interstitial connect-
ive and muscular framework of the prostate body (diffuse
prostatitis), or it may occur in the peripheral connective
tissue (periprostatitis). The phlegmasia may be superacute,
acute, subacute, or chronic.
Causes. — Prostatitis may arise from urethritis, from ve-
nereal excesses, from the contact of some irritant with the
mucous membrane of the prostatic region of the urethra,
such as often repeated strongly astringent injections in the
treatment of " gonorrhoea," from external injury, from vio-
lent catheterism, or from exposure to cold and dampness.
The superacute and acute types are of very rare occurrence,
and generally caused by the extension of acute or superacute
urethritis into the prostatic ducts and follicles, whence the
phlegmasia diffuses itself into the interstitial substance, and
sometimes extends into the peripheral connective tissue.
This is sometimes excited by the so-called abortive treat-
ment of "gonorrhoea " by the injection of a strong solution
of nitrate of silver. The subacute type affects at first the
parenchyma only, but later invades the interstitial substance,
and may gradually pass into the chronic type.
These several types of phlegmasia are apt to leave the
prostate in a very seriously damaged state, such as follows
destruction of a considerable proportion of the glandular
substance, induration, shriveling, etc.; still there are many
cases that end in resolution without apparent injury to any
part of the organ.
The chief symptoms of the acute types of prostatitis are,
in the beginning, a sense of weight in the perineal region ;
increased frequency and difficulty of urination ; pain ref-
erable to the urethro-vesical orifice ; and a sense of fullness
in the rectum, with tenesmus. . When the affection is con-
secutive to urethritis the patient notices a cessation of the
discharge, which is ordinarily the case in most of the conse-
quences of urethritis. In the course of two or three days
all these sensations are greatly intensified. The rectal
tenesmus is much increased, and the urgent desire to empty
the bowel is ungratifiable by reason of the prostatic swell-
ing. The dysuresis and stranguria become very distress-
ing; finally, ischuria supervenes, and there i< much pain in
the lumbar region and along the course of the sciatic and
anterior crural nerves, from the fast-accumulating urine in
the bladder. Any pressure in the perimeum gives a sharp
pain, w hich is acutely felt at the extremity of the urethra —
such as that experienced when a calculus comes in contact
with the urethro-vesi,cal orifice.
Trachelocystitis is almost always associated with pros-
32
OOULEY: DISEASES OF THE URINARY APPARATUS.
[N. Y. Med. Jod*
tatitis, and two other unwelcome guests — gonecystitis and
orchitis — sometimes intrude themselves to further distress
the sufferer.
The little urine passed spontaneously before the advent
of ischuria is acrid, high-colored, purulent, and at times
bloody.
Exploration with the finger introduced into the rectum
reveals much swelling, tension, heat, and hardness of the
prostate, which nearly fills the lower end of the rectum.
The slightest pressure made with this finger causes great
suffering to the patient, the pain extending to the glans
penis.
The diagnosis of acute prostatitis is based upon the
analysis of the symptoms detailed above and upon the rectal
exploration.
Progress. — Acute prostatitis generally resolves in the
course of three or four weeks, but sometimes suppurates.
The superacute type almost always suppurates.
The subacute type is slow in resolving, and sometimes
ends in an abscess or in multiple abscesses of very gradual
development.
In the superacute and acute types the advent of sup-
puration may be predicted when the occurrence of rigors
and febrile reaction is followed by throbbing pains in the
rectum and perinanim. The pus may find an outlet in the
bladder, in the urethra, in the rectum, or may point forward
toward the perina?um or backward toward the peritoneal
cavity. The relations of the prostate to the bladder render
possible the discharge in this viscus of an abscess pointing
superiorly and posteriorly. The directions most commonly
taken by the pus are toward the urethra and toward the
rectum. When the abscess opens on the floor of the urethra
by several small orifices, and freely discharges its contents,
no harm ensues, but w hen there happens to be a large open-
ing, the dangers of destruction of the whole prostate by the
urine, and of consequent pyosapraemia, are great.
A case illustrating this point occurred in 1864 at Bellevue
Hospital. The patient, a young man, was suffering from
retention of urine consequent upon a prostatic abscess. For
his relief a silver catheter was introduced, but met, in the
prostatic region, with an obstruction, which was, however,
overcome, the incidental pressure causing the instrument to
suddenly advance about an inch, when two ounces of creamy
pus flowed, but the bladder was not entered. From that
time the bladder relieved itself spontaneously. Symptoms
of pyosapraemia supervened, and the patient died in two
weeks. The necropsy revealed a ragged opening in the
floor of the urethra leading to a large cavity, with sloughy
walls, containing stale urine and pus. The whole prostate
was disorganized.
When the abscess points toward the rectum, digital ex-
ploration reveals fluctuation in that situation ; the prostate,
hard and tender during the periods of increase and stasis
of the phlegmasic process, is now soft and little sensitive
to the touch, one lobe or both lobes being in this state of
suppuration.
In periprostatitis, which is caused most frequently by
violent catheterism, the abscess often points forward toward
the perina-um. The abscess very rarely points backward.
The great danger in such cases lies in its breaking into the
peritoneal cavity. When the bladder is empty the recto-
vesical fold of the peritonaeum descends to about half an
inch of the base of the prostate, but as the bladder fills, the
peritonaeum ascends with it so that the antero-posterior
space uncovered by peritomeum is doubled in extent. In
some instances, however, as shown by the specimens ex-
hibited, the peritonaeum reaches and even overlaps the base
of the prostate. These facts are sufficient to account for
the occasional occurrence of peritonitis in cases of acute
prostatitis.
In the treatment of the acute types of prostatitis, local
antiphlogistic measures should be promptly adopted, the
main indications being to prevent suppuration and hasten
resolution. Antiphlogistic treatment is, however, applica-
ble only during the stages of increase and stasis. Later —
that is to say, when there are already signs of softening
and suppuration — this treatment is of no avail, and may
even be harmful.
In any case of acute prostatitis the first inquiry of the
physician should relate to the condition of the bladder. If
he finds retention of urine, he should lose no time in reliev-
ing the distended bladder. Unless the bladder is kept
empty, any mode of treatment tending to favor resolution
of the phlegmasic process in the prostate must inevitably
fail, for the distended bladder mechanically impedes the
venous circulation in its vicinity. Catheterism in cases of
swollen prostates is often very difficult and requires the ut-
most caution and gentleness. The use of metallic catheters
is unjustifiable in the vast majority of cases of retention of
urine from acute prostatitis. The safest and most efficient
instruments for this purpose are the soft, curved, so-called
gum catheters, not larger than No. 9 of the English scale.
Such catheterism is ordinarily required every five or six
hours for at least a week. Recumbency is, of course, en-
joined.
After the intestinal tract has been emptied, the rectum
should be thoroughly washed. Immediately after the cleans-
ing process three or four leeches should be applied to that
part of the rectum underlying the prostate. This can be
conveniently accomplished with the aid of the leech-tube
devised by Dr. James S. Hughes, of Dublin. This tube is
much better than those of Begin, Henderson, and Craig.
The following is Dr. HughesVdescription of his leech-tube :
" The instrument . . . consists of a curved gum-elastic
or gutta-percha tube, of about six inches in length, open at
one extremity, closed at the other, the latter being rounded
off and inverted or bell-shaped, and perforated with two or
more conical holes capable of enabling the leeches to do
their duty but not to escape through. The lesser curve of
the tube is grooved or concave externally. The following
is the mode in which the instrument should be used : The
patient having been placed in the kneeling posture, the
surgeon should pass the forefinger of his left hand, pre-
viously well oiled, into the rectum with a gentle rotatory mo-
tion, until it has reached the inflamed prostate; he then
should take with his right hand the leech-tube, previously
oiied and furnished with from one to four leeches, as the ease
might be, and pass it along the curved dorsal aspect of the
Jan. 9, 1892.]
OOULEY: DISEASES OF THE URINARY APPARATUS.
33
left forefinger to the exact spot where the leeches ought
to be applied, the left forefinger acting as a director to
the leech-tube, and forming with it, as it were, one instru-
ment, the concave surface of the tube traversing and adapt-
ing itself to the convex surface of the finger. By this
simple contrivance leeches can be brought and kept in con-
tact with the rectal surface of the prostate without danger
of their escaping from the instrument into the intestine,
on the one hand, or of the tube becoming blocked with
feculent matter on the other." These leech-tubes of Dr.
Hughes's have lately been made of glass.
There may be circumstances forbidding the application
of leeches to the rectal mucous membrane. In such cases,
ten or twelve leeches may be applied to the perineal and
anal regions, the effect of either mode of leeching being
to disgorge the pne-prostatic plexus of veins and thus re-
lieve the blood stasis in the capillary vessels of the prostate.
When it is judged that a sufficient amount of blood has
escaped after the dropping of the leeches, the rectum should
be cleansed and then packed with ice, which should be re-
newed as fast as it melts, means, such as the introduction
of a gum-elastic tube, being provided for the escape of the
water if it does not flow freely during the insertion of new ice
suppositories. This ice treatment should be continued two,
three, or four days, according to the necessities of the case.
The relief afforded by the cold is great, and enables the pa-
tient to obtain much refreshing sleep. During the day the
ice is renewed every half-hour if need be, but once every
two hours in the night generally suffices, the patient wak-
ing to ask for a renewal of the ice suppositories. Should
it not be possible to continue the use of ice by the rectum,
an India-rubber bag filled with ice could be applied to the
periiueum, and the benefit of dry cold thus obtained.
During these three or four days catharsis should be kept
up by drachm doses of sulphate of sodium, dissolved in three
ounces of hot water, every four hours. Tartarized anti-
mony was formerly given in doses of one eighth of a grain
every four hours, but this can now be judiciously replaced
by diaphoretics that cause less depression than the anti-
monial salt.
To insure diuresis, from forty to sixty grains of bicar-
bonate of sodium should be given in six ounces of water
three and even four times daily. This alkali, in such cases,
acts as an antiphlogistic and as a diluent counteracting the
acridity of the urine. A full dose of morphine by the
mouth or hypodermically serves the purposes of relieving
pain and inducing sleep. The diet should be restricted to
broths and bread and milk.
If resolution begins within a week from the onset of
the phlegmasia, it may be promoted by hot enemata, hot
fomentations to the hypogastric and perineal regions, and a
hot hip bath of five minutes' duration every night. Inter-
nally, five grains of chloride of ammonium may be <;i\cii
four times daily, and mild saline aperients administered
every morning. Under favorable circumstances, in the
course of two or three weeks from the beginning of resolu-
tion the prostate nearly regains its normal condition. Re-
constituents and a generous diet are then indicated.
When resolution fails and suppuration occurs, the sooner
the pus is allowed free outlet the better. If the pus is dis-
charged into the urethra, the greatest care should be taken
to prevent the urine from entering the abscess cavity. The
patient should not be allowed to urinate spontaneously, but
the catheter introduced, as before, every five or six hours,
for two or three weeks after the first gush of pus, so as to
give time for contraction of the cavity and healing by
granulation from the bottom. If the pus points toward the
rectum, a Sims speculum should be introduced and a suffi-
ciently free incision made into the abscess, whose cavity
should be well disinfected and loosely packed with antisep-
tic gauze. If the cavity is very small, it may be left to
granulate without packing. When, as in periprostatitis, the
abscess points toward the perinasum, if fluctuation is de-
tected by perineal palpation, a central perineal incision an-
swers the purpose of emptying it ; but if the indications of
suppuration are entirely by rectal exploration, a crescentic
incision, followed by careful dissection between the urethra
and rectum, is required to safely reach the purulent focus,
after whose evacuation and cleansing with peroxide of hy-
drogen solution the same dressing may be made as in the
other cases. As a general rule, the parts heal by granula-
tion in the course of four or five weeks.
Prostatitis from exposure to cold and dampness is not an
uncommon occurrence among elderly men whose urination
may or may not have been impeded before such exposure.
From the cases observed, three are selected to illustrate the
ill effects of a phlegmasia which involves the mucous mem-
brane of the prostatic region and of the urethro-vesical
orifice, together with a very superficial layer of the prostatic
parenchyma, causing an ^edematous swelling of the mucous
membrane that may be likened to oedema of the glottis
from the suddenness of its invasion and rapidity of swell-
ing. In two or three hours after the exposure there is fre-
quent and difficult urination, and, within six or eight hours,
retention of urine.
A patient, sixty-six years of age, who had never had
any hindrance to urination, left the city in apparent good
health to spend the night at his suburban residence on a
cool mid-September evening. From the railway station to
his house the distance is about a quarter of a mile. He
walked briskly and was somewhat heated on his'arrival.
He remained for a time out of doors, and, desiring to uri-
nate, exposed his pudendal region in the act of relieving bis
bladder. At that moment he experienced a distinct chilly
sensation, and thought nothing of it until later in the night,
when he was several times obliged to urinate. Before sun-
rise the frequency of urination had greatly increased, so
that he was disturbed every ten minutes, suffering much
burning pain at each act. He returned to the city early in
the morning, when he was unable to pa-s single drop of
urine. The catheter was used, much to his relief, but he
could not afterward urinate spontaneously. He died within
six months from the date of the attack. The necropsy re-
vealed a hard, thick, bar-like obstruction at the urethro-
vesical orifice, but the prostate was very little enlarged.
Tins urethro-vesical bar indicated that suprainontanal en-
largement had begun, but was not sufficient to interfere wit I i
urination until the advent of the acute pbleginasic swelling.
34
GOULEY: DISEASES OF THE URINARY APPARATUS.
[N. Y. Med. Joue.
Tt is evident that the continuance of the obstruction was
owing to an abundant unresolved exudate.
A similar accident happened to a patient, fifty-eight
veais of age, who sat for several hours in the evening on
the piazza of a watering-place hotel late in the autumn, the
ail- beinn' chilled and the fog dense. During the night he
was tinahle to urinate, and from that time was compelled to
rely upon the catheter for relief, lie had never before had
any impediment to urination.
A patient, sixty-three years of age, who in the course
of the previous ten years had several times suffered from
retention of urine, imprudently sat during the evening on
the stone steps of his house late in the month of August.
At length, feeling chilly, he Avent to bed. In the morning
he was unable to urinate, and from that moment required
frequent catheterism for nearly two months, after which he
was able to urinate spontaneously, but could not completely
empty his bladder, the urethro-vesical obstruction having
become permanent. At the time of the retention of urine
the prostate was considerably swollen, but was afterward
reduced to nearly its normal size, except, of course, in the
supramontanal region.
The same phlegmasia occurs very commonly in young
and middle-aged subjects from exposure to cold and damp-
ness during the decline of acute urethritis or during a de-
bauch. This has been improperly called acute inflamma-
tory stricture. The bladder, suddenly distending, causes
great suffering, and the patient is likely to apply for relief
during the first day. Not many years ago these cases were
subjected to vigorous antiphlogistic treatment, but of late
years the first care has been to empty the bladder by the
prompt introduction of a gum catheter. This is followed
by the use of ice suppositories for a few hours, and then by
free catharsis. Sometimes a single catheterism suffices, but
it is ordinarily advisable to enjoin two or three days of re-
cumbency and the free use of diluent beverages. Deliques-
cence, or at least very rapid resolution, generally occurs in
these last-named cases.
The chronic type of prostatitis — variously named
catarrhal prostatitis, mucous prostatitis, follicular prosta-
titis, canalicular prostatitis, prostatorrluea, etc.— is of much
more common occurrence than the acute types, and be-
gins in the mucous membrane of the prostatic sinus,
reaching filially the utri cuius, the prostatic ducts, crypts,
and interstitial tissues. Its development is so gradual
that often it is not recognized for a long time. It is
ordinarily one of tin; phases of chronic urethritis, whether
this urethritis be the outcome of acute urethritis, of mas-
turbation, or of venereal excesses, or whether it is excited
by hyperlithuria, by the lodgment of urinary calculi in the
prostatic sinus, by chronic cystitis, by a urethral stricture,
bv frequent catheterism, by the extension of phlegmasia
from the seminal vesicles,, by the irritation caused by
haemorrhoids, or by the prolonged retention of catheters in
the bladder.. Chronic prostatitis may also be a sequel of
acute prostatitis. Although chronic prostatitis ordinarily
affects young and middle-aged men, it not infrequently
occurs among elderly men suffering from prostatic enlarge-
ment. In these cases it is the outcome of the frequent
catheterism rendered necessary by the urethro-vesical ob-
struction.
The chief symptoms of chronic prostatitis are sensations
of fullness and weight in the perinaeum and rectum, perineal
tenderness experienced in the sitting posture, dull pains in
the perineal and anal regions increased by active exercise
and sexual contact, pains in the lumbo-sacra) region and in
the lower extremities, occasional painful seminal emissions,
costiveness, frequent urination, painful urination particu-
larly at the close of the act, a slight muco-purulent, yellow-
ish urethral discharge, and, during defecation, a free urethral
discharge of milky prostatic fluid rendered slightly viscous
by the admixture of the secretion of the urethral mucous
glands. The characteristic odor of the mucus of these
glands is imparted to the prostatic fluid and semen, which, by
themselves, are odorless. To this last symptom the name
prostatorrhcea owes its origin, and from this symptom arose
the erroneous popular belief that the glairy fluid in question
was semen. To some patients this discharge of prostatic
fluid is a source of much anxiety. They imagine them-
selves affected with seminal incontinence and even impo-
tency, and become the easy victims of designing charlatans.
In. certain cases the sexual act is attended with so much
pain that it is at last abandoned and in time the desire is
abolished. Such patients become sullen and lead a life of
seclusion, their thoughts are centered upon their supposed
infirmity, and their forebodings are of countless imaginary
evils. This mental state is more likely to exist in men
whose health is already impaired, but undoubtedly causes
its further deterioration. Their sedentary life leads to loss
of appetite, disturbance of digestion and consequent hvper-
lithuria, costiveness, leucomainal toxaemia, languid circula-
tion, etc.
The physical characters of chronic prostatitis become
known partly during life and partly after death. Begin-
ning in the mucous membrane of the prostatic sinus, it
gradually invades the ducts, the crypts, and the interstitial
tissues. In some cases the prostate is soft, in other cases
it is indurated. Either condition may be ascertained dur-
ing life by digital rectal exploration.
In a large proportion of cases of chronic prostatitis the
mucous membrane of the prostatic sinus is in a granular
state, which can be seen with the aid of the urethroscope.
In some cases small retention cysts from the occlusion of
ducts, or degeneration cysts from isolated gradual degen- E
erative processes, or abscesses from sudden local necrosis,
are slowly developed in the substance of the prostate and
are detected by rectal exploration with the ringer, and by
subsequent puncture with a small trocar. Very rarely it is
found that the greater part of one lobe is destroyed by an i
abscess.
Dissection of the prostates of patients affected with
chronic prostatitis, dying from some intercurrent disease,
has revealed the granular condition to which reference has
already been made, the granular mucous membrane being
red fnun congestion up to the vesico-urethral orifice, a
spongy, soft state of the prostate, which is somewhat larger
than natural and may contain degeneration cysts or small
Jan. 9, 1892.]
GOVLEY : DISEASES OF THE URINARY APPARATUS.
35
abscesses, or a hard state of the prostate, which is decreased
in size and sometimes contains retention cysts, and the
ptri cuius occasionally rilled with pus.
When the prostatic crypts have become involved in the
phlegmasia process, their microscopic sympexia are set free
by the exudate and are then metamorphosed into calculi
which, by the accretion of concentric phosphatic layers,
attain in time very considerable dimensions. In one case
a thousand such calculi, each about half a millimetre in
mean diameter — except three, one of which weighed three
grammes fifty centigrammes, and the other two weighed
together twenty centigrammes — were removed, through a
perineal incision, from the prostate of a man twenty-six
years of age. In another case eighteen prostatic calculi
were similarly removed from a man fifty-four years of age.
These eighteen calculi averaged seven millimetres, the
largest measured ten by fourteen millimetres, the smallest
three millimetres; the whole weighed one hundred and forty-
grains — about nine grammes. Both patients were cured by
the operation.
In perhaps five per cent, of the prostates dissected dur-
ing the past twenty years, several small calcareous concretions
have been found occluding the mouths of prostatic ducts or
lying free in the prostatic sinus, and in a much greater
percentage of these prostates, particularly those of elderly
men, the calcareous transformation was verified by the in-
ordinately gritty state of the substance of the organ. This
it seems is evidence of chronic phlegmasia action sufficient
to disturb or even to kill the sympexia, which then become
foreign bodies. It is when these foreign bodies are not
speedily cast away that they receive successive layers of
calcium phosphate until they greatly dilate and finally de-
stroy most of the prostatic crypts.
In chronic prostatitis arising from narrow urethral strict-
ures, not only are the ducts dilated by the refiuent urine,
but the prostatic sinus also undergoes expansion. One of
the specimens exhibited is from an extreme case of ectasia,
the prostatic sinus being dilated to the extent of containing
at least thirty grammes (one ounce) of fluid, the substance
of the prostate being soft and spongy.
The diagnosis of chronic, prostatitis is based upon close
analysis of the symptoms, examination of the urine, physi-
cal exploration, the anatomical characters, and the history
of the affection. The symptoms can be rightly interpreted
only in connection with the examination of the urine and
the physical exploration.
The urine of patients affected with chronic prostatitis
is generally somewhat cloudy, owing to the presence of pus
and epithelium from the prostatic region and sometimes
also from the bladder. The many shreds and scrolls so
Commonly seen in this urine are shown on microscopical
examination to consist of pus, epithelial cells, and some
blood-cells held together by mucus. Among these shreds
and scrolls are sometimes seen long cylindrical bodies which
appear to be casts of the smaller prostatic ducts. Greal
quantities of octaedra of calcium oxalate are frequently
found in the urine of these patients; at times lozenges of
uric acid, at other times the urates in great abundance.
Microscopic sympexia cast away from the prostatic crypts
are often found in this urine, particularly in the case of
elderly men.
A convenient method of obtaining pus from the pros-
tatic sinus for microscopical examination is to introduce
into the sinus of the urethral bulb a hollow, soft, No. 12
English bougie, with an acorn-shaped vesical extremity,
with three or four perforations at the base of the acorn,
and to syringe in four or five ounces of warm water for the
purpose of washing away, by the retrograde current, the
pus that may have accumulated in the spongy urethra.
This accomplished, the bougie is carried onward as far as
the urethro-vesical region and then withdrawn. The pus
found coating the base of the acorn is then placed upon a
glass slide, properly covered, and subjected to microscopic
inspection. Mixed with this pus are many epithelial cells,
perhaps some easts of the smaller prostatic duets, and pos-
sibly a few sympexia, but no spermatozooids.
The first step in physical exploration is digital rectal
examination. By this it is ascertained if the prostate be
tender or insensible to the touch," hard or soft, decreased or
increascd in size, smooth or nodular; if nodular, whether
the nodules be firm from organized plasma, doughy from
purulent accumulation, tense from cystic formation, or of
stony hardness from the presence of calculi.
The next step in this exploration is an examination of
the urethra fur the purpose of excluding urethral stricture,
trachelocystitis, or vesical stone. Chronic prostatitis be-
ing sometimes the indirect outcome of urethral stricture,
the urethra should be explored with a bulbous bougie to
make sure of the existence or of the non-existence of
stricture. The granular condition already referred to can
be ascertained with the aid of the urethroscope.
The sharp pain at the urethro-vesical orifice during
urination or at the moment of entrance into the bladder of
a bougie or catheter indicates the complication trachelo-
cystitis, which is so frequent that the coexistence of these
affections has given rise to the term chronic prostato-cys-
titis. The persistent vesical pains simulate so much some
of the symptoms of stone as to warrant an exploration of
the bladder with a rectangular staff to clear any doubt in
this respect. When the pain caused by the exploration i.s
slight and confined to the prostatic region, the case may be
regarded as uncomplicated chronic prostatitis.
The treatment of chronic prostatitis is varied in accord-
ance with its different phases, complications, and conse-
quences.
Uncomplicated chronic prostatitis attended with a flow
of from a few drops to nearly a drachm of prostatic fluid
during defecation, so common among continent men, and
still more so among those addicted to masturbation, re-
quires moral as well as local and constitutional treatment.
The moral treatment is the most difficult of the self-
imposed tasks of the physician, who must employ much
circumspection before he can pass judgment upon the
needs of particular cases. In examining and advising any
individual, he may exercise the greatest firmness, tempered,
however, with patience, forbearance, and kindness. Thus
he enlists the confidence of the sufferer, endeavoring to
lead him to understand, first, that his local ailment is cura
36
GOULEY: DISEASES OF THE URINARY APPARATUS.
[N. Y. Med. Joob.,
ble ; second, that he is not suffering from seminal inconti-
nence ; third, that he is not impotent ; and fourth, that he
can not be cured unless he gives up the had habits he may
have acquired, and occupies his mind with subjects other
than his ailments. When the patient is responsive to the
moral treatment, more than half of the cure may be con-
sidered accomplished.
The local treatment of uncomplicated chronic prostatitis
consists in irrigating the prostatic sinus once daily, with the
object of washing away the mucus and pus which may have
accumulated in the sinus and in the larger prostatic ducts.
The fluid for irrigation should at first be a one-per-cent.
watery solution of boric acid, using not less than four
ounces of this solution for each irrigation. This often suf-
fices in certain cases, but may be used with advantage as a
preparatory step to more active measures when such are
necessary. The manner of making this irrigation is to in-
troduce a No. 8 or No. 9, English, uniocular, curved gum
catheter into the membranous region of the urethra, and to
slowly inject the fluid, which, passing through the prostatic
urethra, dislodges and carries into the bladder the muco-
purulent contents of the prostatic sinus. If any of the thud
flows out of the urethra beside the catheter, it is an index
that the catheter has not reached the membranous region.
In that case the instrument should be made to advance a
little farther ; then the injection surely enters the prostatic
region and bladder. When the four ounces have been
thrown in, the catheter is pushed into the bladder, whose
contents are allowed to escape into a glass vessel to be ex-
amined for flocculi of muco-pus and epithelium, and to
make sure that the cleansing process has been successful.
These irrigations are very effective also in the chronic
prostatitis of elderly men. In many cases the prostatic
sinus is filled by a plug of tenacious slime, which for hours
is a source of irritation and of frequent prostatic spasms,
until it is suddenly forced out by a stream of urine. The
daily use of irrigations with the boric-acid solution almost
invariably has the effect of breaking up this tenacious slime,
or of preventing its accumulation. In case of granular ure-
thritis of the spongy portion, it is wise to irrigate the whole
canal. When these simple irrigations are insufficient to
relieve the local distress, the use of steel sounds of increas-
ing size has the double effect of dilating the canal and, by
compression, of causing the granulations to disappear. The
sound should not be passed often er than twice each week.
In conjunction with this process of dilatation, every third
or fourth day the prostatic region of the urethra should be
irrigated with a solution of nitrate of silver, one grain to
the ounce, increasing its strength at subsequent sittings to
two, three, and even five grains to the ounce of distilled
water, and using only one ounce of the solution. The blad-
der should contain a few ounces of urine, so that the nitrate
of silver may be decomposed and rendered harmless to its
mucous membrane. The method of Guyon, by the instilla-
tion of five, ten, or twenty minims of nitrate-of-silver solu-
tion, from five to thirty grains to the ounce, is also em-
ployed in chronic prostatitis, but the use of a larger quan-
tity of a weaker solution, such as one ounce, is preferable,
as the fluid has a better chance of entering the prostatic
ducts, and it is not desirable that the strength of the solu-
tion exceed five grains to the ounce. Before making the
injection the prostatic urethra should be well cleansed with
pure water. The immediate effects of the injection are a
severe burning pain in the prostatic region and frequent
and almost irrepressible urination, lasting an hour or two
hours. There may even be a slight haemorrhage, which,
however, soon ceases. Afterward the muco-purulent dis-
charge is much increased, but lessens and nearly disappears
in two or three days. It sometimes happens that after the
first or second injection of nitrate-of-silver solution there
are no longer any manifestations of chronic prostatitis, but,
as a general rule, several injections are necessary to effect
a cure.
Other substances have been used in solution for irriga-
tion in chronic prostatitis, such as mercuric or zinc chlo-
ride, copper or zinc sulphate (five grains to the ounce), res-
orcin, otherwise known as metadioxybenzol (ten grains to
the ounce), but they are not equal to nitrate of silver in
solution of moderate strength, the great advantage of ni-
trate of silver being that.it is decomposed and becomes in-
nocuous as soon as it has caused coagulation of the albumin
of the superficial layer of epithelial cells.
In some cases of chronic prostatitis, owing perhaps to
a slight imprudence or error in diet, the urethral discharge
greatly increases, becomes creamy, simulating acute viru-
lent urethritis. There are inordinate frequency and pain in
urination, and a train of symptoms which are very apt to
mislead the inexperienced. Such patients should not at
first be subjected to local treatment, as it would be likely to
aggravate the phlegmasia and cause some serious complica-
tion. Three or four days of iest and the free use of dilu-
ent drinks generally suffice to cause the cessation of all
these phenomena. Then the local treatment may with safety
be applied.
It is scarcely necessary to say that no success in treat-
ment can be attained in complicated cases unless the com-
plication is treated at the same time. If chronic cystitis
exists, it demands special local treatment ; if a urethral
stricture should be detected, dilatation, divulsion, or ure-
throtomy might be required. If painful haemorrhoids or
anal fissures are the complication and perhaps also the cause,
they should be appropriately treated. When prostatic cal-
culi have already formed, they should, if possible, be re-
moved without delay.
In those cases attended with constant dull pain in the
perineal region and tenderness of the prostate it is proper
to use counter-irritants for five or six weeks. Painting the
perimeum with strong tincture of iodine, first on one side
of the rhaphe, then on the opposite side, every two or three
days, often answers the purpose ; otherwise vesicating col-
lodion may be similarly applied, avoiding the scrotum and
anus, and covering the vesicated part with a thick layer of
absorbent cotton. Suppositories of opium and belladonna
may be occasionally used to relieve pain.
Small cysts or abscesses of the prostate may be tapped,
by way of the rectum, with a small trocar and irrigated w ith
pcroxide-of'-hydrogen solution.
Constitutional medication is necessitated by the generally
Jan. 9, 18112.]
GOULEY: DISEASES OF THE URINARY APPARATUS.
37
impaired health of most suiferers from chronic prostatitis,
and this medication is subject to such variations as may be
indicated by the characters of the constitutional manifesta-
tions. The use of bitter tonics in conjunction with an im-
proved diet is likely to sharpen the appetite and facilitate
digestion. Active treatment for hyperlithuria may be neces-
sary. Iron and quinine are of value as reconstituents. Lax-
atives soon have the effect of preventing faecal accumulation,
and afterward equal parts of tincture of chloride of iron,
tincture of cantharides, and fluid extract of ergot, given in
doses of ten minims twice daily, complete the internal medi-
cation. Then frequent general bathing followed by fric-
tions, and increasing exercise, comprise the hygienic meas-
ures.
Bulbo-urethral Adenitis. — Before examining the
phlegmasia processes to which the bulbo-urethral glands
are subject, some points in their history, special anatomy,
and physiology may with profit be studied. These glands,
the analogues of the vulvo-vaginal glands, were discovered
by Mery, and a very brief description of them was inserted
in the Journal des savants, June, 1684. Fifteen years after
this, in 1699, Cowper published, in the Philosophical Trans-
actions, a note on these glands, and in 1702 gave of them a
detailed description, and they have since borne his name.
Several other anatomists laid claim to their discovery and
each gave them a new name, such as little prostates, acces-
sory prostates, inferior prostates, antiprostates, etc. In
1849 Gubler published, as his inaugural thesis, an exhaustive
study of the anatomy and the phlegmasia of these glands,
and adopted for them the name of bulbo-urethral glands on
account of their site. They consist of a pair of compound
racemose glands encapsulated by fibrous tissue, situated be-
hind the urethral bulb, between the two layers of the tri-
angular ligament, in the substance of the ischio-urethral
muscle, and beneath the membranous portion of the urethra.
They are generally about one millimetre on each side of the
median line, but sometimes in contact. They are globular,
discoid, or ovoid in form, and from five to eight millimetres
in mean diameter. In the foetus they are proportionately
much larger than in the adult. In some of the lower ani-
mals, as the Rodentia, they are very large. In color they
are pinkish yellow, in consistence firm and elastic.
In structure they are similar to the racemose glands and
consist of roundish cellules, ranging from the one six-hun-
dredth to the one three-hundredth of an inch in diameter,
grouped around small ducts after the manner of bunches of
grapes, the whole being bound by connective tissue and
capillary blood-vessels. The cellules and duels are lined by
a cubical epithelium. The ducts of several primary lobules
unite and form larger ducts which end in a common excre-
tory duct.
Each gland has a single common excretory duct which
(emerges from the anterior extremity of the gland. This
excretory duct varies in length from three to six centime-
tres, ami in diameter from a quarter of a millimetre to one
millimetre. As it emerges from the gland, this duct enters
the substance of the urethral bulb and traverses it obliquely
froin behind forward for" the space of one centimetre, where
are found the accessory lobules which led Cowper to be-
lieve in the existence of a third gland. The duct then takes
a nearly longitudinal course underneath the urethral mu-
cous membrane for a distance varying from two to five cen-
timetres and ends in a very narrow orifice beside the median
line a little in advance of its fellow, the two very rarely
having a common orifice. This orifice is sometimes so small
as scarcely to admit a hair. It is generally very difficult and
often impossible to find this orifice even in carefully dissected
fresh specimens. The mucous membrane of the ducts is
surmounted by a cubical epithelium resting upon a thin
membrane surrounded by longitudinal and circular bands of
smooth muscle tissue to be found also among the divisions
of the duct in the substance of the gland.
The secretion of the gland in the natural state is color-
less and viscid, and in pathic states becomes opaline or even
markedly turbid, without, however, losing its viscidity.
This secretion, whether in health or in disease, is much
more consistent than that of any of the uro-genital glands,
and it is this consistence which distinguishes it so well from
the others. This viscidity of the mucoid fluid is such that
it is easy to draw it into threads from ten to fifteen centi-
metres in length. It is of alkaline reaction, and when
rubbed has the property of frothing like soap-suds.
These glands are annexes of the genital as well as of the
urinary apparatus. As genital organs, their secretion, pro-
fuse at the beginning of the act, serves to lubricate the
glans penis to facilitate intromission, and, continuing during
the act, serves to dilute the semen. As urinary organs, their
secretion is among those designed to lubricate, and so pro-
tect the urethral mucous membrane.
Bulbo-urethral adenitis — phlegmasia of a bulbo-urethral
gland — is ordinarily the outcome of urethritis, but may also
arise in consequence of a blow upon the perinaeum or of an
injury of the gland's duct by the accidental penetration of
a capillary bougie. The left seems to be more commonly
attacked than the right, and very exceptionally are both
glands affected. The phlegmasia may be acute or chronic.
In the great majority of cases the acute type resolves in a
short time, suppuration being a rare termination. The
chronic type is more frequent than it is generally supposed
to be, and often constitutes one of the varieties of chronic
urethral discharge. Observation of this chronic discharge,
with induration and enlargement of the glands, led Cowper
and several of his contemporaries to believe that " gonor-
rhoea " was often caused by phlegmasia of the bulbo-ure-
thral glands, whereas this phlegmasia is in reality one of
the occasional consequences of " gonorrhoea. "
Acute bulbo-urethral adenitis consequent upon acute
Urethritis is often overlooked, because the perineal pain and
tension which so frequently occur on the second, third, or
fourth week of urethritis are not rightly interpreted, or not
considered worthy of attention, or perhaps they are at-
tributed to a purely neurotic condition, and the cessation of
the pain is believed to be due to the remedies that may
have been administered, whereas, in the majority of cases,
the pain ceases owing to rapid resolution of the phleg-
masia.
The subjective symptoms of this mild type of bulbo-
38
METTLER: THE TREATMENT OF INFLUENZA.
[N. Y. Med. Jode.,
urethral adenitis are painful tension m the perineal region
on the affected side, tenderness to pressure while the patient
is in the sitting posture, pain during walking exercise, from
friction by the clothing, and more or less burning sensation
in the region of the urethral bulb.
The objective symptoms are slight tumefaction corre-
sponding to the situation of the gland, which, though hard
and increased in volume, is movable ; moderate compression
of the gland with the finger, causing more or less pain,
which is propagated to the urethra. There is no febrile re-
action, no redness of the skin.
The progress of acute bulbo-urethral adenitis is ordi-
narily very rapid. As a general rule, resolution begins in a
few days. Otherwise, suppuration is established in the
course of ten days or, at most, two weeks. The phlegmasia,
at first confined to the gland, finally extends beyond its
fibrous capsule and into the ambient connective tissue, and
there is periadenitis. Then the gland can no longer be
felt, for it lies in a pus cavity. The abscess sometimes en-
croaches upon the opposite side, and extends forward to the
scrotum. The skin is cedematous, becomes red, then livid
in the center of the swelling, and at length ulcerates and
gives issue to the pent-up pus, and later, perhaps, to urine,
unless timely surgical aid had been obtained. The begin-
ning of the suppurative process is known by febrile reaction,
throbbing perineal pains, and increase of tenderness and
tension.
Among the consequences of neglected bulbo-urethral
adenitis are retention of urine from mechanical compres-
sion of the urethra by the abscess, perforation of the ure-
thra and urinary fistula, and obliteration of the excretory
duct of the gland.
The diagnosis is easy during the period of increase of
the phlegmasia. The situation of the swelling, its mobility,
its tenderness, viewed in conjunction with the history of
the case, demonstrate the existence of bulbo-urethral adeni-
tis. But when periadenitis is superadded, it may be con-
founded with urinary or simple abscess or a boil. Here,
again, the history of the symptoms comes in aid to make
certain the true nature of the swelling. If, after the ab-
scess has been opened, a fistula persist for months and dis-
charge a very viscid fluid, particularly at the beginning of
sexual contact, it may be asserted with confidence that this
fistula springs from the gland or from its duct, which may
be obliterated at its anterior portion. A fistula giving
issue also to urine indicates perforation of the urethra.
The treatment of acute bulbo-urethral adenitis during its
period of increase should be antiphlogistic, consisting in
the application of half a dozen leeches to the perinaeum,
after which the ice-bag is to be used for three or four days.
If at the expiration of that time resolution has not begun,
the swelling and tension have increased, and the pain is
throbbing, an incision should forthwith be made into the
substance of the gland. The patient is placed in the
lithotomy posture, a narrow, straight bistoury is plunged
into the swelling tat its most prominent point, and the
wound is enlarged to half or three quarters of an inch in
withdrawing the instrument. A few drops only of pus or
none may flow, but the tension will have been relieved and
perforation of the urethra prevented by this timely incision,
without which it is almost certain to occur. As soon as
the incision is made the cavity of the abscess should be
irrigated with pcroxide-of-hydrogen solution until the re-
turned fluid is clear. The wound is then dressed antisepti-
cally. Under favorable circumstances cicatrization is com-
plete in the course of ten days. In the case of an abscess
containing an ounce or two of pus there is very likely per-
foration of the urethra, and the healing process is necessa-
rily long. To insure cicatrization, the patient is not allowed
to urinate except through a catheter. In the case of a
persistent fistula springing from the bulbo-urethral gland
or its duct, attempts have been made to stop the flow of
viscid mucus by injecting through the fistulous orifice
different fluids designed to impair the structure of the
gland, such as nitrate of silver, tincture of iodine, etc., but
generally without success. Excision of the gland was pro-
posed by Gruget, but it does not appear that he has ever
performed this operation, which, from the situation and
relations of the gland, would present no great difficulties,
and which is justifiable in view of the facts that the affected
gland is of no further use, and that the constant discharge
of the viscid mucus is a source of no little annoyance to the
patient.
( To be continued.)
NOTE ON
THE TREATMENT OE INELUENZA.
By J. HARRISON METTLER, A. M., M. D.,
CniCAGO.
As it seems probable that we are to have another outbreak
of the grip, though less extensive and milder in degree, this
winter, it is judicious for us to occasionally compare notes
in regard to its treatment. Two years ago, when the epi-
demic first appeared in all its pristine severity, I endeavored,
out of a large experience with it, to formulate some definite
line of treatment that might be more or less applicable to
all cases. I accomplished this to a certain extent, to my
own satisfaction, but last winter, and so far this winter, I
have met with such unusual manifestations of the disease
that I have learned to recognize the fact that no two cases
can be cared for in precisely the same way.
When the affection first appeared, the high fever and
bronchitis seemed to me to be its most prominent feat-
ures. Other symptoms — such as the aches and pains in the
back, headache, coryza, and nervous depression — were com-
mon enough, but certainly not so universal, in my experi-
ence, as the fever and bronchitis. Indeed, many able prac-
titioners at that time believed that the majority of the cases
were nothing more nor less than severe general colds with
bronchial cough. The cases that are falling under my ob-
servation now, however, portray an almost different type of
the disease. The same fever and bronchial symptoms are
present, but to a less marked extent, while the headache,
the bodily pains, the bizarre sensations of all sorts, and es-
pecially the nervous depression, are much more loudly com-
plained of. In a word, the present manifestation of the
Jan. 9, 1892.]
METTLER: THE TREATMENT OF INFLUENZA.
39
epidemic partakes more of the neurotic type. Its charac-
ter rather than its severity differs. , Frontal headache im-
mediately above the eyes and of a most distressing nature
is very common ; with this there is little if any nasal catarrh.
Pains of various character are felt in the chest, but there is
very little cough, no difficulty of breathing, and absence of
the physical signs of pulmonary trouble. The pains in the
loins and back of the neck are especially frequent and in-
tolerable. Pain is not infrequently complained of in the
lower part of the abdomen, and one of my patients says
that she is most distressed by a peculiar, heavy aching pain
around the thighs just above the knee. I do not find the
temperatures rising so high now as when the epidemic first
came upon us. In one of my cases the fever strangely dis-
appears almost entirely if the patient gets up and exerts
herself, whereas it rises to 102° and 103° as soon as she
lies down and becomes quiet again. The appetite usually
fails, while the action of the bowels remains normal. While
these curious symptoms are severe and most annoying, the
condition in my cases is less alarming as a whole than
it was two years ago. In general, it may be said that
the fever then was of the sthenic type, while now it is of
the asthenic. For infants, aged people, and those debili-
tated by other chronic and intercurrent maladies, the one is
no less a dangerous form of influenza than the other. Now,
as then, such cases arouse anxiety and should be afforded
unusual attention.
As soon as I see a simple case of the grip I at once
recommend absolute mental and physical rest. Rest and
quiet I have found the sine qua non for the successful
treatment of the disease. Not only is this necessary to
prevent possible complications, but it is desirable to coun-
teract the nervous depression. A patient who consents to
remain indoors until the attack has worn off is, of course,
not liable to contract the pneumonia which renders this dis-
ease so fatal ; and the absence of all excitement to the nerv-
ous system enables the proper remedies to effect a speedy
and satisfactory cure. I am satisfied that we can not be
too imperative with our patients in regard to this matter of
rest. When I meet with one who is inclined to be argu-
mentative, I even go so far as to say that I am certain I can
cure him in four or five days at the most if he will remain
quiet ; but if he insists upon being up and attending to his
business, it will take at least two weeks to effect the same
result, let alone the risk of contracting a fatal complication.
A plain statement of this sort I usually find restores to me
the needed authority, and the patient is ready for the fur-
ther treatment.
In the absence of the Turkish bath, 1 order the patient
to take a hot bath that same night just before retiring. I
am careful to explain that I mean as hot as he can bear it
and only for a few moments. He must then rub himself
thoroughly with a rough towel, take some stimulus, and
place himself in bed beneath heavy blankets. If there has
been some elevation of temperature, 1 do not forego the
bath, but 1 administer in the early part of the evening or
late in the afternoon about eight or ten grains of quinine.
This acts as a febrifuge and stimulus. Immediately after
he is in bed lie takes a pill containing extract of opium,
one fourth to one half a grain ; camphor and ammonium
carbonate, each two grains. This relieves the pain, induces
sleep, favors free diaphoresis, and stimulates. Upon visit-
ing the patient next morning I have generally found that
the night's rest has resulted in a marked improvement in
his subjective feelings. The greatest trial at this time is to
prevent him from getting up and going at once to his daily
occupation. I remind him of my statements the last even-
ing, and inform him that he is now ready to begin the
regular course of treatment.
I urge him to remain in bed, but if the rooms are warm
and he is feeling comfortable, I allow him to dress and lie
upon the couch. Every two hours he must take some stimu-
lus, either in the form of milk punch, eggnog, or brandy,
whisky, or rum in sweetened water. Usually he will take
the punch about three or four times a day and the pure
stimulus in the intervals. Between the latter there is very
little choice. If the bowels are inclined to be loose, I pre-
fer brandy ; if constipated, whisky. I have some patients
who find that the stomach tolerates the rum better than
either the brandy or the whisky. The quantity given each
time need not be large, if the effect produced is satisfac-
tory. One or two teaspoonfuls is quite sufficient in the
average case. To this stimulation I sometimes add, par-
ticularly if the fever be a prominent symptom, a two-grain
quinine pill to be taken four times a day. If there is simply
nervous exhaustion with the various bizarre sensations pre-
viously referred to, with absence of febrile symptoms, I
order, in place of the quinine, the syrup of the hypophos-
phites in stimulating doses, or a pill three times a day con-
taining arsenious acid, gr. ^ ; strychnine, gr. ^ ; dried
sulphate of iron, gr. ij ; quinine, gr. j. If, in spite of this
treatment, the fever shows a tendency to rise toward even-
ing, bringing on a return of the headache, I leave with the
patient a powder containing two grains and a half or five
grains of phenacetin, to be taken every two hours until
there is free diaphoresis and an indication of the fever de-
clining. I have usually found this to occur after the sec-
ond or third powder. The phenacetin is also analgesic and
thus relieves the headache and other pains. Upon going to
bed the patient takes the opium, camphor, and ammonium
pill as he did the night before. If the fever has reappeared
in the afternoon, in addition to this pill and the control of
the fever by the phenacetin, he is to place his feet for fif-
teen or twenty minutes in a hot-water bath and then to wrap
himself up in bed between blankets. He takes a light, nu-
tritious diet with milk as its staple article every three or
four hours during the day. No special attention is paid to
the bowels or kidneys. With the regulation of the diet,
absolute rest, and the above described line of treatment, I
have found the majority of patients with simple epidemic
influenza to get rapidly well in three or four days. The pa-
tient is then cautioned about going out too soon and everv
suggestion offered to prevent his contracting the disastrous
sequelae which seem to follow a too early resumption of an
outdoor life. This line of treatment is explicit enough and
adapted to the vast majority of cases so far as my observa-
tion has gone, but yet, as 1 said in the beginning, each ease
I must be treated largely by itself and special indications met
40
WILLIAMS: COMPOUND FRACTURE OF THE SKULL.
[N. Y. Med. Jouk.,
with special therapeutic agents. If complications are pres-
ent, such as bronchitis, pneumonia, or rheumatism, they
must be treated by themselves as such affections usually
are, with, however, this proviso : that it be remembered
they are the complications of a state of extreme nervous
depression requiring always the full and free use of stimu-
lants.
4228 Greenwood Avenuk.
COMPOUND FRACTURE OF THE SKULL
AND WOUND OF THE ARM CENTER*
By L. L. WILLIAMS, M. D.,
PASSED ASSISTANT SURGEON, U. S. MARINE- HOSPITAL SERVICE.
John W., negro roustabout, aged twenty-three years, was ad-
mitted to the United States Marine Hospital, Memphis, Tenn.,
March 29, 1891.
Two days before his admission be received a blow from a
heavy club on the rigbt side of the head, and was unconscious
for a short time after sustaining the injury. A compound fract-
ure, with marked depression and extensive comminution, was
found in the right parietal bone, at the center of the Rolandic
region. The left arm below the elbow was completely paralyzed.
There was slight motion at the shoulder and elbow. The intel-
lect was unimpaired, and sensation was normal. Operation three
hours after admission. An oval flap was raised and the fracture
exposed. The area of depressed bone was circular in shape and
as large as a silver half-dollar. Thirteen fragments of bone were
removed; several of these were imbedded in the brain, and were
extracted with some difficulty. The inner table of the skull
was extensively comminuted, and, in order to remove all of the
spicula, the opening in the bone was freely enlarged with the
rongeur. There was a laceration of the surface of the brain
three quarters of an inch long, with slight, loss of substance.
An irregular laceration of the dura, an inch and a half long,
was sutured with fine catgut. The edges of the wound of en-
trance in the scalp were then carefully excised, and a short
rubber drain placed in the resulting orifice. The oval flap was
then adjusted, sutured with catgut, and a sublimate dressing ap-
plied. After recovery from the anaesthetic, the patient com-
plained of various abnormal sensations in the left arm and leg.
At times he felt as though these limbs were immersed in hot
water, and when pinched had a sensation of pricking above the
point pinched.
April 2d. — Wound suppurating ; has slight motion in the
fingers.
From this date until April 10th the patient was inclined to
be somnolent, with occasional delirium. At times an uncontrol-
lable tremor of the whole body, like a severe rigor, would come
on. There was constant and severe pain referred to the back
of the neck. The pulse varied from 46 to 52. The respira-
tion was normal. The temperature never exceeded 37"4° 0.
[99-(i° F ], and was for several days subnormal.
11th. — Has hernia cerebri; no delirium ; pain in neck less
severe; applied compression.
13th. — Hernia increased in size; there is now paresis of the
left leg, and tongue deviates to the left ; intellect not im-
paired ; shaved off hernia at the level of the scalp and reap-
plied compression.
18th. — lias regained considerable motion in leg, and can ex-
* Read before the Tri-State Medical Association of Tennessee, Mis-
sissippi, and Arkansas, November 20, 1891.
tend the fingers and wrist to a slight degree. The hernia con-
tinued to increase in size in spite of treatment, and was shaved
off three times. Nevertheless, the paralysis slowly improved.
On April 28th clastic compression was applied. The tumor
rapidly decreased in size and soon sank below the level of the
scalp. The paralysis likewise rapidly improved.
May 15th. — Was suddenly seized with a peculiar sensation
of throbbing in the floor of the mouth. Upon examination, the
tongue was found to be the seat of violent clonic convulsive
movements. He could protrude and withdraw it at will, but
could not keep it still. A finger inserted between the tongue
and the teeth of the lower jaw was firmly grasped on the left
but not on the right side. The spasm was therefore unilateral
— a true focal or " Jacksonian epilepsy. The dressing was
taken off and the gauze packing removed from the wound. The
spasm ceased at once. The dressing was reapplied without the
gauze drain and no further spasm occurred that night.
On May 18th he had clonic spasms of the left arm and leg
lasting fifteen minutes. This was followed by temporary in-
crease of paralysis, but in a day or two the lost ground was
regained. Shortly after this the wound healed.
On July 16th the patient was examined as to the degree of
paralysis remaining, and the following points were noted:
Motion at shoulder almost normal ; can flex and extend the
elbow and wrist; pronation and supination imperfect; can flex
fingers, but can not completely extend them. All of the fingers
of the left hand are partially anaesthetic, but not analgesic.
Perception of heat and cold is normal ; the tactile sense alone
is affected. He picks up articles with difficulty — fumbles with
them as a child would. With his eyes shut he can not pick up
a book, and can not distinguish between a knife and a pencil
held in his hand. There is marked rigidity in the muscles of
the left arm and forearm, and has been ever since motion re-
turned— a spastic condition which becomes more pronounced
when voluntary motion is attempted. The forearm is flexed
and extended slowly and in successive jerks. Pronation and
supination, wrist movements, and movements at the shoulder
are executed in the same manner. When told to flex and extend
the wrist, he can not avoid at the same time flexing the forearm
and fingers. He can not flex the forearm without flexing the
thumb and fingers, but can extend the forearm with the fingers
flexed. Can stand for only a few seconds on the left leg. The
joints of the lower extremity can be flexed and extended easily,
and the femur rotated inward and outward. In walking, how-
ever, the toes are turned inward. The knee-jerk and ankle-
clonus are exaggerated on the left side.
When he was discharged, two weeks later, there was but
little rigidity in the muscles of the shoulder, but the muscles of
the forearm had not improved in this respect.
The spastic rigidity of the muscles of the arm, combined
with paresis, as exhibited in this case, is quite similar to
the condition that obtains in so-called spastic spinal paraly-
sis, and is probably due to a like cause — viz., degeneration
in the pyramidal tract and lateral column of the cord ; in
this instance a descending secondary degeneration, the re-
sult of partial destruction of the arm center. The per-
sistence of numbness in the fingers has been noted in a
number of cases involving injury of the cortical motor area,
and would appear to indicate, at least, a very close relation
between the centers for motion and sensation. The in-
ability to pick up articles with the eyes closed, and the
awkwardness manifested in picking them up at all, seem to
indicate faulty co-ordination, although these symptoms may
be partly due to anaesthesia of the fingers.
Jan. 9, 1892.]
BULL: TUMOR OF THE BRAIN.
41
In reviewing the operation, it is to be regretted that the
lacerated brain tissue was not excised in the first instance.
Primary healing might thus have been secured, and the sub-
sequent loss of brain substance from suppuration and
hernia avoided.
Since writing the foregoing I have seen this patient
again. He is working on the levee, and is able to manage
a dump-cart. The anaesthesia of the fingers and rigidity of
the pronator muscles remain, and will, in all probability, be
permanent.
REPORT OF
A CASE OF TUMOR OF THE BRAIN,
WITH AUTOPSY*
By CHARLES STEDMAN BULL, M. D.,
PROFESSOR OP OPHTHALMOLOGY IN THE UNIVERSITY OP THE CITY OP NEW YORK ;
SURGEON TO THE NEW YORK EYE INFIRMARY \
CONSULTING OPHTHALMIC SURGEON TO ST. LUKE'S HOSPITAL AND TO
ST. MARY'S HOSPITAL POR CHILDREN.
In April, 1890, I was consulted by a gentleman, aged forty-
five, on account of a difference in the size of the two pupils,
whicb bad then existed for nearly a year without any change,
and which interfered somewhat with bis comfort in reading. I
bad known the gentleman for many years, but bad never ex-
amined him professionally. He was a man of very active mind,
by profession a civil engineer, and of somewhat irregular habits.
He bad always been myopic and astigmatic and had worn
glasses for twenty-five years. He had contracted a chancre
fourteen years before, and bad bad numerous lesions of consti-
tutional syphilis since then, but none of them severe. For five
years be had had no demonstrable constitutional lesion, until
about two years before I saw him. He then began to have
some curious, ill-defined brain or nerve symptoms of which he
could give no very clear description, but he stated that lie was
sure they arose in his brain. From the general ill-defined de-
scription furnished I concluded that they were probably attacks
of petit mal, which were at times accompanied by transient
loss of consciousness, which was never of long duration, but the
attacks increased in frequency. There was no regularity in
these attack-. There were at times lapses of memory of very
varying duration. At no time was there any headache until a
few hours before his death. When I saw him in April there
was marked, though not complete, ptosis of the right upper lid
and paresis of both internal recti. In the left eye the iris was
moderately dilated and immovable, the pupil on this side being
more than t wice the diameter of the right pupil. With the
right upper lid raised and the refractive error corrected, there
was crossed diplopia, the right image being lower, and the two
images were brought to a level by a prism of 2°. The internal
recti were not completely paralyzed, but paretic. There was
no paresis of any of the other ocular muscles. The difference
in the size of the pupils had existed unchanged for nearly a year.
R. E. with sph..— D. 8 3 cyl. + D. 2-50 axis 90° = £§.
L. E. ¥J«5 : with sph. — I). 4 3 cyl. + I). 0'50 axis 90° =
There were small, irregular central opacities in both lenses. In
the right eye there was a moderate case of neuro-retinitis with
not much swelling of the disc, but with two or three small
haemorrhages in the retina near the margins of the disc. The
fundus of the left eye showed merely the ordinary changes of a
myopic eye. The field of vision was apparently normal in each
eye, and there was no interference with the color sense. He
was then under treatment by mercury and potassium iodide, and
* Read before the American Ophthalmologics] Society at its twenty-
seventh annual meeting.
the dose of the latter was increased to thirty grains four times
a day. Under this treatment the neuro-retinitis and the mus-
cular paresis slowly subsided, and finally entirely disappeared.
During the summer ho began to have attacks of vertigo, and in
the early autumn these vertiginous attacks increased in inten-
sity, and there appeared a hemianresthesia of the left side which
gradually became well marked. During the autumn there were
a number of regular, well-marked epileptiform convulsions, and
the lapses of memory became more marked. On November
14, 1890, I made another careful examination, and found that
not a trace remained of the neuro-retinitis, or of the ptosis, or
of the paresis of the internal recti muscles. The vision re-
mained the same. A test of the dynamics of the muscles
showed for 18 inches a convergence of 12° and a divergence
of 5°. For 20 feet there was no convergence at all, and a
divergence of 5°. There was no diplopia at any distance. His
intelligence was apparently unaffected, except for the lapses of
memory. The condition of the left pupil had remained un-
changed. There was no loss of power in any of the extremities,
but the hemiansesthesia was very marked. I had previously
made a diagnosis of pachymeningitis, and a prominent and very
careful neurologist had made a diagnosis of multiple sclerosis of
the brain. The patient remained in about the same condition
until the night of January 28, 1891. lie had gone to bed feel-
ing as well as usual, and woke suddenly about two o'clock in
the morning shrieking with severe pain in the occipital region.
Be it remarked that this was the first attack of pain in the head
which had occurred. He became rapidly delirious, then sank
into coma, and died comatose about 11 a. m., January 29, 1891.
The autopsy was made at 4.30 p. m. the same day. The
frame was large, the muscular condition good, and the adipose
layer considerable. The dura mater was rather thicker than
the average and more adherent to the skull, but there was no
trace of pachymeningitis anywhere within the skull. The
sinuses were normal. The convolutions were flattened, espe-
cially over the anterior lobes. The anterior half of the left
hemisphere was larger than that of the right hemisphere. A
section made through the middle of the left frontal lobe passed
through a tumor, two inches in longitudinal diameter and an
inch and three quarters in a transverse diameter, with a broken-
down center. The anterior portion of this growth was firmer
than the brain substance, and was grayish-pink in color, with a
few small haemorrhagic spots. This mass reached to within
two inches of the anterior extremity of the hemisphere.
A vertical incision made from the lower extremity of the fis-
sure of Rolando, and cutting the longitudinal fissure two inches
and a half in front of the fissure of Rolando, passed behind the
tumor.
The tumor involved the corpus callosum and protruded
downward from the roof of the left, lateral ventricle.
The heart was normal. The right lung was normal. The
left lung contained a few fibrous nodules in the lower lobe. In
the right iliac region there were several old peritoneal adhesions
between the omentum, caecum, vermiform appendix, and the
abdominal wall. The spleen was normal. The liver was nor-
mal. The capsule of the left kidney was adherent, and its sur-
face a little roughened by fine irregular sears.
A careful microscopical examination of the tumor proved it
to be a glio-sarcoma.
Actaea Racemosa. — " The tincture of cimicifuga, or aetata racemosa,
combined with small doses of iodide of potassium, is very effectual in
acute rheumatism and sciatica. It is rapidly absorbed into the blood,
depressing both the force and frequency of the pulse. Rheumatism in
the hands and wrists seems especially to yield to the action of this drug
when many others fail." — British and Colonial Druggist.
42
LIXK: . 1 PPENDICITIS.
|N. Y. Med. Jul-*;
APPENDICITIS*
By W. H. LINK, M. A., M. D.,
PETERSBURG!!, IND.
There is hardly a doctor in Indiana of ten years1 prac-
tice but has a private grave-yard in which are buried one
or more victims of appendicitis. Most, if not all, of these
unfortunates might have been restored to health and useful-
ness had the natural history of the disease been as well
understood as it is to-day. Many of them perished with a
different diagnosis accounting for the " inscrutable decrees
of an all-wise Providence." " Bilious colic," no doubt,
carried some away. Some were euphemistically removed
by " obstruction of the bowels." Others went by the broad
highway of gastro-enteritis. A few were swept into the
river by the twin forces " typhlitis and perityphlitis."
While many, very many, found in " idiopathic peritonitis"
their facile descensus Aver no.
These grave-yards, though not filling so rapidly as in
times not very remote, still occasionally make room for
another tenant. Melancholy as the facts just stated may
be, let us remember that they constitute only the obverse
side of the shield. We now know that these cases do not
necessarily die. That they did heretofore die was due to
a wrong conception of the disease, to baneful therapy, and
an utter failure to grasp the surgical aspects of the case.
The patient was first, last, and always stupefied with opium.
It was "the sheet anchor." He was next besliined with
poultices from one weary day to another, till patient and
nurse were alike exhausted. Now and then eminent counsel
was called in, and, because he knew not what else to do, the
poultice was replaced by a blister. Occasionally, when the
obstipation became very marked, large enemas were ordered.
The exhausting effects of septicemia and peritonitis were
combated with quinine, milk, and whisky. If, perchance,
the pus was kind enough to make its way to the outer ab-
dominal wall, some one, a little bolder than the others, in-
cised the " boil " and the patient got well. This, I think,
is a fair picture of past treatment. It is not yet altogether
past.
The first and greatest advance made in this disease was
in a better knowledge of its pathology. So long as typh-
litis and perityphlitis or paratyphlitis were the nearest ap-
proach to a correct understanding of the condition, just so
long was treatment uncertain and shadowy. We now know
that a vast majority of the inflammatory troubles located in
the ileo-ca?cal region are, primarily, due to inflammation,
ulceration, or perforation of the appendix vermiformis. We
have learned that the question of therapy or surgery de-
pends upon the advance made in the general progress of
the case from a simple catarrhal or adhesive inflammation
to a gangrenous perforation. Unfortunately, we are not yet
advanced far enough in our diagnostic resources to determine
with positive certainty the exact status of a case from the
rational symptoms or physical signs. There are no pathog-
nomonic symptoms, no invariable or infallible physical re-
* Read before the Mississippi Valley Medical Association at its
seventeenth annual meeting.
actions or conditions, that, like guide-boards, point both
forward and backward, marking the exact distance alike
from the inception and the end. But while both diagnosis
and prognosis are only a balancing of probabilities, the in-
dications for a given line of treatment, founded either on
an enlightened experience or scientific research, are un-
equivocal. Locking up the bowels with opium is supreme
folly, for they are already locked in a vast majority of
cases by the paralysis of distention and the obtunded sen-
sibility induced by disease. But opium does not only lock
up the bowels. The secretions of the entire alimentary
canal are deranged, and some of the emunctories in other
parts of the system fail in their activities under the influ-
ence of this baleful drug. Should the trouble be due to the
presence or contact of irritating accumulations, the effect
of opium is to increase rather than diminish the underlying
causes. My own experience and that of others teaches me
that most frequently the condition under consideration is
due to traumatisms from without, or infections and trau-
matisms from within — those from without acting acutely
in the form of blows, falls, and strains ; those from within,
either acutely or in a chronic manner, as foreign bodies,
hardened faices, improper food, or the invasion of pyogenic
bacteria which find a culture medium in accumulations of
necrotic material due to abundant secretion excited by some
local irritant, decomposition being favored by abnormal re-
tention. By locking up the bowels with opium this condi-
tion is not only maintained in statu quo, but, being an active,
not a passive one, the destructive processes are hastened.
At the same time, the pain being subdued, neither patient
nor physician has any means by which the downward prog-
ress of the case can be measured until often a septic perito-
nitis appears and the patient is beyond the reach of help.
In such cases the indications are certainly plain : To
get rid of irritating material. To place the absorbing and
digesting powers of the peritonaeum at the best advantage.
To lessen inflammation by depleting the local engorgement.
To sweep away bacteria and their poisoning ptomaines in a
copious exudation of fluid from the capillaries of the bowel.
Every day such a line of treatment is the salvation of the
patient who submits to a section for the removal of a pus-
tube or an ovarian abscess. If it works wonders in these
pelvic troubles, why not in appendicitis \ This lesion pro-
duces death pretty much in the same way that a leaking
pus-tube does. The line of treatment good for one ought
to answer equally well for the other. Instead of giving
opium and applying poultices, the indications are far better
met by a full dose of sulphate of magnesium every hour till
free watery discharges occur. Then absolute rest in bed
and a strictly fluid diet. To illustrate the application of the
foregoing principles, I wish to report the following cases
coming under my care within the last year :
Case I. — Young man, twenty-four years old, printer by
trade, perfectly healthy heretofore, family history good (except
that his father died of appendicitis under the old opium treat-
ment), came into my office saying that he had a " soreness in
his side " which gave him great pain, and which had been
troubling him for the last twenty- four hours. Temperature,
102°; pulse, 100, and of that quick, jerky character noticeable
Jan. 9, 1892. J
in any trouble involving the abdominal viscera. Physical ex-
amination showed marked resistance over right ileo-caocal re-
gion, with great tenderness on palpation. Pressure with the
Snger-tip at the McBurney point elicited prompt remonstrance.
He was ordered to bed, forbidden anything but fluid nourish-
ment, and put upon the following prescription:
I£ Magnesia; sulphatis § j.
Sig. : Take one drachm every hour till free catharsis fol-
lows.
Next day his pain had disappeared, soreness and resistance
diminished, fever abated, and pulse improved. His general im-
I provement continued, until in a week he was apparently as well
as ever, which condition he has maintained ever since, or almost
a year.
Cask II. — Boy, sixteen years old, brought to the office by his
father. Had been complaining of pain in his side while going
to school for the previous three days. The boy, being very
stoical in disposition, would not give up till the pain became so
agonizing that he could endure it no longer. When he was first
seen his features were pinched and drawn in a manner that ex-
pressed great suffering. He was bent over toward the right,
and walked in a way to shield himself from sudden jars or
movements. Tongue coated, bowels constipated, anorexia,
fever, and the peculiar abdominal pulse as in the previous case.
Physical examination showed very great tenderness in ileo-caecal
region, marked rigidity of the abdominal muscles, and the Mc-
Burney point easily demonstrated. Prescribed rest, fluid diet,
and —
R llydrarg. submur gr. x.
Sig. : To be taken at once, and followed in five hours by one
drachm of sulphate of magnesium. Take in small amount of
water, and repeat every hour till free watery dejections occur.
By next morning there was relief from pain and marked
decrease in the abdominal tenderness and resistance. Improve-
ment continued, so that in four days he was able to leave the
bed, and in a week was apparently as well as usual. He has
had perfect health since, or for'about six months.
Case III. — B. Y., young man, twenty-seven years old. Family
history good ; previous health good, except some trouble of late
from constipation. Came in for advice in regard to " a lump in
his side and a general bad feeling." Tongue coated ; tempera-
ture, 102-5°; pulse, 105, and of that quick, jerky character as
in the cases before described. In the ileo-cascal region there
was a large fusiform swelling. Over and around it there were
well-marked abdominal resistance and tenderness on pressure.
Pain was most easily demonstrated with the finger-tips at the
McBurney point. He complained of pain down the inner and
back part of the thigh of the affected side, lie kept the right
leg and thigh slightly flexed when lying on his back. About a
week before applying for relief he was attacked with severe
colicky pains radiating from the right side. After this, and
about three days before I first saw him, he noticed the tumor in
his side. Since then he had suffered so much from pain and
soreness in his side and back that he could not turn over in bed
without great suffering. The tumor itself was tense and elastic,
but at no time could anything like fluctuation be obtained, and
both oedema and redness were absent. Ordered him to bed,
and forbid any but liquid nourishment. Prescribed —
R Magnesia; sulphatis 3 viij ;
Acidi sulphurici aroinatici 3 jss ;
Aquae q. s. ad § viij.
M. Sig. : One ounce every hour till all is taken.
He took the entire amount before noticing any effect. He
then passed a large number of copious stools, completely empty-
ing the gut. Next morning felt better, but there was no im-
provement in general symptoms, except that the temperature
43
had fallen to 100°. No change for four days, when tongue be-
came more heavily coated and bowels ceased to move with
regularity. Ordered —
R llydrarg. submur gr. xx.
Ft. chart, no. ij.
Sig.: One every two hours, and after five hours give one
drachm of sulphate of magnesium every hour till three doses are
taken.
Free catharsis followed. After the effects of the calomel
had disappeared the only improvement noticeable was in bis
ability to take nourishment. Considering his condition such
that further medication was uncalled for, I advised a resort to
surgery. Dr. Byers, Dr. Lamar, and Dr. Duncan then saw him.
and, concurring in the diagnosis, advised an operation. At the
request of himself and friends surgical interference was post-
poned till next day, in order that we might have daylight in
which to do our work. In the mean time he had grown more
restless, his temperature had risen to 103°, and his pulse gone
up ten beats. The soreness was greater, and he thought he
could feel a throbbing. Just after midnight he sent for me in
great haste, saying it had burst inside, he thought. When I
reached his bedside I found some diminution of the swelling ;
temperature, 98'5° ; pulse, 85, and stronger. When we visited him
the next morning his improvement was still noticeable, and opera-
tion was indefinitely postponed. His temperature continued to
go above normal in the evening for three days, when both pulse
and temperature remained normal. The swelling and tender-
ness gradually disappeared, till in fifteen days from the time I
put him in bed he was able to walk about the house. After
that his improvement continued so rapidly that in ten days more
he was able to go to work. Four months afterward I examined
him carefully, and could elicit neither swelling, tenderness, nor
abdominal resistance. He is seemingly in perfect health, though
I fear a recurrence.
Case IV. — A. J. S., man, forty-six years old, farmer, always
strong and healthy, came into the office with a soreness in his
side and wanted medicine for relief. He had suffered for more
than a week from severe colicky pains radiating from the right
side, with great tenderness on pressure at ileo-caacal region.
Riding horseback or in buggy or wagon increased the pain and
soreness. Tongue coated, bowels constipated, fever, rapid jerky
pulse, abdominal resistance on palpation, McBurney point easily
found. Ordered him to go home and go to bed ; to take only
fluid nourishment. Prescribed, as usual —
IJ llydrarg. submur gr. x.
Sig. : Take at bed-time, and follow in the morning by one
drachm of sulphate of magnesium every hour till the bowels
move freely.
After catharsis he felt better. The next day, after being
purged, he felt so much better that he got up and went to
work. He has been working at intervals since, but when he
"lets his bowels clog up he has pain and his side cakes.'*
Salts give prompt relief, but some tenderness remains. Carries
his hand in his pocket with the palm pressed against his abdomen
over the site of the appendix, when riding or walking, to guard
against sudden movements. He will not go to bed or keep
quiet, but goes about his work. Any severe exercise brings on
an exacerbation of Ins symptoms. I fear perforation with re-
sulting peritonitis, but my patient will take medicine much more
readily than he will take advice.
The foregoing' represents my own experience with the
saline treatment, and my own views founded on that expo
rience and on what I have been able to glean from the ex-
perience of others. As late as four years ago physician .
in my part of the world at least, had just begun to see the
LIJSfK: APPENDICITIS.
44
WEED:
LACTIC ACID IN LARYNGEAL TUBERCULOSIS.
[N. Y. Med. Jons*
light on the mountain-tops. Before that period — typhlitis,
opium, poultices ! These were the nearest we ever got to
the truth. Since then Morton, Sands, the Prices (Mor-
decai and Joseph), McBurney, and others, have let in a
flood of light ; and prompt surgical treatment saves from
an untimely death many an unhappy sufferer who, under
the old regime, would have been removed with certainty if
not with dispatch. Though surgery has responded to ad-
vanced knowledge, the old opium Man of the Sea has his
legs still entwined about many a professional neck, and diag-
nosis is often obscured, prognosis made uncertain, and time-
ly relief rendered impossible by his stupefying influence.
The patient sleeps, and so does his medical attendant.
It was my misfortune to treat one patient under the old
opium, poultice, do-nothing plan. He died from a septic
peritonitis about as promptly as if he had been knocked on
the head with a club. Observation in the practice of my
friends has shown me two other cases. One of them died
from idiopathic peritonitis, the other of shock from a sec-
tion deferred for months till he was moribund. From the
foregoing principles and facts I would beg leave to offer the
following conclusions:
In the commencement of an attack give salines often and
liberally till the gut is completely emptied. Advise perfect
rest in bed. Forbid any but liquid nourishment. If pain
is severe, apply counter-irritation and dry heat locally till
salines act.
If the patient improves, wait. If the pulse grows worse,
if the temperature rises, if pain increases, if tumefaction
becomes larger, if tenderness becomes more marked, oper-
ate. At no time give morphine, but consider an increase of
pain sufficient to demand relief by opium an imperative, un-
equivocal, and emphatic indication for surgical interference.
THE TREATMENT OF
LARYNGEAL TUBERCULOSIS WITH
LACTIC ACID LOCALLY.
By CHARLES R. WEED, M. D.,
UTICA, N. Y.
It is not necessary to repeat here the many details of
general therapeutics, dietetics, or hygiene which have been
so fully discussed in the past ten years by writers upon
tuberculous disease, and I shall confine myself simply to the
local treatment as used in three typical cases, trusting that
my experience may add to the future a remedy to combat
the inroads of tuberculous laryngitis.
In presenting these cases I have taken care to observe
closely each condition, and particularly to assure myself
that the disease germ or tubercle bacillus was present in
each, confirmed by microscopic investigation. I do not
claim originality in the use of lactic acid, but, after reading
that Krause, of Berlin, had been most successful in this
form of local treatment, claiming, and no doubt justly, the
cure of a small number of cases, in an exhaustive paper read
before the Laryngological Subsection of the Fifty-ninth
.Meeting of the German Naturalists and Physicians, at Ber-
lin, September 21, 1886, I determined to try it, and the
efficacy of his suggestions is shown in the following cases :
Case I.— I. M., German, aged thirty. eight years, occupation
furniture finisher, called on me November 2, 1887, and gave the
following history : About two years previous he had noticed
that his general health was failing, and, heing troubled with a
bad cough, consulted a physician, who diagnosticated his trouble
to be phthisis. He was put upon treatment, but the disease pro-
gressed until in June, 1886, when his throat began to trouble
him. He drifted from one practitioner to another, but could get
no relief. At last he was advised by friends to consult me (I
being a new-comer here), as he was unable to either eat or drink
without great distre-s. This man was terribly emaciated ; his
face was anxious; breathing hurried ; temperature, 101° ; pulse,
90 and weak; voice lost ; in fact, every symptom betokened the
" beginning of the end.'' Considering the case hopeless, I gave
him no encouragement, but said I would do what I could to re-
lieve the laryngeal pain and the dyspnoea.
Examination laryngoscopically revealed as follows: Mem-
branes pale; ventricular bands and space infiltrated ; submucous
membranes covering the arytenoids and ary-epiglottic folds
tumefied ; vocal cords but slightly visible, the edge of the left
one having the characteristic ulceration of tuberculous disease.
I proceeded to cleanse the parts carefully with a mild alkaline
spray ; then applied, with the cotton carrier, a six-per-cent. so-
lution of cocaine thoroughly ; after this a sixty-per-cent. solu-
tion of lactic acid to every visible diseased surface of the larynx.
Though weak, he stood the application well, and after giving
him general instruction as to his treatment at home — sprays,
medication, etc. — he left, to call again two days after.
This patient improved wonderfully ; in two weeks he was
able to eat and drink without much discomfort, and at the end
of three months had gained several pounds in weight. The
treatment was kept up at short intervals for a period of eight-
een months, and a gain of sixteen pounds resulted ; the voice was
slightly improved, now reaching to a hoarse whisper. As lie
considered himself on the road to recovery, I saw less and less
of him, and he left here in June, 1889, for the West, and I lost
track of him ; but a lease of life of two years nearly was a re-
sult to be satisfied with, particularly after the prognosis made in
his case.
Case II. — On November 26, 1890. I was called in consulta-
tion by Dr. Nicholson, of Madison, N. Y., to see a Mrs. B.,
aged forty-one ; family history bad ; cancerous disease, both
parents ; had been ailing for three years, and lately had ema-
ciated rapidly ; weight at present time, eighty pounds: menstru-
ates regularly, no pain. The lung sounds were negative, which
coincided with the opinion of other physicians who had examined
her prior to my being called. In September, 1890, she lost her
voice, and now speaks in whispers; she complains of pain over
and in the larynx: temperature, 100°; pulse, 88; appetite
good, but can not gratify it, owing to the dysphagia, regurgita-
tion of fluids, and constant cough ; sleep disturbed, and she feels
very weak and discouraged.
Laryngoscopies examination shows the characteristic lesions of
tuberculous disease, but not so far advanced as in Case I. The
disease here being primary, I at once decided to treat the case
with the lactic acid, and, following the routine above given,
made the application, and with direction to the attending phy-
sician left, requesting him to acquaint me from time to time of
the patient's condition.
Two months after I was sent for to see this patient and was
surprised at her improvement. Deglutition was resumed and
without pain ; the swelling and infiltration in the larynx had
subsided and the ulcerations healed (originally there were sev-
Jan. 9, 1892.)
MONTGOMERY: UMBILICAL HAEMORRHAGE.
45
eral small tuberculous ulcers on the epiglottis) ; she could sleep
the night through, and the cough had decreased so that the irri-
tation from that source was remedied ; I gave a few suggestions,
curtailing the acid in strength and frequency, also modifying
the sprays which she was using.
The last report from this patient is that she is still improving,
and that the throat gives her no discomfort. Her general health
is better, and there is slight increase in weight ; the voice con-
tinues about the same ; at times she thinks she notices a slight
increase in tone.
Case III. — Miss E. D., aged eighteen years, sent by Dr.
Shumway, of Utica, Nt Y., September 2, 1891, with history of
phthisis, which was confirmed on examination. For the past
two weeks she had complained of inability to swallow either
liquids or solids without great pain; voice lost; is very thin,
only weighing seventy-two pounds; menstrual function normal.
This was simply a question of immediate relief or slow starva-
tion, and for this reason I had been consulted. Examination
showed a great amount of infiltration, with tumefaction of the
membranes, and space nearly closed ; I also noticed that the ul-
ceration in this case coalesced, and part of the cartilage was de-
stroyed. I was obliged to scarify to relieve the oedema present,
and then followed the routine employed before, but only using
in this case a twenty-per-cent. solution of the acid. The patient
did not stand the application very well, there being so much
pain present, which the cocaine did not control as well as in
Cases I and II ; still, she promised to call the day following,
which she did, and I increased the acid to a thirty- per- cent, so-
lution ; this treatment was continued tri-weekly, and she now
experiences no pain upon either eating or drinking. This case
I have little hopes of, as the disease 'in the lungs is so far ad-
vanced, but I cite it with the other two to prove the value of
relief obtained from the use of the acid over every other form
of local medication.
Other cases under treatment I do not consider myself
justified in presenting, as time sufficient to prove results has
not transpired, but all show improvement from their origi-
nal conditions when first seen by me.
In conclusion, I will say that the treatment that these
patients had been subjected to prior to my seeing them had
consisted of about all the local remedies from menthol to
iodoform, and the nitrate of silver — so strongly lauded by
the late Professor Horace Green, of New York — in strength
varying from a twenty to a sixty per cent, solution, but
without relieving the diseased conditions. Have we then
in lactic acid the remedy par excellence in this disease ? I
trust so, and hope that others of my medical brethren may
be led to use it, and, like myself, give to medical literature
the results they obtain.
226 Gknksek Street.
A CASE OF UMBILICAL HAEMORRHAGE.
By R. H. MONTGOMERY, M. D.,
CLEVELAND, OHIO.
On the 24th of December, 1890, I was called to see Mrs. E.
She had been married eleven years; had had one child eight
years ago. No miscarriages. She was a large, well- nourished
woman, and had always enjoyed excellent health. She was
now eight months pregnant. On the preceding day she had
taken a laxative. I was called to check a violent diarrhoea
which had been in operation during the night and forenoon.
She had considerable griping, but no uterine pains or uterine
haemorrhage. No vaginal examination was made. Morphine
was prescribed and in six hours I called again. She wa9 then
having labor pains, and the os was dilated to the size of a half-
dollar. It was a face presentation. Labor progressed normally,
and in four hours she gave birth to a male child weighing three
pounds and a half. It was weak, poorly nourished, and had a
pronounced " old-man " appearance. The possibility of heredi-
tary syphilis was entirely eliminated by information from a
thoroughly reliable source.
The child was enveloped in cotton and intrusted to a com-
petent nurse. It did well. On the fourth day the cord sepa-
rated and the umbilicus assumed the usual appearance.
By the eighth day it had gained considerable strength, and
its battle for life seemed to have been won. On the afternoon
of this day the nurse found the abdominal band stained with
blood from the navel. When I called I ordered alum to be ap-
plied if there was any more bleeding. I was called in three or
four hours, there having been a return of the haemorrhage which
alum and other astringents had failed to control.
I poured brandy over the navel, which immediately stopped
the bleeding, and it did not return for six hours.
Upon its reappearance, brandy was again tried, but without
avail. Pledgets of absorbent cotton, saturated with Monsel's
solution, were then pressed into the umbilicus and held there.
This promised good results.
Dr. A. C. Wilson, of Yonngstown, was called in consulta-
tion. It was decided to pack the navel with the saturated
cotton and arrange a graduated compress over this, held in
place by an elastic bandage encircling the abdomen.
For eight hours no haemorrhage was visible, and the anxiety
of the family and myself had somewhat abated. At the end of
this time, to our dismay, blood was found oozing from beneath
the bandage. A fresh dressing was applied, but to no pur-
pose.
I then placed my thumb upon the navel, and, with my fin-
gers over the lumbar vertebra, the navel could be compressed
against the bodies of the vertebrae, controlling the bleeding. The
father and myself alternately compressed the umbilicus in this
way for several hours, but eventually the blood would well up
around the compressing finger with every movement of the now
restless and almost transparent babe. Finally no degree of
compression we were able to make would control the haemor-
rhage. Our efforts were as fruitless as those of Sisyphus.
At this juncture I obtained the consent of the family to
transfix the umbilicus with needles. The needles were intro-
duced at right angles to each other, going deeply into the tis-
sues and crossing each other beneath the umbilical depression.
The ends of the needles were approximated and a figure-of-
eight ligature applied. This controlled the bleeding at once.
After forty-eight hours the needles were removed and, happily,
there was no return of the haemorrhage.
The child rapidly gained flesh and strength, and now. at the
age of eleven months, is a fine, healthy baby, never having been
sick since this early experience.
Fortunately, these cases are rare, occurring only once in
about five thousand births. The case reported in the Journal
for October 31st by Dr. Wagoner is a very interesting one.
The method of treatment which proved successful in his
hands should not be lost sight of, as the high percentage
(eighty-three per cent.) of deaths in these cases shows how
inefficient treatment has been, and the success of this treat-
ment, after the usual remedial measures had been tried and
found wanting, bears testimony to its efficiency.
842 LOO AN A vkm'E.
46
Bl'RUOUGlI: BASILAR MENINGITIS.
[N. Y. Med. Jomk..
A CASE OF BASILAR MENINGITIS
DEVELOPING FIVE WEEKS AFTER AN INJURY TO THE HEAD.
By EDMUND Y. BURROUGH, M.D.,
SURGEON, RED STAR STEAMSHIP LINE.
On the morning of Tuesday, the 22d of September, I was
called to see H. C. B , a seaman, aged twenty three years, a
native of Denmark. He was a robust, well-developed man. I
found him in his berth in the forecastle. He complained of
feeling alternately hot and cold. His bowels had not moved
for four days. He had headache; his pulse was 120 in the
minute. I gave him four compound cathartic pills and twelve
grains of quinine, to be taken in divided doses during the day.
At midnight of the same day I was again called to see him. Ili>
messmates told me that he was " out of his head," and that
they had great difficulty in keeping him in his berth.
He replied to my questions in a rational manner ; said that
his bowels had moved three times since morning, and quite
freely each time, but that his headache was no better. I gave
him ten grains of antipyrine and left three five-grain powders
to be taken an hour apart. On Wednesday, at 9 a. m., I saw
him again, and found that he had passed his urine and faeces in
bed. At this time he was comatose, his eyes wandering about
restlessly, and he took no notice of the hand passed before his
eyes. The conjunctival retlex was absent; the patellar reflex
was present in both legs; the ankle clonus was present, and
equally good in both ankles. No strabismus was apparent.
The point of a pen-knife drawn across the soles of his feet
elicited no response. On pressure there was a slight gurgling
sound in the right iliac region. On the abdomen were some
spots resembling those seen in cases of typhoid fever, but tbey
disappeared on pressure. He was given one tenth of a grain of
calomel every hour for ten hours, and an ice-bag was applied to
his head.
In the afternoon of the same day he took a small quantity of
milk and beef-tea, this being the first nourishment he could be
induced to take. At 7 p. m. his temperature was 99-9°, pulse
120, and he was in a profuse perspiration. The spots visible on
the abdomen in the morning had disappeared.
At 10 p. m. his temperature was 101-9°, pulse 140. Strabis-
mus was now noticed for the first time, as well as paralysis of
the alas of the nose. Opisthotonos was well marked. The pa-
tient now lay with his head turned toward the left side, and
there was constant twitching of the right arm and leg.
At 8 a. m. on the 24th his pulse was 120 and very weak;
temperature, 101-8°; respiration, 48 in a minute. At 9.15 he
died.
The interest in this case lies in the fact that five weeks
before the symptoms of meningitis manifested themselves
the patient was, with others, hauling on a watch-tackle
when the hook of the distant block broke off and the block,
flying back, struck him on the left parietal region with con-
siderable violence. Although the skin was scarcely broken,
he appeared to suffer great pain at the time, but after a few
minutes seemed relieved and resumed his work. He did
not " lay up " on account of the blow, or, as far as I know,
did he sutler any further discomfort from it until the be-
ginning of his fatal illness, which was undoubtedly the re-
sult of the accident.
The International Dermatological Congress of 1892 will meet in
Vienna, on September 5th to 10th". Dr. Prince A. Morrow has been
appointed secretary of the Congress for North America.
THE
NEW YORK MEDICAL JOURNAL.
A Weekly Review of Medicine.
Published by Edited by
D Appleton & Co. Frank P. Foster, M. D.
NEW YORK, SATURDAY, JANUARY 9, 1892
THE PHYSIOLOGY OF TEARS.
This subject is considered in a bright* and interesting paper
recently published in the Axclepiad. Fear, grief, and joy, to
say nothing of pathos and anger, bring tears to the eyes. They
are said to come from the heart; and this is true, for no one
ever reasoned himself into weeping without a first appeal
through the imagination to some emotion. Tears are the natu-
ral outlet of emotional tension. They are the result of a storm
in the central nervous system, giving rise to changes in the vas-
cular terminals of the tear-secreting glands. These changes in-
duce profuse excretion of water, and weeping results. Jn a
mild degree some excretion is always in process, to bathe the
eye and clear it of foreign matters. The controlling center is
at a distance, though the secretion may be kept up by the small
trace of saline substance that is present in the tears themselves.
The lacrymal glands lie between the nervous center and the
mucous surface of the eyeball. Tears afford a good illustration
of the way in which nervous fibers are capable of conveying to
a secreting organ exciting impulses from both sides of a gland
lying in their course. Afferent and efferent communications
bring about a similar result. Internal nervous vibrations and ex-
ternal excitation or reflex action cause a flow of tears. In both
instances the exciting impulse is a vibration. Niobe, " all tears,"
and the unfortunate pedestrian with a minute particle of steel
from the rail of an elevated road in his eye, are unwilling ex-
ponents of a similar process. They weep the same kind of
briny fluid, in exactly the same way, though from widely differ-
ent causes. Imagination is at times sufficient to excite the nerv-
ous system into the production of tears, without external aid or
reflex. Writers and readers of good fiction weep over it alike,
and the actor loses himself so entirely in the exigencies of
dramatic art that he sheds real tears and the audience shed
tears with him. Of a truth, the man who never weeps has a
hard heart, and the quality of his intellect may also be ques-
tioned.
Emotion, then, affection, grief, anxiety, incite to tears, not
pain or discomfort. The pangs of maternity are tearless, though
the influence of ether or chloroform may cause some emotional
dream that results in weeping. In the earlier days of surgery
patients might scream and utter such pitiful cries as to sicken
the by-standers, might even faint with pain, yet there were
seldom any tears. These, being pure waves of emotion and a
relief to the heart, are almost powerless to mitigate pain. Per-
haps one who weeps from pain does so from unconscious
though selfish pity — in other words, from emotion.
For the tearful, change of scene, mental diversion, and out-
door life are the best remedies. The author quoted objects to
Jan. 9, 189'2.|
LEA Dim ARTICLES.— MINOR PARA GRAPHS.— ITEMS.
47
alcohol as fearfully injurious-. It disturbs and unbalances the
nervous system, keeps u|> a maudlin and pitiful sentimentality,
and sustains the evil. Alcohol is the mother of sorrow. An
opiate, however, prescribed at night, soothes and controls and
really disciplines rebellious nerve centers. Sleep cures tears.
And so does Time, the restorer. Persons subjected to many and
repeated griefs forget how to weep, and the old as compared to
the young are almost tearless. Tears have their value in the
life of humanity, not as tears but as signs. They show that
grief centers are being relieved of their sensibility, and that the
nervous organization is learning how to bear up against sorrow.
TETANUS NEONATORUM.
The infectious nature of tetanus was for a long time sus-
pected, and the truth of that belief is now conclusively proved.
Nicolaier eight years ago found in superficial soil a bacillus
which by inoculation produced tetanus in animals. Not long,
after, a germ of similar appearance and life history was found
by Rosenbach in the secretions from a wound of a patient suf-
fering from tetanus. The chain of evidence was not completed
until recently, when Kitasato, a student in, Koch's laboratory,
succeeded in isolating the germ and produced tetanus by in-
oculation of its pure cultures. There is still doubt as to
whether this germ is the only one which may produce the dis-
ease. Examination of the surface soil of various countries
shows that the bacillus of Nicolaier is very wide spread, being
more common in that from tropical regions. This agrees with
clinical experience, for the disease, as a rule, is much more
common in hot than in cold countries. Experiments show
that while the digestive fluids have not the power either to kill
or alter the germ, a dose vastly greater than that required to
produce death by inoculation can be taken into the stomach
with impunity. This is also in accordance with clinical experi-
ence, for the disease develops in connection with an open
wound or an unhealed umbilicus. The evidence is strong that
the disease is at first local in character, and there is ground for
the belief that it may be prevented by early treatment at the
point of inoculation. There is certainly much to be expected
from cleanliness and antisepsis as prophylactics, and this,
again, is in accord with practical experience.
The fact that the disease is prevalent in certain localities,
causing the death of a large proportion of new-born children,
and attacking nearly every surgical patient, is strong evidence of
its infectious nature. It has for years been a scourge of Iceland,
contrary to the usual rule that it is more prevalent in warm
climates. The Lancet for July 15, 1891, reports that it is also
alarmingly frequent in St. Kilda, one of the Hebrides Islands.
The disease has for several years been vastly on the increase in
spite of the amelioration in the comfort and social condition of
the population. The mortality has become so alarming that an
agent has been sent to confer with the medical authorities of
Glasgow. The symptoms develop within a week after birth
the most marked being tetanic convulsions, which increase in
severity until the child dies. The disease runs its course in
about twenty-four hours, and is always fatal. Of the numer-
ous hypotheses regarding the {etiology of tetanus, that of its
infectious nature is the only one which satisfactorily explains
the condition existing at St. Kilda and other isolated com-
munities.
MIXO II PARA GRA P IIS.
HELAPSE IN SCARLET FEVER.
It was believed by the older authors that relapse in scarlet
fever doc s not occur. As opposed to recurrence, true relapse is
certainly rare, but that it does sometimes occur can not now be
doubted. It would seem to be analogous to the relapse of ty-
phoid fever. Henoch believes that, though less common than
in typhoid, actual relapse does occur. After the patient has
been free from fever several days or even weeks the tempera-
ture suddenly rises, the rash again appears, sometimes over a
portion of the body only, and the patient passes through a typi-
cal course followed by desquamation. In many cases the course
of the disease in the relapse is irregular. However mild the
symptoms may be, the relaji.se must not be regarded as less im-
portant than the primary attack. In the Edinburgh Medical
Journal for October, 1891, Mr. Boddie reports two undoubted
cases of relapse. The first patient, after passing through an at-
tack of scarlet fever of moderate severity, followed by desqua-
mation anil albuminuria, had apparently made a perfect recov-
ery. On the thirty-seventh day, following exposure to cold and
wet, the temperature suddenly rose to 103° F., a rash appeared,
and he passed through another typical attack of s.carlet fever.
Desquamation was more profuse than after the first attack. In
the second case the relapse occurred on the twenty-seventh day.
The attack continued about five days and was not as severe as the
first illness. The second desquamation began on the thirty-fifth
day. It was partial and was quite over in a week.
A STUMBLING-BLOCK TO MEDICAL WRITERS.
Is there ever to be an end of the pranks played by the little
Latin word — whether meaning bone or mouth — in medical
writings? It is not many months since we called attention to
an instance in which the Centralblatt fur Gynakologie used the
expression " ossis uteri," and now we find the Lancet heading
one of the editorial annotations in its issue for December 19th
A Case of Defecation per Oretn .'
ITEMS, ETC.
The Alumni Association of the College of Physicians and Surgeons
will give a dinner on Saturday, the 16th inst., in honor of the consum-
mation of the active union recently established between their Alma
Mater and Columbia College. Addresses are expected from President
Low, of Columbia College; Dr. J. W. McLane, Dean ol the Medical
School: Dr. \V. II. Draper, of the medical faculty; Mr. J. H. Choate,
Mr. F. Hopkinsou Smith, and others.
The Harlem Medical Association. — At the meeting held on the 6th
inst. the order of business was a paper by Dr. T. II. Manley, on The
Pathology and Treatment of Diseases of the Hip, Knee, and Ankle
Joints.
The New York Academy of Medicine, Section in General Surgery.
— The meeting to lie held on Monday, the 11th inst., will be devoted to
a consideration of the subject of Surgery of the Intestinal Tract.
Specimens illustrating intestinal tumors, sutures, anastomosis, etc., will
be exhibited; Dr. R F. Weir will present a patient in whom the ileum
was transplanted to the sigmoid flexure; Dr. R. Abbe will read the re-
48
ITEMS.— LETTERS
TO THE EDITOR.
[N. Y. Med. Joob.,
suits of his personal work in this field, and the subject will be discussed
at length by Dr. J. A. Wyeth, Dr. B. F. Curtis, Dr. W. T. Bull, the
chairman, and others.
Medical Attendance in the Jury-room. — " The sanctity of a jury-
room appears to be so well guarded that, even in case of sudden sick-
ness, a physician may not enter except after due process of law. In
the Foss will case, tried recently in Boston, the jury were deliberating,
when, late in the evening, one of them was suddenly attacked with
what proved to be a stroke of apoplexy. The officer in charge notified
the deputy sheriff, who, not having authority to let any one into the
jury-room, drove across the city and informed the sheriff, but even this
official was not high enough to act, and another expedition started in
search of the judge. As the latter happened to be at home, the requi-
site order was obtained to summon a doctor." — Boston Medical and Sur-
gical Journal.
Marine-Hospital Service. — Official List of the Changes of Stations
and Duties of Medical Officers of the United Stales Marine-Hospital
Service for the three iceeks ending December 19, 1891 :
Bailiiaciie, P. H., Surgeon. Detailed as chairman of Board for Phys-
ical Examination of Officer, Revenue Marine Service. December
17, 1891.
Sto.ner, G. W., Surgeon. Granted leave of absence for twenty- one days.
December 16, 1891.
Carter, H. R., Passed Assistant Surgeon. To proceed to South At-
lantic Quarantine for temporary duty. December 10, 1891.
Banks, C. E., Passed Assistant Surgeon. To inspect unserviceable
property at Marine Hospital, Baltimore, Md. December 10, 1891.
Devan, S. C, Passed Assistant Surgeon. To proceed to Montreal, Can-
ada, on special duty. November 30, 1891.
Pettus, W. J., Passed Assistant Surgeon. To report in person to the
Supervising Surgeon-General, December 3, 1891. To proceed to
New Berne, N. C, on special duty. December 12, 1891.
Goodwin, H. T., Passed Assistant Surgeon. Granted leave of absence
for ten days. December 2, 1891.
Stoner, J. B., Assistant Surgeon. Granted leave of absence for seven
days. December 18, 1891.
Condict, A. W., Assistant Surgeon. Granted leave of absence for sev-
enteen days. November 30 and December 15, 1891.
Guitekas, G. M., Assistant Surgeon. Granted leave of absence for ten
days. December 15, 1891.
Stimpson, W. G., Assistant Surgeon. Granted leave of absence for ten
days. December 2, 1891.
Brown, B. W., Assistant Surgeon. Detailed as recorder of Board for
Physical Examination of Officer, Revenue Marine Service. Decem-
ber IV, 1891.
Cofer, L. E., Assistant Surgeon. Granted leave of absence for fifteen
days. December 15, 1891.
Society Meetings for the Coming Week :
Monday, January 11th : New York Academy of Medicine (Section in
General Surgery) ; Lenox Medical and Surgical Society (private) ;
New York Ophthalmological Society (private) ; New York Medico-
historical Society (private) ; New York Academy of Sciences (Sec-
tion in Chemistry and Technology); Boston Society for Medical Im-
provement (annual) ; Gynaecological Society of Boston ; Burling-
ton, Vt., Medical and Surgical Club ; Norwalk, Conn., Medical So-
ciety (private) ; Baltimore Medical Association.
Tuesday, January 12th : New York Medical Union (private); Kings
County Medical Association ; Medical Societies of the Counties of
Chautauqua (semi-annual), Chenango (annual), Clinton (annual —
Plattsburgh), Erie (annual — Buffalo), Genesee (semi-annual — Bata-
via), Greene (quarterly), Jefferson (annual — Watertown), Livingston
(semi-annual), Madison (semi-annual), Oneida (semi-annual— Rome),
Onondaga (semi-annual — Syracuse), Ontario (quarterly), Oswego
(semi-annual — Oswego), St. Lawrence (annual), Schenectady (an-
nual— Schenectady), Schuyler (annual), Steuben (semi-annual), Tioga
(annual — Owego), Wayne (semi-annual), and Yates (semi-annual),
N. Y. ; Newark, N. J. (election), and Trenton (private), N. J., Medi-
cal Associations ; Norfolk, Mass., District Medical Society (Hyde
Park) ; Baltimore Gynaecological and Obstetrical Society.
Wednesday, January 13th: New York Surgical Society; New York
Pathological Society; Metropolitan Medical Society (private);
American Microscopical Society of the City of New York ; Medical
Societies of the Counties of Albany and Dutchess (annual — Pough-
keepsie), N. Y. ; Tri-States Medical Association (Port Jervis, N. Y.) ;
Pittsfield, Mass., Medical Association (private); Hampshire (quar-
terly— Northampton) and Worcester, Mass. (Worcester), District
Medical Societies; Bennington, Vt., County, and Hoosic, N. Y.,
Medical Society (annual — Arlington, Vt.) ; Philadelphia Countv
Medical Society; Kansas City, Mo., Ophthalmological and Otologi-
cal Society.
Thursday, January 14th: New York Academy of Medicine (Section
in Paediatrics) ; Society of Medical Jurisprudence and State Medi-
cine; Brooklyn Pathological Society (annual, election); Medical So-
cieties of the Counties of Cayuga, Fulton (annual — Johnstown), and
Rensselaer (annual), N. Y. ; South Boston, Mass., Medical Club
(private); Pathological Society of Philadelphia.
Friday, January 15th : New York Academy of Medicine (Section in
Orthopaedic Surgery) ; Baltimore Clinical Society ; Chicago Gynae-
cological Society.
Saturday, January 16th : Clinical Society of the New York Post
graduate Medical School and Hospital.
betters to tin <Lrbitor.
DISAPPEARANCE OF SUGAR IN A CASE OF DIABETES
MELLITUS.
Augusta, Me., January 5, 1892.
To the Editor of the Nero York Medical Journal:
Sir: In the issue of the New York Medical Journal for
January 2d J. Page Burwell, M. D., of Washington, D. C, re-
ports a case of diabetes mellitus and its successful treatment.
Having seen equally pleasing results follow very different treat-
ment in a similar case, I am prompted to report the case.
On March 8, 1889, I was called to see Mrs. H., married, aged
forty-eight. The patient complained of intense pruritus of the
genitals, accompanied by considerable tumefaction, and an ex-
coriated condition of the inner aspect of the thighs. There was
great polyuria, frequent and painful micturition, followed by
extreme distress, after the act. and lasting some minutes. She
complained of severe headache, backache, and general malaise.
Upon examination of the patient, I found that she further
complained of intense thirst, that the tongue was red and
glazed, and the appetite deranged — at times excessive, at other
times almost nil. There was also feebleness of vision, and an
eczematous eruption upon different portions of the body. The
embonpoint of the patient was very noticeable.
An examination of the urine gave a specific gravity of P056
with an acid reaction. Fehling's test showed a large amount of
sugar.
The treatment was five-grain doses of iodide of potassium
before each meal. One saline and chalybeate pill three times
daily. A teaspoonfnl of Sprudel salts in a glass of water before
breakfast each morning.
The diet consisted of gluten bread, milk, fish, and those
vegetables allowable in this disease.
Under this treatment the .-ugar gradually disappeared, as de-
termined by fortnightly tests of the urine, until a test made
July 1, 1889, failed to show the slightest trace.
The patient returned to her normal weight in a few months,
and is now apparently well. W. 11. Harris, M. D.
Jan. 9, 1892.]
PROCEEDINGS OF SOCIETIES.
49
fjroeccittncfs of Societies.
NEW YORK NEUROLOGICAL SOCIETY.
Meeting of December i, 1891.
The President, Dr. L. C. Gray, in the Chair.
Resection of Posterior Branches of Upper Three Cervical
Nerves for Spasmodic Torticollis, with Report of a Case.—
Dr. Charles A. Powers read a paper with this title. (Will
be published.)
Dr. R. W. Ambon thought that Dr. Powers had been too
modest in that he had not called attention to the marked improve-
ment in the patient's right arm. Before the operation this had
been practically powerless, while now its functions were restored.
The position of the head was now similar to that before the
operation, but the spasm was now tonic instead of clonic, and
therefore much more endurable. There was now no elevation
of the chin, which was conclusive proof that none of the muscles
originating or inserted in the occipital bone were now impli-
cated. The elevation of the right shoulder was now much more
marked and there was no doubt that the levator anuuli scapula;
entered largely into the production of the deformity. The
speaker then went over the action and nerve supply of the mus-
cles of the shoulder with the view of demonstrating that pos-
sibly the present condition might be brought about by this
group, the nerves which had not been cut.
Dr. C L. Dana thought that the muscles of the right side,
which had been cut, had possibly entered into the production of
the spasm, but that the nerve force was now distributed through
fewer channels, and perhaps this was the reason that the spasm
was now tonic. The question was at any rate of extreme inter-
est, because heretofore there had been much skepticism as to the
value of operation for wryneck. He thought that the experi-
ence of American observers was that operation on the spinal
accessory had been uniformly fruitless, but the relief obtained
where the upper cervical nerves were involved had given a
more favorable showing. With better technique, perhaps more
favorable results would come in the case of the spinal accessory.
He did not doubt but that the condition under consideration
was the result of a central nervous lesion. Why surgical treat-
ment should cure he did not know, unless it was the result of
the operation per se.
Dr. M. A. Starr had seen these cases treated by division of
the spinal accessory. No improvement had followed. He had
therefore hesitated to recommend such procedure. He thought
it had yet to be demonstrated that the condition was one of
cerebral origin, as there was nothing analogous to w ryneck in
the form of cerebral spasm of any other muscle. A patient had
come to him last February with an extremely pronounced case
of wryneck. This patient had noticed that pressure on the
right side of the occiput high up would relieve the spasm. An
apparatus was accordingly constructed which, being constantly
worn, had enabled him at the onset of the spasm to bring the
necessary pressure to the required spot by means of a system of
levers worked by his arm. The speaker had that day seen the
patient, and had found him apparently perfectly cured and able
to leave off the apparatus, it was difficult, to determine in
these cases what muscles or set of muscles was implicated. The
spasm was probably a complex act by a large number of mus-
cles and usually reflex in character, induced by sensory irritation
somewhere.
Dr. W. M. Leszynsky thought that there was a lack of such
pathological knowledge of the disease as would indicate that
there existed a central lesion. It was remarkable that so few
microscopical examinations bad been so far made of nerves
which had been resected. In the present case no explanation
had been offered as to the cause of the arm symptom, and
whether it was supposed to have borne any relation to the
spasm in the neck. He had been interested in a few cases of
spasmodic wryneck, and felt confident that the hypodermic in-
jection of atropine had helped them. He had reported a case
in which the spinal accessory was implicated, and he had felt that
the benefit done was the result of the atropine. He thought
that this measure should be energetically tried as part of a
treatment by drugs before surgery was resorted to.
Dr. G. M. Hammond said that the general idea was that
operations of this kind were not successful. The result in the
present case seemed to relate more to the comfort of the pa-
tient than to benefit from a pathological standpoint. It might
be easier for the patient to have a tonic instead of a clonic
spasm, but the condition of wryneck remained.
Dr. J. M. Morton cited the history of a patient who had
come to him with a well-marked case of spasmodic wryneck of
long standing. Every effort had been made therapeutically.
He had tried suspension. The seances had numbered about
five, each lasting about five or six minutes, the patient's toes
being just free of or barely touching the floor. Improvement
had been prompt and had continued to a cure, which had been
maintained up to the last report.
The President had never seen any good results from'opera-
tive work in these cases. While out of a large number operated
upon for him by different surgeons temporary improvement had
taken place in some, relapse had ultimately occurred. He had
obtained more satisfactory results by deep injections of atropine
than from any other form of treatment, though he had found
the internal administration of belladonna effective. As to the
permanency of the atropine benefit he could not speak, the pa-
tient having passed from observation. Temporary results were
worthless for purposes of deduction, and relapses were probable
at any time.
Dr. Powers thought that the indications for operation must
come from the physicians, surgeons being hardly justified in in-
terfering until every other method of treatment had been tried.
Promise of amelioration must be guardedly given. If the tech-
nique were perfected so as to cover the nerve supply to the
muscles involved, he did not see why the spasm could not be
stopped.
Alleged Cerebral Tumor. — Dr. Leszynsky showed a pa-
tient whom he had presented to the society three years ago; at
that time the diagnosis had been made of cerebral tumor. The
symptoms had then been frontal headache, vomiting, and double
optic neuritis. Now this man was in perfect health, and since
treatment had never lost a day's work from illness. There was
atrophy in both optic nerves. Vision was in one eye, f £; in
the other, f$. There was no disturbance in the color field. The
treatment during the acute stage had been by large doses of
!odide of potassium, with leeches and cathartics when the in-
flammation was excessive. The speaker had been able to find
only one case where autopsy had revealed localized basilar men-
ingitis in the region of the optic chiasm.
NEW YORK ACADEMY OF MEDICINE.
section in general surgery.
Meeting of November 9, 1891.
Dr. William T. Bull in the Chair.
The Pernicious Effect of Early Excision of the Knee
Joint in Children. — Dr. V. P. Gihney exhibited a number of
patients for the purpose of illustrating this point. In all the
50
PROCEEDINGS OF SOCIETIES.
[N. Y. Mko. Jour.,
cases shown there was marked shortening, in some instances
amounting to five inches, and the excisions had left sinuses and
other sequelse, which had called for treatment by osteotomies
at the hands of the speaker when the patients had come under
his care.
The Fibula used to effect Union after Compound
Fracture of the Tibia.— Dr. \\. F. Curtis showed a patient
who last June had caught his leg in the belt of a planing ma-
chine, the limb being forcibly carried against the pulley. The
resulting injury had been compound fracture of the tibia and
fibula and fracture of the femur. Three inehes of the tibia had
projected through the wound and union had taken place in the
femur and in the fibula, but had failed in the tibia. When the
speaker saw the patient first there had existed a considerable
gap between the ununited fragments, the space being occupied
by a granulating mass. Pie had found that any attempt at
freshening the ends of the bone and using mechanical approxi-
mation would result in a total shortening of the leg of three
inches. He had therefore cut down on the fibula and forced it
through the soft parts into the gap between the tibia frag-
ments, which had been previously freshened. The resulting
union had given the patient a leg with only an inch and three
quarters of shortening, much of which was due to the fracture
of the femur. Union had taken place slowly, but was already
sufficiently firm to enable the limb t,o support the man's weight.
There had been no inflammatory action.
Trephining for Traumatic Epilepsy. — Dr. A. J. McCosri
presented a boy, seven years of age, who, on August 11, 1890,
had fallen down stairs and had been found in a semi-comatose
condition. He had remained in this state for some twenty-four
hours at the hospital and could only be aroused with difficulty,
lapsing immediately into unconsciousness. There had been no
paralysis and no lesion of the scalp. On the third day the pa-
tient had been less stupid but extremely irritable. By the sev-
enth day intelligence had been restored, but there had been
partial paralysis of the left upper extremity and of the left side
of the face, with twitchings over these areas, going on to con-
vulsions limited to the left side. On the eighth day paralysis
of the left upper and lower extremities had been complete and
the patient had had several epileptic seizures commencing in the
left arm and becoming general. The diagnosis had been that of
pressure by clot on the motor center for the left arm, face, and
leg in the posterior and anterior ascending convolutions. Op-
eration had demonstrated the external surface of the skull as
uninjured, but that there was a clot, which was followed back-
ward, by use of the rongeur, from the original trephine open-
ing, made three quarters of an inch in front of and about the
middle of the Rolandic fissure. This clot was beneath the dura
mater, which had appeared to be uuinvolved. To fully expose
and enucleate this clot, which was half an inch thick, had re-
quired an opening in the skull of two inches and a half in
diameter. It had then been observed that at the posterior part
of this opening there was a fissure running upward and back-
ward, meeting at a sharp angle a second fissure running down-
ward toward the ear through the squamous portion of the tem-
poral bone. This triangular piece of bone being removed, a tear
was seen in the dura mater an inch and a quarter long, with a
quantity of broken-down brain substtnee beneath it. After thor-
ough removal of clot and debris the scalp was sutured over a
drainage-tube. Some slight movements had taken place in the
paralyzed left arm as the boy had come from under the anaes-
thetic. In twenty-lour hours movements had become pretty
general over affected areas. In three weeks motion had been
complete, and in six weeks they had been of normal strength.
The patient had become perfectly well and had so remained.
There was at present no inconvenience of any kind. The case
was one of brain irritation with destruction and with symptoms
of both. The exact localization of the clot had been made from
the symptoms alone.
Dr. R. II. M. Dawbaen cited a case in which he had tre-
phined on the right side for left hemiplegia. The patient had
complained of most pain on this side, but on the brain being
exposed there hail been no lesions to account for the compres-
sion symptoms. Post-mortem examination had revealed a large
clot on the same side as the paralysis. This case he regarded
as one in which there was no crossing of the motor fibers in the
medulla. In future cases, while he would make his first tre-
phine disc on the side indicated by physiological rules, he would
then, if he failed to find cause for the symptoms, make his
next attempt over the most recent external evidence of injury
he could find.
Dr. J. D. Bryant said that one of the special features of
the cases mentioned was that trephining had been resorted to
at all. Two cases had come under his observation within six
months in which the trephine had been used when there had
existed no scalp lesion, the operation being undertaken on ac-
count of the paresis and convulsive symptoms. In one case
removal of bone had revealed a large blood-clot between the
dura and pia, which had given rise to pachymeningitis. In an-
other case, in the service of Dr. Janeway, the speaker had been
asked to operate. In this there had been partial paresis of one
side with semi-unconsciousness. The paresis had been upon
the same side as the injury. He had not operated at once, and
meantime the patient had died. The compression had been
found to be on the same side as the injury.
Dr. T. II. Manley showed a piece of bone removed from
the skull of a child of four years of age who had fallen down
four flights of stairs. Four days after the accident there had
been paralysis of the left side. The speaker had found the por-
tion of skull shown imbedded in a mass of clotted blood. In
cleansing he had employed no chemical solutions. The child
had got along quite well except that there now existed a cere-
bral hernia, which he must confess he would be glad to know
how best to treat.
Hysterectomy for Prolapsus Uteri. — Dr. McCosh also re-
lated the case of a woman, forty-two years of age, who for
twelve years had suffered from prolapse of the uterus. For six
months there had existed an irreducible mass composed of the
enlarged uterus, the entire bladder, and the dragged-down rec-
tum. This mass 1iad been of the size of a Derby hat and ex-
ternal to the vulva. After the patient had rested a week in
bed the mass had been still irreducible. A sound passed into
the urethra had defined the limits of the bladder entirely out-
side of the vulva. The uterus, which had been retroverted and
of double the normal size, had been dragged two inches below
and behind the vulvar orifice. The speaker had decided to do
hysterectomy, and dissection had been commenced within half
an inch of the os uteri and carried upward until the lower por-
tion of the broad ligament had been reached, and this had been
tied with silk and cut. Dissection had then been continued in
front and behind and carried upward until the peritoneal cavity
had been opened. The remainder of the broad ligament had
then been secured by two sutures on each side and the uterus
had been removed. ft had measured six inches in length.
There had still remained a large cone of vaginal wall nearly
an inch thick and the bladder and rectum. The vaginal mass
had been carefully dissected away. The remaining prolapsed
mass could not be returned at the time of operation and had
resisted all efforts at reduction until the twentieth day. The
bladder had gone back into place and three months had now
elapsed since the operation without recurrence of any protru-
sion of the parts. The speaker, of course, recognized the fact
Jan. 9, 1892.]
PROCEEDINGS OF SOCIETIES.
51
ghat too short a time had elapsed to allow of this case being
used in citation as to the ultimate value of the operation.
The Thiersch Method of Grafting in Plastic Operations
on the Nose. — Dr. 0. A. Powers presented a female patient upon
whom he had operated for vascular papilloma springing from the
nose. Three fresh grafts had been taken from the arm and the
wound had healed throughout. On previous occasions the
speaker had applied a single large graft in regions where the
skin could not he approximated, and twice these grafts had
failed to catch. He could only account for this by the assump-
tion that the ligatures used had interfered with the blood-supply.
He thought that where a single large graft would catch the cos-
metic effect was better. When the graft was taken from the
arm it was introducing a skin different in color from that at the
site it was to occupy.
Errors in the Use of the Cystoscope. — Dr. L. B. Hangs,
in a paper on this subject, said that there could be no doubt as
to the value of the cystoscope as an instrument of precision
and an aid to diagnosis. Conditions of the bladder formerly
unrecognizable were now clearly definable by the use of this
instrument. Stone in the bladder, cysts, ulcerations, localized
hyperemias, infiltrations of various types, .and tumors might all
be seen and diagnosticated definitely. The situation of the
mouths of the ureters could be detected and inspected with per-
fect accuracy; and by means of the tube attachment by Dr.
Brenner, of Germany, these channels might be cathcterized and
the fluid descending from each kidney reserved for microscopic-
al examination. But the cystoscope bad its limitations and
fallacies, and tha first step in the direction of their removal was
to recognize them. One of the symptoms frequently met with
in diseases of the genito-urinary organs was hematuria or blood
in the urine. Sometimes the source of this was extremely
doubtful. A diagnosis was often made with resort to instru-
mental observation, and, notwithstanding the existence of the
cystoscope, we might still have to resort to the older and more
ordinary methods of diagnosis. In other words, the amount
of blood present in the urine or in the bladder might be so
abundant that the cystoscope would be of no use and reliance
would have to be, as formerly, upon the process of exclusion.
Another difficulty arising from present imperfection in the
cystoscope was the possibility of optical illusions which were
at times very deceptive — such, for instance, as the magnifying
of the object by too close an approximation to it of the window
of the instrument. It should be borne in mind that an object
seen through a fluid medium was more likely to be magnified
when looked at directly or outside of the body. Only the skill
which came from frequent practice could enable the operator
to eliminate this source of error. Again, it had frequently hap.,
pened to even the most skillful to see things which did not
really exist or which gave to the eye the appearance of exist-
ence. The bladder had been opened for the purpose of remov-
ing tumors seen through the cystoscope which when the bladder
was opened were not present. Another limitation to the use
of the cystoscope was in the case of elderly men in whom stone
was suspected and in whom there was a tortuous or long pros-
tatic urethra making catheterization difficult or impossible.
The speaker did not wish to have it inferred that he was
not an enthusiastic user of and believer in the cystoscope. He
employed it under all possible circumstances. His practice had
been enlightened by it and cases had been cleared up and suc-
cessful treatment made possible by the knowledge which it
gave. He did urge, however, that difficulties existed only to
he overcome by long experience with the instrument and by
the most careful exclusion of all sources of error.
Dr. W. K. Otis thought that there existed an idea that it was
only necessarv to possess a cystoscope to make sure of the diag-
nosis. As to the question of hemorrhage into the bladder, it was
wonderful how small an amount of blood would make it impos-
sible to see anything with the cystoscope. He thought that it
would be rare that hemorrhage from the kidney would be suffi-
ciently rapid to mar the use of the cystoscope. Bleeding from
the kidney was comparatively readily recognized, but when the
hemorrhage was from the bladder the resorption test by iodide
of potissium would give the knowledge that the bladder was
at fault, and then the cystoscope could be used to define the
exact cause. Another source of error in the French instru-
ments was the spherical aberration, so that a perfectly flat sur-
face examined in the phantom bladder looked like a globe. The
speaker and Dr. Stratford were now at work upon a cystoscope
which they hoped would give a flat field.
Dr. Willy Metee said that Nitzc and other authorities had
always maintained that it was necessary to have five ounces of
water in the bladder when making an examination, and he
thought that when this point was observed the eye could be
more readily trained. In stretching the bladder by fluid a
syringe — not a fountain syringe — should be used. When there
was hematuria it was impossible to view the bladder, and it
was better to wait. It was also necessary that the urethra
should admit of the passage of a catheter of 23 caliber.
The Chairman inquired if there was any record of accident
occurring as a direct result of the use of the cystoscope.
Dr. Bangs had not heard of anything other than some slight
burning from too prolonged contact of the lamp.
The Treatment of Haemorrhage. — Dr. R. H. M. Daw-
barn, in a paper on this subject, advocated the more frequent
use of the Spanish windlass where this measure was indicated.
He also gave the particulars of a case which he had successfully
treated in the following manner: Being able to make out the
pulsation of the femoral artery, he had introduced a hypoder-
mic needle, and, having verified its position by seeing the blood
enter the barrel of the syringe, he bad removed the barrel, and,
attaching a soft-rubber catheter to the base of the needle, had
used this as a connection to a Davidson syringe apparatus. A
warm saline solution bad been employed and passed thus into
the arterial circulation. The case had been one of imminent
gravity, and the result of the treatment most efficacious.
Dr. W. W. Van Arsdale had found these saline solutions
of little benefit. Certainly his experience had been limited to
operative cases. The most satisfactory results, lives having been
saved, he had got where blood had been used with the saline
solution. The injections bad all been intravenous.
The Chairman thought more experience should be gained
before accepting the method of puncturing the femoral with
even so small a needle as a matter of routine. He could indorse
the value of the saline solution, and made it a point to have in
readiness a quantity of proper strength for addition to a given
quantity of water. He thought a vein could usually be entered
without much difficulty, and that for the present he should pre-
fer that method of making these injections.
SECTION IN PEDIATRICS.
Meeting of November IS, 1891.
Dr. A. Caille in the Chair.
Soxhlet's Modified Milk Sterilizer.— Dr. Louis Fisoheb
demonstrated the working of a recent modification by Professor
Soxhlet of his now widely known apparatus for the steriliza-
tion of milk for infant feeding. The recent device, which had
been patented in Germany, consisted in placing a small rubber
disc upon the bottle containing the milk. This disc was held
in place by a loosely fitting metal cap. When the bottle was
heated the contained air, in expanding, escaped by lifting the little
52
NE W INVENTION'S. — MISCELLA NY.
[N. Y. Med. Jouh.,
disc. When cooling was commenced there was a vacuum above
the milk in the bottle and the air-pressure without drove the
disc home upon and partly into the neck of the bottle and
effectually sealed it until the disc was forcibly removed. The
disc could not be replaced after being removed.
The Physiological Importance of the
Proximate Principles.— Dr. W. H. Porter read
a paper on this subject.
The Chairman said that the equivalent of
foodstuffs had been ascertained, as shown in the
dietary of animals, but that in pathological con-
ditions we did not always know what the
changes were.
Dr. W. H. Thomson said that the paper was of value as it
dealt with the physiological chemistry of the urine and the
physiological importance of water. In high-tension pulse and
in other symptoms of lithnemia water was required, and from
it we obtained a therapeutic result. Probably the system got
water in some other way than by the mouth. He had observed
patients with diabetes insipidus who passed two or three times
as much as they had taken. Workmen in glass factories would
lose two or three pounds in sweat and in a little time regain
their weight without drinking. We had probably the power
of acquiring water from the air as well as of losing it in per-
spiration. He regarded the mineral waters as of value in cases
where the portal circulation was at fault, but thought that the
contained chloride of sodium did the most of the good. He
hesitated to admit physiological chemistry to the bedside, and
he doubted whether we could follow these foods in the abstract
and say that too much or too little of this or that was used.
He would not give meat, as indicated in the paper, to children,
but would rather employ vegetable albumins and milk and thus
avoid nervous disorders.
Dr. A. Zeh thought that in cases in which too much starch
had been taken albumin and skimmed milk should be given and
the starches and sugars be limited.
Dr. Porter did not regard the internal mechanism and the
laboratory as identical. He considered milk the fundamental
article of food. In infancy, however, the biliary and pancreatic
ferments being limited, there was not a complete digestion of
fat and proteid. The milk sugar caused a little fermentation,
which was productive of peristaltic movement. He had found
that by the use of proteids he could drive uric and oxalic acid
from the urine, when by the continued use of a diet of starches
and sugars he had failed. Uric-acid infarcts in the foetus and
infant he believed to be due to the use of improper food by the
mother.
raal plate the needle grip is rendered invincible. When this heel plate
is unscrewed the four portions of the instrument drop apart. Release
of the needles is effected by compression of the spring, one hand only
being required.
ftcto fnbcntions, etc.
A NEW NEEDLE-HOLDER.
By G. Willis, M. D., L. R. C. P. (Ed.),
GREENVILLE, CAL.
I venture to present to the surgical profession a new pattern of
needle-holder, devised to carry the ordinary surgical needle, Hagedorn's
needle, and Thiersch's spindles for ligature en masse. The holder con-
sists of four very strong and simple parts :
1. A hollow tube with a distal plate.
2. A central stem.
3. A spiral spring.
4. A proximal (or heel) plate.
The spring forms the grip or handle ; the proximal plate screws on
to the central stem, has a milled edge, and compresses the spiral spring,
which, in turn, compresses the stem and tube. By turning the proxi-
The advantages alleged for the instrument are simplicity of construc-
tion, aseptic form, the ease with which it may be instantly separated
for purposes of boiling or cleansing, and the combination of Thiersch's
most useful spindle apparatus with a simplified Hagedoru and other
needle-holder.
Needles pass in at a right angle or obliquely upward. The instru-
ment in its present form has been developed from my rough model by
Messrs. George Tiemann & Co., of New York, from whom it may be
procured. My best thanks are due these gentlemen for the skillful
manner in which they have expanded my crude idea.
lit i s c e 1 1 a n n
The Brain of a Great Chess Player. — An article On Blindfold Play
and a Post-mortem, by Charles Tomlinson, F. R. S., published in the
British Chess Magazine for August, 1 891, serves as a text for the fol-
lowing editorial in the British Medical Journal for December 19th:
To most people playing at chess seems rather too strenuous an effort
to be called an amusement. It is said that ten years of incessant study
and practice are necessary to make a first-rate chef s player. A good
deal of his excellence consists in the memory of problems, and we are
told that, since the institution of a time limit, the professionals in
match games endeavor to construct intricate positions for which correct
solutions can scarcely be found within the time at command. Never-
theless, some strong-headed people go a good deal beyond this ; they
can play a game blindfold — that is, the moves are made without seeing
the board. Blindfold play, Mr. Tomlinson tells us, is at least a thou-
sand years old, but it has taken a marvelous development in our own
day. " When it was revived by Philidor," writes Mr. Tomlinson, '"the
world was astonished at his skill in playing two games at once without
seeing boards or men ; and it was thought that his brain during the
performance must have been in a fearf ul state of tension. To the sur-
prise, however, of all present he was quite at his ease, and even mingled
light conversation with his play. In our own time llorphy played
eight games without sight of boards or men; Blackburne played twelve
in my presence, Zukertort fourteen."
Mr. Tomlinson tells us that Blackburne, during his blindfold per-
formance, " sat on a low platform with his face to the wall, his eyes
closed, and he grasped tightly the fingers of one hand in the grip of the
other; he took no refreshment within the ten hours that the contest
lasted except some lemonade." When asked how he slept after such a
task he replied : " Badly, unless I take time to cool down, but if I go
to bed about three hours after the play I don't experience much incon-
venience." This is the usual result of intense mental exertion.
Of course the blindfold player must have a distinct mental image of
the chess hoard with its sixty-four black and white squares, and also
the position of the different pieces of chess varying with each move ;
but in the case of a man playing a dozen games at once this requires an
enormous effort of memory. The success of the game must greatly de-
pend upon the distinctness of the image. "Zukertort's account of the
mental process was that he had somewhere in his brain fourteen boards,
numbered from 1 to 14, placed in separate closets side by side in a
row, each closed by a door ; having made his move, say, on No. 1
Jan. 9, 1892.J
MISCELLANY.
53
board, the door closed and that of No. 2 opened, and in this way he
passed in due order from one to another until he arrived at No. 14. He
dismissed from his mind, at the moment, all the boards except the one
before him ; a mental glance enabled him to realize the position, receive
his adversary's move, and dictate his own. Then, passing on to the next,
he acted in like manner, just as if the apparatus described were actu.
ally before him." This is in accordance with precedent ; not only
would it be necessary that the boards should be mentally realized, but
each would need some distinctive mark to prevent confusion. We are
told that the process is so exhausting that Morphy became deranged
and died under melancholy circumstances while still young. Zukertort
and La Bourdonnais are also said to have died from illness produced by
the intense mental strain of these blindfold games.
The most wonderful piece of information is still to come. A great
blind chess player, Mr. Richard Rookwoode, could play twelve blind-
fold games with ease, but could not get on with fourteen. This gentle-
man died about a year ago, and his brother, " who is a skillful anato-
mist and physiologist," obtained permission to examine the brain of the
great blindfold player. He took for his basis phrenology, which is as-
sumed to be the explanation of the functions of the brain at present in
acceptance. The organ necessary for a good chess player is locality,
other faculties being subsidiary. On examining the portion of the brain
occupied by the organ of locality it was found that " the molecules had
arranged themselves into forms somewhat resembling chess-boards,
with certain marks on the squares supposed to represent the final posi-
tion of the pieces in the last twelve games that had been played blind-
fold. Twelve positions were thus probably indicated by the aid of the
highest power the microscope could supply ; the thirteenth or four-
teenth boards, or what might represent them, were blurred and indis-
tinct." It is lucky that Dr. Rookwoode, in making his microscopic sec-
tions, went the right way — for example, if he had cut at aright angle
instead of horizontally to the surface of the molecular chess squares,
his important discovery could scarcely have been made. For further
details we must still wait for "the elaborate Memoir which is to be sub-
mitted to the Royal Society as soon as the numerous illustrative draw-
ings are completed. The purely anatomical details are to be laid be
fore the College of Surgeons." This makes some questions on mental
philosophy delightfully easy. We wonder whether in molding a statue
or painting a picture the " molecules " of the brain of the sculptor and
painter arrange themselves into a little model or sketch. This should
be sought for when the next great sculptor or painter dies, and the re-
sult might be laid before the Royal Academy of Laputa.
The Question of paying Hospital Nursing Pupils has lately been
discussed by various correspondents of the Evening Pout, one of whom,
Dr. J. West Roosevelt, writes as follows:
The letters of '' J." and " P. T. D." present a question of impor-
tance to the public. The education of nurses is a matter of moment.
Having taken rather an active part in a discussion of the same topic
in certain professional journals, I have read the communications of
your correspondents with great interest. May I be allowed to say
something in the Evening Post f
It is necessary to state clearly the question, for the public in gen-
eral have not yet become familiar with it. It may be summarized as
follows :
Training-schools for nurses give their pupils an education which
enables them to earn a living, provide them with board, washing, aud
lodging during the period of instruction, and also pay them more or
less money while teaching them their profession. Is it right to pay
them ?
The policy adopted by the Government at West Point or Annapolis
has no relation to the subject. As "J." points out, the cases are not
parallel ; but if they were, it would make no difference. The methods
of the Government are not necessarily right. In the particular in-
stances alluded to the Government is undoubtedly right, but as the
training-schools do not educate nurses for the purpose of providing
trained employees to do needed work for the benefit of these schools,
while the Government has this purpose, and this alone, in view, there
is no resemblance between the aim of the Government and that of
training-schools.
It is possible, though not at all probable, that nurse pupils really
should be paid. If a sufficient number of equally good pupils can be had
in no other way, they must be offered money. In that case also there
can be no justice in calling the wages " charity," for they are fairly
earned. The demand for pupils exceeds the supply. Nurse-pupils
while under instruction necessarily work, and few can understand how
hard they work, for the good of the sick in hospitals ; one reason for
the existence of training-schools is to provide good nursing for hospi-
tal patients. Indeed, I believe that this was the first object in the
minds of those who established the oldest institution of the kind in
this country. Hospital nursing is very hard work, and must be paid
for in some way. If the education given is a sufficient reward, any
money paid is not earned, and therefore those who give it offer, and
those who take it accept, " charity " in the same sense meant by " J.,"
or, to speak plainly, alms. Moreover, it is hard to see what excuse the
managers of trust funds, such as those belonging to these schools, can
offer for the needless expenditure. Trustees have no right to be sen-
timental. They are bound to make the best use of their trust. It is
their duty to get the best pupils, and it is also their duty to spend as
little money as possible. The fact that at one school during the year
1890 there were forty five applicants for each vacancy surely makes it
more than probable that the pay is not necessary.
There seems to be an idea in the minds of many that the schools
are intended to provide certain unfortunate young women (especially
those in "reduced circumstances ") with a means of livelihood. This
is utterly false. They exist to teach competent women to become
nurses, and to furnish hospitals with good nursing. The previous cir-
cumstances of an applicant (except in so far as they affect the question
of her fitness), her misfortunes, her social position, the " pull " she may
have, her extreme goodness of heart, the fact that her father was a
missionary or something equally meritorious, are unimportant; her
ability to become a nurse is the only question to be considered. The
managers of these schools can not, in justice to their trusts, knowingly
admit incompetent scholars. As to paying the latter, their action
must be determined by the law of supply and demand.
As a most sincere friend of the training-schools, and one who quite
as much as "F. T. D." resents any attacks upon the dignity of the
nurse's calling, I feel that the pay system is a source of danger to the
very existence of the former, while as to the effect of giving unearned
money upon the dignity of the recipient — is it likely to be elevating?
The Diagnostic Significance of Alterations of the Reflexes. — Dr.
James Jamieson, of Melbourne, contributes the following article to the
November number of the Australian Medical Journal :
In spite of the great increase of knowledge in the department of
diseases of the nervous system many questions of almost fundamental
importance still remain unsettled. It might rather be said, indeed, that
because of the recent progress in their study, the whole subject is con-
stantly being subjected to revision. This holds good of the significance
to be attached to alterations in the reflexes, even though the chief points
in the interpretation of these alterations are generally accepted as set-
tled. Of all the phenomena of this kind, which can be elicited in the
various regions of the body, those to which appeal is most ferquently
made are the reflexes at the knee and ankle joints. The alterations in
the knee and ankle reflexes are chiefly of service in the diagnosis of dis-
eases of the spinal cord and its nerves, though not of these exclusively;
and, for general diagnostic purposes, they are undoubtedly the most
important of the reflex phenomena producible in the trunk and limbs.
The others may be helpful in confirming the indications which they pio-
vide, and may further be required for definitely fixing the exact seat or
extent of a lesion. But for determining the existence of spinal disease,
or fixing its characters, the evidence supplied by observing the changes
in the knee and ankle reflexes is of supreme importance. If I limit
myself, therefore, to a consideration of that evidence aloue, there are
good practical reasons ; and perhaps I shall be pardoned for beginning
this discussion with a reference to the mechanism of production of the
patellar and other similar reflexes.
The parts of the nervous apparatus, in the so-called reflex arc, are
these: (1) An afferent nerve or nerves conveying an impression from
the surface to the nerve center ; (2) a sensory apparatus, cells in the
M JSC ELLA XV.
[N. Y. Med. Jouh.,
posterior column of the cor<], by which tli;it impression is received ; (3)
a motor apparatus, cells in the anterior column, to which the impres-
sion is transmitted, and by which, in turn, an impulse is communicated
to (4) an efferent nerve or nerves, conveying that impulse to certain
muscular libers, which respond by contraction. It is perhaps necessary
to postulate (fl) a system of fibers by which communication is made be-
tween the sensory and motor parts of the cental apparatus. Practi-
cally, however, we know nothing about any independent affection of this
portion of the arc; and it may be doubted if any interruption in the
transmission, from periphery to center and back to muscles, could be
explained by a break in the communications there.
For the production of a normal reflex, like the knee-jerk, we have
to assume the integrity of all these parts of the sensorimotor apparatus
forming the arc.
An alteration of the patellar reflex may be in the way either of in-
crease, or of diminution even to complete abolition. And w hile aboli-
tion of the reflex is something definite, it is not by any means easy to
define what the normal condition is, or to say with certainty whether
an apparent increase or diminution is actually a pathological condition.
Certainly, there are great differences in different persons, as regards the
ease with which the jerk is produced; and even considerable differences
iu the same person at different times, and independently altogether of
the supervention of disease of nerve or nerve center, lu occasional,
though probably rare, cases the knee-jerk can not be elicited, and that
though there is no other evidence of disease of the nervous system. It
can not, therefore, with certainty be said that even absence of patellar
reflex is a patholozjcal condition, though its abolition, in a person for-
merly exhibiting it, would be more significant. Alterations of the knee-
jerk, therefore, in the way of diminution especially, are not always easy
to estimate for diagnostic purposes.
In the case of the ankle joint there is nothing which can be regarded
as strictly analogous physiologically to the knee-jerk. The muscles of
the calf may offer some involuntary resistance to dorsal flexion of the
foot, and the same muscles may contract involuntarily, when the tense
Achilles tendon is struck. But diagnostic significance does not belong
to the degree of readiness with which such contraction takes place. The
phenomenon connected with this joint, which alone has importance, is
ankle clonus, and its significance is so far definite that its production
is always proof of the existence of some abnormal condition. What
the conditions are, which lead to its production, will be considered later
on, along with exaggeration of the patellar reflex, with which it is regu-
larly associated. It may be said merely that these conditions are far
more complicated and difficult of interpretation than those which cause
diminution or abolition of the knee-jerk.
Taking abolition as something definite and ascertainable, it may be
said that if its causes are numerous, they are also easily definable in
the great majority of cases. We may leave out of consideration cases
of severe shock to the central neivous system, as from injuries or cere-
bral haemorrhage, in which almost all the superficial and deep reflexes
may be absent. But taking cases in which the patient is conscious, we
may arrange the causes of abolition of patellar ieflex according to the
part of the reflex arc whose functional capacity is lowered or abrogated.
Interruption of communication, along either afferent or efferent nerve,
will of course lead to such abolition. But as sensory and motor fibres
are so closely intermingled toward the periphery, it can not readily
happen that interruption will be confined to the sensory or motor path
respectively. Injuries of nerves may of course cause abolition of reflex
contractions, but far more frequently the cause is neuritis. Of late
years, multiple peripheral neuritis has occupied a large place in nerve
pathology; and it must be reckoned among the most frequent causes
of abolition of patellar reflex. The discovery of this symptom is im-
portant, therefore, in the diagnosis of peripheral neuritis, as it is seen
in eases of alcoholic and diphtheritic paralysis for instance ; though,
for absolute differential diagnosis, account must be taken of other con-
ditions present or absent, the history of the case often supplying im-
portant help.
Of pathological conditions seated iu the posterior column of the
cord, and interfering with the reception of sensory impressions, the
best known is the degenerative change associated with the disease
known as locomotor ataxy. Of the systemic diseases of the cord affect-
ing its motor portion, and by loss of function in that preventing the
transmission of motor impulses to the muscles, the best known is an-
terior poliomyelitis. This, which is the cause of infantile paralysis, is
occasionally found also in adults, and absence of patellar and other re-
flexes is one of its symptoms, being in fact one of the results of the
very complete loss of motor power in this form of disease. But while
we can thus distinguish cases in which the abolition of the knee-jerk
is due to a lesion confined either to the sensory or the motor region of
the cord, there are other cases in which both parts are involved. In
diffuse or transverse myelitis, affecting the lumbar portion of the cord,
loss of knee-jerk and of other reflexes in the lower extremities forms
part of the large group of symptoms by which the disease is character-
ized. These causes cover the vast majority of cases in which there is
loss of patellar reflex. It is noted as one of the symptoms which mag
be present in acute ascending (Landry's) paralysis : but there is no uni-
formity in this respect, and it is very probable thai, under this heading,
there have hitherto been often placed cases really belonging to other
conditions, and notably to poliomyelitis anterior with paraplegic char-
acter, and multiple neuritis of a very severe and acute form. It is pos-
sible, also, that abolition of knee-jerk may be due to pressure on nerve
roots, or on the cord itself, by tumors, or hemorrhagic or other exuda-
tions within or outside of the spinal canal, or as a result of mechanical
injuries (fracture, etc.). But if this symptom is to be manifested, the
pressure must bear on the lumbar portion of the cord or its nerves, and
specifically on the parts normally governing the reflex If the piessure
is higher up, and the lumbar portion is not affected, then the knee-jerk
is more likely to be exaggerated. The history of the ease will often go
far to determine its nature, while the exact seat of the lesion may be
fixed, partly by observation of the state of the reflexes of the trunk or
upper extremities.
The general conclusion, therefore, is that diminution and ultimate
abolition of the patellar reflex must be interpi eted as due to a lesion,
acute or chronic, mechanical or pathological, affecting one or more of
the parts already enumerated as making up the reflex arc. The lesion,
if not actually destructive, must at 'least be such as to interfere with
the transmission of impressions from the surface to the sensoii-motor
center in the cord, and back again to the muscles. The lesion need
not be, and generally indeed is not limited to that portion of the cord
or its nerves ; but w hatever other portions of the nervous system may
be affected, that segment certainly is ; and in so far the symptom is
helpful in determining not only the nature of the lesion, but to some
extent also its seat.
If the causes which lead to lessening or abolition of the patellar
tendon reflex are thus on the whole plain, it is not so with those which
lead to its exaggeration. The knee-jeik may have an increased range,
or be too easily produced, in many states other than organic diseases of
the nervous system. In tetanus and in poisoning with strychnine it is
increased in marked degree; and so it may be in hysteria. The same
may readily be the case also in febrile states, or in emotional conditions
of various kinds. In these latter it is most probable that the exaggera-
tion is, in its nature, practically the same as the intensification nhich
is obtained by Jendrassik's procedure — viz., causing the person under
observation to make some voluntary effort, such as pulling at the hands
which have been hooked into each other. It should always be remem-
bered, however, that increase or exaggeration of a reflex is only rela-
tive, and its reality should not be too hastily assumed. If the person's
normal or ordinary condition is known, the determination of an in-
crease may be easy and safe ; but otherwise it should be accepted as
real only when present in marked degree. We have a useful test of
its reality, or at least as to the presence of any organic nervous disease
as its basis, in its association with or independence of the occurrence
of ankle clonus. It is safe to assume that the latter always has some
abnormal state of the nervous system as its cause. For, just as it may
be found where the muscles of the calf have been quickly exhausted by
standing on tiptoe, so it may sometimes be found after an epileptic
attack, and possibly in other states of exhaustion. But these causes of
the production of ankle clonus are generally obvious enough, and the
phenomenon itself, when so produced, is usually not marked, and the
artificial susceptibility is of short duration.
There are cases, however, in which there is room for uncertainty
Jan. 9, 185,2.]
MISCELLANY.
55
whether a ease of p'aresis or paralysis is a hysterical manifestation, or
is actually due to organic disease. It is a common observation that, in
hysterical paralysis, there is habitually exaggeration of reflexes, in ad-
dition to other peculiarities. Still, a> the san e i< true also in many
cases of paralysis Irom disease of the brain or cord, this condition lias
but a relative diagnostic value But the check, supplied by testing the
ankle condition, then becomes of extreme value in doubtful cases.
If the increase of the patellar and other reflexes, superficial or deep,
has ankle clonus as its accompaniment, the presumptirn in favor of
the presence oi organic disease is immensely greater ; while absence of
clonus, under these circumstances, if not absolute proof, is very strong
evidence that we have to deal with nothing more formidable than hys-
terical paresis.
There are three conditions in which exaggeration of tendon re
Btexes in the lower extremity or extremities is regularly met with: (1)
In hemiplegia of cerebral origin, at some stage of its course ; (2) in
Sclerosis of the lateral columns of the cord, whether it be the pure
form, known as spastic paralysis ; in the mixed form, known as amyo-
trophic lateral sclerosis, in which the anterior gray column is also in-
volved; or in disseminated sclerosis, in which the exact grouping of
symptoms must depend on the distribution of the degenerated patches;
and (3) in conditions interfering with or stopping conduction from the
lower part of the coid to the brain, and vice versa. These are chiefly
transverse myelitis and pressure on the cord by tumors, ot as the result
of disease or injury of the vertebra'. To produce this effect, it, is
manifest, however, that the disease or injury must be seated clear
above the reflex arc, which must itself be intact. It is in these cases
that careful investigation into the state of the other reflexes of the
trunk and upper extremities is needed, for determining the exact level
of the lesion in the cord, whether it be in the dorsal or the cervical
portion.
Conditions, in many respects so diverse, having in common this
symptom of exaggeration of the reflexes, the question at once arises
whether the mechanism of production is the same in all. The purely
reflex or automatic centers in the cord being subject to regulation or
inhibition by the higher centers in the brain, it is a most natural and
generally accepted opinion that exaggeration of reflexes may be, and
indeed often is, the result of mere withdrawal of the subordinate spina]
centers from the control of higher centers seated in the cerebrum. This
explanation covers sufficiently the majority of cases in which exagger-
ated patellar reflex is found, whether the morbid condition be hysteria,
an epileptic attack, pressure on the middle or upper part of the cord,
or a cerebral lesion producing hemiplegia. But, though this be ad-
mitted, there remains the question whether such withdrawal from cere-
bral control supplies a sufficient explanation of all cases, and in par-
ticular of primary lateral sclerosis in which the increase of reflex ac-
tivity is most marked. It is held by some authorities that the exag-
geration of reflexes in lateral sclerosis, whether primary or secondary,
is, like the contractures which are another prominent symptom, the re-
sult of irritation in the cord itself, caused by the formation and sub-
sequent sht inking of the new tissue deposited in the lateral columns
chiefly. That irritation of the cord may cause increased reflex activity-
need not be questioned, tetanus and strychnine poisoning being instances
of it. But it is a fair objection to this explanation that the sclerosis is
essentially a degenerative process of slow production, and therefore not
of the kind which would be expected to produce an increase of activity
in the part affected, or in those adjacent to and standing in close func-
tional relation with it. Is it not far more likely, indeed, that in this,
as in the other cases already enumerated, the exaggeration of the pa-
tellar reflex and production of ankle clonus are due to the cutting of
communication between the cerebral centers and the lower spinal gan-
glia by degeneration of the great path in the lateral columns ? Even
where, in a case of hemiplegia, the exaggeration of reflexes appears to
become more marked in the paralyzed extremities, when secondary de-
scending degeneration has set in, it is not necessary to assume irrita-
tion of the cord as the cause. It is just as rational to explain it as
the consequence of more complete withdrawal of the spinal cent* ts
from cerebral cpntrol, when to the lesion of the brain there comes to
he added degeneration of one of its main paths of communication
with the spinal centers. Light is thrown on the mode of product ion
of exaggeration of knee and ankle reflexes by the phenomena observed
in eases of hemiplegia, accompanied by early rigidity. One such case,
under my care lately in hospital, was of interest in this respect. The
case was one of right hemiplegia, with partial aphasia and slight facial
paralysis. Theie was great exaggeration of reflexes on the paralyzed
side, ankle clonus being very easily produce d.; and there was also some
exaggeration of knee-jerk on the left side, with distinct, though less
marked, clonus. After a time there was great improvement, the rigidi-
ty of muscles relaxing, the clonus disappearing altogether on the left
side and becoming less distinct on the light, pari passu with the recov-
ery of power over the limbs. Here, evidently, descending degeneration
and associated spinal irritation were not the cause of the knee and
ankle phenomena, as they and the rigidity accompanying them could
not have been expected to pass off as they did during a stay of a few-
weeks in hospital if they had been consequent on a secondary degen-
eration of the motor tracts in the cord.
The balance of evidence, therefore, is in favor of the doctrine that
increase of knee-jerk and ankle clonus have a similar mode of origin,
whether the lesion with which they arc associated be seated in the
brain or in the cord. That mode of origin we must take to be an un-
regulated action of motor spinal centers, owing to withdrawal of con-
trol by the higher center in the cerebrum. It is only by careful obser-
vation of associated symptoms that we can determine what the nature
of that lesion is and what is its exact seat.
Leaving out of consideration temporary conditions operating in
various ways — such as shock, febrile or emotional states, toxic influ-
ences, etc. — and taking account of actual pathological conditions of the
nervous system only, it may be said that the general laws which gov-
ern alterations of the knee and ankle reflexes are these: I. Diminution
or abolition of the reflexes is caused by conditions which interrupt the
communication of impressions and impulses in the reflex loop whose
spinal segment is seated in the upper lumbar portion of the cord. II.
Increase of patellar reflex and ankle clonus are due to withdrawal
from cerebral control of the same portion of cord, which must itself be
intact, that loss of control being due either to a lesion in the brain it-
self or in the cord at some higher level.
But when the laws have been thus formulated it remains to be
considered whether there are exceptional cases or conditions in which
they do not hold good.
In 1882 Dr. Charlton Bastian expressed the opinion that certain
cases of lax paraplegia, in which there is loss of sensation as well as of
motion, and absence of patellar reflex as well as of ankle clonus, owe
the latter peculiarity to the fact that the spinal lesion is complete
transversely, whether it be softening or separation mechanically from
some injury. He held, thus, that there are cases of spinal lesion in
the dorsal or cervical portion, cutting off the lumbar portion completely
from connection with the brain, in which, notwithstanding, the reflexes
are abolished instead of being increased. This view did not commend
itself to authorities on the subject of nervous diseases. Even with the
proofs and arguments contained in Dr. Bastian 's book, Paralyses:
Cerebellar, Bulbar, and Spinal, the doctrine that transverse lesions are
and must be attended with exaggeration of reflexes, if the lumbar por-
tion of the cord is intact, continued to be held. In a communication
published in the Medico-chirurffic<d Transactions for 1890, however, he
returns to the subject, and, by the help of cases carefully observed
during life and examined after death, he establishes the correctness of
his opinion, which has since received confirmation from other observ-
ers. The duration of some of the cases makes it impossible to explain
the absence of retiexes by the existence of shock, as was at first sug-
gested by some critics. The cases showed not only that complete
transverse destructive lesions do cause abolition of reflexes, but, fur-
ther, that the descending degeneration of the lateral columns which
follows the lesion does not cause rigidity and contracture in the para-
lyzed extremities. It seems to be almost a necessary inference that the
spastic condition observed in lateral sclerosis, primary or secondary, is
not due to the sclerosis as such, as is taught by most authorities. The
explanation of the great difference in the state of the reflexes in cases
of pirapleuia due to lesions of the cord in its middle and upper portions,
beyond the circumstance that in some the lesion is a complete trans-
verse one and in others incomplete, must at present be almost purely
56
MISCELLANY.
[N. Y. Med. Jour
hypothetical. Dr. Bastian, following an earlier suggestion by Dr.
Hughlinga Jackson, believes that we must assume a double controlling
action by the brain over the functions of the cord. The cerebrum ex-
erts a regulating or inhibiting influence over the purely spinal reflexes,
and when this controlling influence is withdrawn, in consequence of
cerebral lesions on the one hand, or sclerosis or other lesions affecting
the lateral columns on the other, the spinal centers act in an exag-
gerated and unregulated way. The controlling or inhibitory influences
evidently pass downward along the pyramidal tracts. But how ac-
count for the absence of this exaggeration when the lesion affects a
complete cross-seciion of the cord, since certainly the controlling influ-
ence must here be completely withdrawn ? The suggested explanation
is that the cerebellum has, as part of its function, the duty of keep-
ing up the state of tonus in the muscles, acting through the cord;
and that its influence in this way is communicated downward in some
part of the sensory columns. When this stimulating or tonic influence
is withdrawn, by destruction of the sensory tracts in the posterior and
central portions of the cord, the spinal centers are unable to effect a
response in the form of a reflex contraction.
The importance of this new doctrine is considerable in regard to
diagnosis, and still more to prognosis, and sometimes to treatment. In
cases of injury to the spine, followed by lax paraplegia with complete
loss of knee and ankle teflexes, the necessary conclusion would seem
to be that, if this condition persisted after shock had passed off, recov-
ery would be hopeless, and that no benefit was to be expected from any
operative measures adopted with the view of relieving pressure. So long,
on the other hand, as the reflexes are preserved, even though the pa-
ralysis is very complete, there is hope of recovery, since the whole
thickness of the cord has not been affected by the destructive lesion.
And that recovery may occur, even under very unfavorable conditions,
is clearly shown by a case of Charcot's, in which the patient had been
affected with and recovered from pataplegia, associated with vertebral
disease and angular curvature. When she died, two years after, it was
found that the spinal cord, at the level where compression had existed,
was no larger than a goose-quill, and when cut, its section was not
more than about one third of that of a healthy spinal cord examined in
the same region. (Charcot, Diseases of the Nervous System, second
series, p. 80, N. S. S. translation. J
Locomotor ataxy has already been referred to as one of the diseases
very regularly associated with loss of patellar reflex. That the asso-
ciation is not an absolutely constant one lias been repeatedly shown,
some at least of these exceptional cases being where the disease began
in the cervical portion of the cord, instead of in the lower portion, as
is the rule. Occasional cases of hemiplegia, occurriug in persons al-
ready the subjects of locomotor ataxy, have been recorded, and in a few
of these it has been noted that the patellar reflex was present. But
with the exception of a case, reported by Dr. Ilughlings Jackson and
Dr. Taylor (British Medical Journal, July 11, 1891), it does not seem to
have been noticed whether the knee-jerk was absent previous to the
coming on of the hemiplegia. In this patient the ataxic symptoms had
existed for about twelve years when he came under observation. He
had then had two attacks of hemiplegia, the second eight days before
admission, the right side being affected, and the knee-jerk ab.^ent on
both sides. Forty-seven davs after the second attack it was noted
that there was slight return of the right knee-jerk. Two years after,
the right knee-jerk was readily obtained, and a slight jerk could also
be got on the left side, though with difficulty. Some of the ataxic
symptoms had improved, while others had remained stationary, or be-
come aggravated. Here, then, there was a remarkable instance of
restoration of a normal physiological phenomenon, apparently
resulting from the addition of a fresh disease, a cerebral lesion
with secondary lateral sclerosis of the cord, to the original disease,
posterior sclerosis, which had caused its abolition. It is difficult
to account for the restoration of reflexes in this case, and the
authors of the paper only venture the suggestion that a few fibers had
remained intact in the posterior columns, but that they had been in-
sufficient to convey strong enough impres-ions from the periphery, till
the sclerosis came on, and by stimulating the anterior horn made it
more prone to respond to slight impressions. In view, however, of the
cases collected by Bastian and others, in which the occurrence of de-
scending scleiosis, following lesion of the cord, led neither to increased
reflexes nor contracture, it is not easy to accept the sclerosis in this
case as, per se, the cause of the restoration of the patellar reflex. In
accordance with the facts and arguments already adduced, it seems a
more probable supposition that the descending sclerosis acted rather in
the way of cutting off. more completely than before, any remains of
cerebral control. In the absence of inhibiting influence, the few fibers
left in the posterior columns might be in a position to convey impres-
sions, strong enough to stimulate the now unrestrained automatic motor
centers in the anterior horn. Whatever lie the correct explanation, it
remains an established fact, not only that the patellar reflex may con-
tinue in well-marked cases of locomotor ataxy, but that it may possibly
be restored after having been abolished.
Perhaps the most important lesson to be derived from this studv of
the relation of leg reflexes to pathological conditions of the brain and
cord is the need for caution in arriving at conclusions on too narrow a
basis of observation. Pathognomonic symptoms are rare, and if it be
necessary in all diseases to make symptoms, and even groups of symp-
toms, serve as checks on each other, for diagnostic and prognostic ends,
above all must this be necessary where conditions are so complicated as
they are in the neivous system and its diseases.
To Contributors and Correspondents. — The attention o f all who pnrjiose
favoring us with communications is respectfully called to the follow-
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dressed to the publishers.
THE NEW YORK MEDICAL JOURNAL, January 16, 1892.
(Original Communications .
PSEUDO-EXPERTS IN LUNACY*
By S. GROVER BURNETT, A.M., M.D.,
KANSAS CITY, MO.,
CLINICAL LECTURER ON DISEASES OF THE MIND AND NERVOUS 8TSTEM,
KANSAS CITY MEDICAL COLLEGE ;
MEMBER OF THE NEW YORK MEDICO-LEGAL SOCIETY j
FORMERLY ASSISTANT SUPERINTENDENT, LONG ISLAND HOME OF NEW YORK
FOR DISEASES OF THE MIND AND NERVOUS SYSTEM, ETC.
In bringing this subject before you at this meeting I
am not prompted by any selfish motive of radicalism, but
rather for the purpose of drawing the attention of both the
medical and legal professions to a subject which should in-
terest us alike. Not only should it be of common profes-
sional interest, but worthy of consideration by all thinking
people generally. It shadows the point where the two pro-
fessions meet, and has always been a delicate and difficult
chasm to bridge over — that all who are so unfortunate as to
come within the pale of the law through either disease or
crime, or both, might be guided over it to a rest of justice.
Any efforts spent upon the solution of a question that means
so much to the human family certainly should not be consid-
ered in vain though the reward be not in view.
That we may at once get at our text there is no better
illustration offered us than in the case of Myers, of this
city, who was adjudged insane on the testimony of the gen-
eral practitioner. Myers, with a companion, was going
about the country, so they aver, in search of work. Not
having comfortable quarters for the night, they went to the
depot where they could keep warm. Seeing a man asleep,
the companion remarked that he had money, when Myers
proposed " to stun and rob him." They secured an iron
pin used for coupling cars and returned to the scene of the
coming tragedy. Myers again proposed the killing, and
asked the companion (a boy) to make the attack, but he
refused, saying he was not strong enough. Myers then
struck the sleeping man several times, each time breaking
the skull. The money obtained was equally divided. Ra-
tional effort was made to escape, and it was only after the
boy had turned State's evidence that arrest was made.
They were convicted, Myers receiving sentence of death
and his companion life imprisonment. On the second trial
Myers received the benefit of a " hung " jury, and a third
trial accomplished his release on the ground of insanity.
He went to the poor-farm for a few days, and then was al-
lowed to go to his home.f
I do not propose to discuss this in full, neither is it
intended to cast a personal reflection upon any of the gen-
tlemen connected with this case ; but in this brief history
there are medico-legal points that should not be overlooked.
First, Myers was the senior co-operator ; he reasoned well
* Read as the opening address at the annual meeting of the Missouri
Valley Medical Society, at Council Bluffs, Iowa, September 17 and 18,
1891.
f I am informed that in obtaining the release of Myers from the
poor-farm the plea was, they feared he would lose his mind if compelled
to remain there. The absurdity of this is difficult to explain without
being personal.
in planning and executing the crime in every particular, ex-
cepting the proposition made by the boy that the man had
money. Myers proposed the killing, and, realizing the
enormity of his crime, tried to use the boy as his tool, but,
failing and realizing the possibility of making a failure of
the deed through the boy's lack of strength, he had the
power to put his premeditated project into effect. Rational
effort was made to escape. Equal division of the booty
was exacted. These facts, all of which were indications of
the mental state at the time of the commission of the crime
and connstitute the onlyr reasonable facts upon which a ver-
dict should be rendered in such a case, are certainly not in
keeping with the verdict in this instance. Keeping the
nature of the verdict in view — that of acquittal on the plea
of insanity — and admitting that it be a just verdict, what
are we to think of it when we recall the manner in which
the individual was disposed of — turned loose to continue
the destruction of human life in accordance with the dic-
tates of an insane mind ? There are two possible explana-
tions of this, as the disposition of the case is directly op-
posite to the meaning of the verdict rendered — namely, un-
due consideration and illogical comprehension of the facts
upon which a diagnosis of insanity should be made, or a
determination to defeat justice to gain personal satisfac-
tion, regardless of the dangers engendered in the future,
to react again upon society by a repetition of the former
deed.
I should regret to learn that we lived in a State whose
statutes were so imperfect in offering protection to its citi-
zens, and, in the face of facts here presented, I can not re-
frain from saying that others should not be anxious to share
the reflections of such a contradictory verdict as was pro-
mulgated by the abettors connected therewith.*
For the benefit of those who have not had the privilege
of becoming familiar with medico-legal technicalities, and
to show how delicate a consideration the subject requires, I
have thought it best to give in brief a review, as near as I
am able, of the indications arrived at, pointing out the pe-
culiar mental conditions to which an individual should be
subjected that he may be classed as an insane criminal.
Among the great thinkers of the medico-legal world there
has been going on for the past quarter of a century a " silent
revolution " with reference to the doctrine of the legal
handling of a class of culprits commonly designated, ow-
ing to the absence of a better nomenclature, as criminal in-
sane.
* In an interview with my friend, Dr. Willis P. King, whose testi-
mony had much to do with the verdict in this case, he says the very
appearance of Myers would immediately call to mind the theory
of Darwin, and there was little doubt that his ancestors had not been
walking on their hind legs very long. According to Dr. Xing, the boy
mentioned was an overgrown^youth with a criminal history in his fami-
ly, and, knowing the weakness of Myers, he urged him to commit the
crime. Dr. King would have me believe that Myers, when questioned,
would be able to say which was right or wrong, but had not the power
to avoid doing the wrong and adhere to the right when urged by the
companion. This is an important technicality, and is possibly well
taken ; it is in keeping with the verdict rendered, and casts great re-
flection upon the legal disposition of the accused.
58
BURNETT: PSEUDO-EXPERTS IN LUNACY.
[N. Y. Med. Jocb.,
As usual in the advancement of scientific procedures'
Germany was an early participant here, and long ago
adopted in her criminal code of laws the proposition that
" there is no criminal act, when the actor at the time of the
offense is in a state of unconsciousness, or morbid disturb-
ance of the mind, through which the free determination of
his will is excluded " (Code of Germany, Sec. 51, R. G. B.).
As we look a little farther we find the interpretations of the
code of France agreeing in every particular, practically
speaking, and gives great support to the efforts of the medi-
cal minds so ardently exercised in perfecting that which is
of such medico-legal interest and utility. This silent revo-
lution (so named by A. Wood Brenton, Esq.) has now
reached the minds of England and America.
Judge Somerville says : " It is the same old fight of
science against the crystallized prejudices of error and ig-
norance " (Medico-legal Journal, December, 1890).
To attempt to discuss the law as to the testamentary
capacity of the insane, and the law as to their capacity to
enter into the contract of marriage, etc., would be a pre-
sumption on my part as well as a digression ; hence I will
confine myself to a mentioning of the various legal require-
ments as have been prominent in the decision of lunacy
cases from time to time, among the first of which was the
" wild-beast " theory of Mr. Justice Tracy, which is of
little interest to us to-day.
In succession of this came the great theory of Lord
Mansfield — namely, " the right and wrong theory " — which
in turn was revolutionized by the decision in the Mac-
Naghten case. Judge Somerville's decision, in the case of
Parsons vs. The State, 1881, Ala., 577, also alluded to by
Mr. Breton, was rendered in the Alabama Supreme Court,
June, 1887 (Medico-legal Journal, September, 1890, and
December, 1890), and was also a repudiation of the right
and wrong test, as affirmed by the MacXaghten case, just
mentioned, which was a decision of the English courts, and
gives its indorsement to the modern view that " no insane
person who, through disease of the brain, has lost the power to
choose between the right and the wrong, and to avoid doing
the act in question, is legally culpable or accountable."
The learned members of the medical profession have
long recognized this feature, and the efforts of both pro-
fessions to bring about a test that would be compatible to
law and medicine alike have been arduous and many. The
great Dr. Ray, of Imgland, was an early benefactor to us in
this line by his approval of the charge in Haskel's case in
these words : " The true test lies in the word -power. Has
the defendant in any case the power to distinguish right
from wrong, and the power to adhere to the right and avoid
the wrong '. "
Many times in my asylum practice have I been called to
recognize this feature among the inmates. Frequently
relatives of the insane have said to me, It is pure cussedness
in him, for he knows it is not right, still he continues repeti-
tion after repetition of the offense. Unquestionably, those
of the medical world of any special training in this direction
will affirm any efforts that will lead to a unanimous adop-
tion of this " modern view " or test.
In the report of the Alabama Hospital for the Insane,
by Dr. Peter Brice, for 1889, we find him voicing the pro-
fession on this subject. He says: "The thousand patients
now under treatment in our hospital, and thousands of
others who have filled its wards during the past twenty-
eight years, furnish unmistaken evidence, even to ordinary
observation, of the fact that persons of diseased brains, af-
fecting the mind, may be capable of distinguishing the
moral and legal quality of a criminal act, and yet not be
able to abstain from its commission. They know the rijrht
from the wrong, and do not hesitate to avoid it, but they
can not choose between the two, and often deplore their in-
ability to control their actions. It would, it seems to me,
be a backward step, in both humanity and science, to place
these victims of disease in the same category with ordinary
convicts in whose behalf no such plea can be interposed.
The whole question is one of disease or no disease to an
extent which practically destroys the patient's power of
self-control." He adds : " The medical profession is almost
unanimous in its repudiation of the right and wrong tests
of this disease, and the interest of society, humanity, and
science would, in my judgment, be promoted by the adop-
tion of the same view by our courts of justice."
This in brief gives us the most acceptable and recent
medico- legal view of a mental condition for which the pos-
sessor should not be held responsible with reference to acts
that may be judged as criminal ; but here the question arises,
By whom and upon what qualifications shall such a mental
condition be determined, and what protection are we going
to offer to society ? Shall the testimony of an embryo
M. D. in the general practice of medicine be acceptable in
such cases I According to present usages such is allowable.
An individual having once been found to be and declared
to be an insane criminal by a court of justice, shall he be
turned loose upon a sister State again to repeat his acts of
violence in order that the State in which he was convicted
may escape the expense of the maintenance of such a char-
acter ' Dr. Gooding says (Medico-legal Journal, December,
1889) : "The finding not guilty by reason of insanity of a
person who has committed a capital offense should carry
with it the presumption of continued insanity and the for-
feit of the personal liberty of the individual." Fortunately,
in our more densely populated States this class of cases is
quite well looked after in the way7 of offering protection to
society ; it would seem quite apparent that errors in such
instances were apt to be the outgrowth of slipshod medico-
legal procedures, if they can be called medico-legal pro-
cedures at all. The insanity plea has become so popular
that it is not difficult to see how hands stained with chronic
criminality would be ready to accept any new resources of
defense. In such instances it has been with the utmost
difficulty and prolonged study of the case that some of our
most learned men in psychiatry, who have spent a lifetime
in its study, have been able to arrive at a definite, logical,
and scientific diaguosis. There are reasons why the plea
of insanity should be adopted ; such individuals, having
come into the hands of the law, would prefer incarceration
in an asylum for a time, with the hope of an early recov-
ery (?) and release from custody, than to suffer capital pun-
ishment. In the case of Myers vs. the State of Missouri
Jan. 16, 1892.]
BURNETT: PSEUDO-EXPERTS IN LUNACY.
59
this process was shortened by turning- him loose at once
upon the State of Pennsylvania. According to Dr. Church
(Medico-legal Journal, September, 1890), our first step in
arriving at a judicious decision in these cases is a difficult
one, as " the question of insanity is made a question of
fact to be decided by a jury." No matter how intelligent
be these twelve men, they are in no wise capable of render-
ing a judicious verdict upon such difficult problems as to
whether the deed was the result of an obscure disease of
the mind unless they are educated men in medicine, which
is never the case. Upon the testimony of the medical ex-
pert, and the ability of the jury to comprehend the same,
depends the solution of the question, and here we reach a
point that may hinge the verdict according to the ability
and character of said witness. If in the power of the at-
torney for the defense, he will not admit of any testimony,
regardless of its proficiency, unless it points out his client's
exit to liberty ; upon such technicalities depends the clash-
ing of expert testimony in lunacy cases. Were the judge
alone empowered to select medical experts, this clashing
would be avoided.
Again we are left largely to speculation, as the point at
issue is not the mental state of the criminal at the time of
the prosecution, but when the act was committed, dating
probably from a few months to a few years prior to the
rendering of the verdict. Charge any man, especially if he
is a little below the average in his physiological stamina,
with murder in the first degree, with convincing evidence
for his conviction, give him from one to three years in jail
to think it over, and certainly his condition may warrant
the plea of insanity at the time of the prosecution. Such
mental strains are sufficient to alienate great minds. If
with this plea and a little legal diplomacy they can sub-
stantiate the fact that the accused was " kicked by a mule "
when a youth, that some one in the same village had hys-
teria or some of the various neuroses, his chance for a trans-
fer to a palatial sanitarium at the State's expense may be
looked upon with favor ; and should he be fortunate enough
to reside in a State where more attention is given to the
getting rid of, instead of the prosecution of, or care of such
cases, he may be liberated in a few days after the rendering
of the verdict with the proviso to skip the State and stay
skipped. It is rational to state that a verdict rendered at
the time of the prosecution must be based largely upon sup-
positions, and often illogical conclusions, as the mental state
upon which the judgment should be made is at the time of
the criminal act — always prior to the date of the individ-
ual's coming under the observation of both jury and experts.
Upon the testimony of the latter will be based the verdict
of the former, and, as it means life or death, justice or in-
justice, we have here placed before us the only class of
testimony that should be accepted before a court of laws,
and that is expressed in the word ability.
I care not how competent a general practitioner is, he is
no more competent to pose as an expert in psychiatry than
lie is to perform the most delicate and critical operation in
surgery. Were I, after having seen a half-dozen or possi-
bly a full dozen operations of a capital nature, to proceed
to usurp the functions of a finished operator, you would rise
up in a body and declare me mad. Then imagine a man
who has seen a whole dozen cases of insanity in his prac-
tice— in half of which number he guessed at the diagnosis
and in the other half accepted somebody else's word for it —
coming forward at so critical a moment and offering a sci-
entific diagnosis and prognosis upon which shall depend the
life or death of the accused, and perhaps the conviction of
the innocent or acquittal of the guilty, which, according to
the decision in the Myers case, means liberty to the of-
fender and danger to the public wherever he may roam.
The diagnosis of insanity, if made scientifically, is often
difficult to minds of long and patient training. In criminal
cases the examination should be made with two possible
features in view — namely, a motive for malingering and
the actual predisposing influences, and the condition of the
mind present, just prior to, and at the time of the commis-
sion of the crime. For instance, the case of Nellie Bly,
who passed under the observation of two of the best clini-
cians in psychiatry that this country has, had a motive for
the deception. It is true her commitment was based largely
upon circumstantial evidence, but it was so convincing that
these learned men were deceived. Evidence of less con-
vincing nature would be sufficient to cause an inexperienced
psychologist, in the majority of cases, to testify to the men-
tal incapacity of the accused. The very fact that Nellie
Bly appeared in the insane pavilion of Bellevue Hospital
among pauper insane cases, with no apparent cause for her
appearance and actions, and that she was watched by com-
petent persons to catch her off her guard with negative re-
sults, seemed ample grounds for committing her to the asy-
lum ; of course it was afterward conceded that she was
simply feigning insanity in order to gain access to the asy-
lum that she might expose the maltreatment which some
supposed to then exist. In the Court the criminal has a
strong motive for feigning insanity, and an error in its de-
tection is a grave error, though difficult of solution at
times ; the error also of finding a man not insane when he
actually is insane is often equally as grave. To show that
the practitioner's examination is apt to follow the routine
of his daily cases is illustrated by the following : Dr. ,
of Jamaica, Long Island, was ordered by the Court to tes-
tify in the case of Mr. A. C, who was then in the asylum
under my care and suffering from an intellectual tvpe of
chronic mania. The doctor examined the pulse, tongue,
temperature, condition of secretory and excretory organs,
etc., and could go no further. He asked me to give him
testamentary evidence, some of which was to the effect that
Mr. C. had at times hallucinations of sight and hearing and
delusions of persecution. This he testified to in Court, and
when asked to explain to the jury the significance of his
testimony, he failed and was dismissed. Here is expert
testimony offered the acceptance of which meant life incar-
ceration in an asylum, and it was obtained in an interview
of about thirty minutes with the patient. Unfortunately
for the witness, he used words too large for his vocabulary
and his weakness was exposed. The readiness with which
some physicians hasten to swear an accused to heaven, or
vice versa, based upon a meager interview or two of a few
minutes each, certainly merits criticism.
(50
Some of the difficulties in making a diagnosis in crimi-
nals supposed to be insane is illustrated by the following
case which came under the writer's observation in the
Tombs Prison, Newr York city :
The charge was grand larceny in the first degree, which
meant, if convicted, five to ten years in prison. My friend, Dr.
Matthew D. Field, examiner in lunacy for the city of New York,
was sent to see him during the filth week of his confinement at
the Tomhs. Mr. J. D.'s condition was then, as it had been
since being in jail, totally indifferent to his person and sur-
roundings; the only voluntary movements were his eyelids and
occasionally his lips; took no food or drink; lie followed wher-
ever led, and remained in the position in which he was placed.
Food and water left with him were never disturbed; the at-
tendants were positive that he could not swallow solid food, and
gave him liquid food, which he swallowed in a mechanical way.
Personal cleanliness was wanting and Nature's demands unat-
tended, his clothing and bed being soiled without notice on his
part. The attendants thought it unsafe to allow him to lie tint
in bed for fear he would smother, and, as a precaution, braced
him up with pillows in a half- reclining position, and they al-
ways found him as they left him, notwithstanding frequent ob-
servations were made; his eyes opened with the same staring
expression. His indifference was such that, when being led
through the cell door, which was low, he would strike his head
terrific blows on the iron casing unless he was caused to stoop.
He received several severe blows in this manner before being
guarded against by the attendants.
With this history in brief Dr. Field first saw the case on
December 18, 1887, and at frequent intervals afterward. When
the patient was led into the examining room the keeper pushed
him back and he sank down without resistance and remained in
that position. He was tall and anaemic, had a fixed, staring ex-
pression, would not speak, or give any evidence of comprehend-
ing his situation or surroundings. He was neglected and care-
less in appearance. His pulse was small and quick; breathing
shallow. Reflexes, superficial and deep, seemed normal. His
limbs when raised sank back, as if from gravitation rather than
from a paralytic condition. Cataleptic indications were nega-
tive. In the mean time two physicians had examined the case
and reported to the district attorney that the patient was in a
cataleptic or cataleptiform state and could not be tried. If Dr.
Field stood in front of the man and threw water in his face or
pricked the skin, no manifestation of feeling was made. When
the same was done from behind, where the examiner could not
be seen, involuntary movement followed. Severe pressure upon
the supraorbital nerve gave no evidence of pain or anger, but
caused suffusion of the face and a few tears to flow from the
eyes. The pain inflicted was certainly as severe as one was
justified in producing. Frequent interviews and various projects
never induced him to speak. Dr Field decided to photograph
him, which he did twice. Owing to defective light, the exposure
was abour a minute and three quarters. No evidence of
movement by the patient was manifest, to the astonishment of
the photographer. I examined the photographs personally and
they certainly were good. E\en the e.xelashes were as perfect
as if portrayed by the delicate touch of an artist's brush. Dur-
ing his stay in the Tombs he became much emaciated, losing
some forty pounds in weight. Dr. Field learned that J. D. had
stolen a watch and escaped by rational effort. When arrested
he pleaded not guilty and subscrihed his signature. That night
lie was reported V> have made an outcry and to have had a fit,
after which he was as heretofore described.
Pergonal History. — At thirteen years of age he received a
fall and was confined to bed five or six weeks. He had always
[N. Y. Med. Jock.,
been " funny " — at times sulky and depressed, and at other
times abnormally gay. Up to the time of arrest he was em-
ployed by his brother, who saw nothing strange in his actions,
lie was sentenced to prison three different times prior to this
offense for felonious assault and larceny ; his entire term of im-
prisonment extended over a period of nine years. When first
arrested on the present charge he was rational and made offer to
return the watch if they would not prosecute him. Relatives
and prison officials were alarmed at his emaciation and were
anxious to have his case settled, but, owing to the report of the
two physicians to the district attorney that he was in a catalep-
tic condition and not fit to be tried, his case could not come up
for trial. Dr. Field was firm in believing the nan to be feign-
ing, and asked that he be sent to Bellevue Hospital for observa-
tion ; this they did not do, but instead sent him on December
29, 1887, to Jefferson Market prison, and he was there lost sight
of. One morning the announcement in the paper was this : " The
silent man departs." By the aid of one John Mack, on the night
of February 5th, he sawed a bar out and escaped. Mack was
recaptured, and from him Dr. Field learned that he and J. D.
had be> n companionable for a month and that he kept watch for
J. D. so as to allow him to exercise and get relaxation without
detection, and that they frequently conversed together.*
This certainly is as typical a case of deception as we are
called upon to diagnosticate, but these are the very cases
that teach us the value of observation. The majority of in-
experienced observers in mental diseases would have made
the same report in substance as did the two physicians who
reported to the district attorney in this case and would have
testified accordingly had the case come to trial ; more es-
pecially would they have given the accused the benefit of
their defective knowledge if there were a lawyer in charge
of the case who understood the handling of lunacy cases and
lost no opportunity in aiding the physician in getting his
testimony in a presentable shape.
Again, there are persons unquestionably of unsound mind
who are able to conceal the mental defects for a long time
in many instances. The insane man will deny that he is
insane, and when so able will conceal his eccentricities from
those about him, as he is aware of their significance and the
appreciation of the same by his friends. This peculiar
deception is common in cases of paranoia, and often their
delusions prompt them to the commission of murder in
order that some imposed duty may be fulfilled. The man-
ner of concealing their mental alienations from their friends
is illustrated by the following well-known case which was
on my service in the Amityville Asylum for two years :
Miss , about thirty-three years of age, was of great liter-
ary talent, and ranked high as a contributor to Harper's,
Scribner's, and other popular magazines of the day. She
conceived the idea of a lover, his going to sea, shipwrecked,
and for a long time supposed to be lost. She learned of
his rescue and return to New York. Through a conspiracy
he was compelled to live under an assumed name, the name
being that of a well-known correspondent of the New
York World. This delusion grew till there were great num-
bers of conspirators in the scheme, and in the mean time
she had decided some one must suffer death to clear up
* Through the kindness of Dr. Field I am given this ease in detail,
for which I am under obligations to him.
UritXETT: PSEUDO-EXPERTS IS LUXACY.
Jan. 16, 1892.]
GOULEY: DISEASES OF THE URINARY APPARATUS.
61
everything ; at limes she thought she was the victim ; at
other times others were selected, owing to individual power
of the conspirators. Her delusions were always systema-
tized. This great deterioration went on for many months
unknown and unobserved, until one Sunday morning a
glowing article from her clever pen, covering nearly a page,
appeared in the papers. Her ability to conceal her delu-
sions finally failed. Fortunately the outbreak came in the
form of a scandalous exposure rather than in murder.
Prominent families were libeled and their good names
stained with disgrace. Her own respected family never
recovered from the shock, and it was only after prolonged
efforts to compromise with the accused persons publicly ex-
coriated in her defamatory article that they were saved
from financial ruin arising from large damage suits. No
compromise was acceptable except confinement in an asy-
lum, and she was committed to Middletown under Dr. Tal-
cott. Even there she was so acute in her deception that
only learned alienists were aware of her true mental state.
She would guard her subject, and, unless forced to speak
upon it, no delusions could be obtained. For nearly two
years I observed this case with interest, and in her delu-
sions became an active conspirator. She continued to con-
ceal her delusions well excepting at intervals, when she had
to be restrained. Her vicious pen and ability to slip her
notes to the public press were dreaded by those who knew
her. Visitors at the asylum who talked with her believed
in her rationality, and many sought to " show up " the
asylum by carrying her writings to liberty. While on my
service she wrote several interesting novels, as follows :
Was it a Delusion ? The Model Boy of the Age ; Hints to
Friends on the Management of the Insane.
Nine tenths of the readers of these novels would find
them well written and of great interest, and rarely detect
anything wrong in the writer's handling of the subject. In
Was it a, Delusion ? a close observer who had known the
author could detect a little something peculiar in the last
four or five pages only.
These cases cited are simply representatives of the class
of .cases upon which medical men are called to render a de-
cision as to whether the accused is or is not to be held
accountable for his deeds and punished according to the
provisions made by the law unto such cases, or whether
he shall be cared for as an invalid as prescribed by the
law of the State in which the crime was committed. You
will observe in the Myer case before alluded to that neither
one of these suggestions was carried out, but that he was
allowed to go home and to liberty and to continue his homi-
cidal acts as prompted by his delusions, and if he is an
insane man he will certainly have his delusions at times.
When the expert swears that in his opinion the subject
before the bar is a malingerer, he assumes a great responsi-
bility, and when he swears that the accused is of unsound
mind and not accountable for his criminal acts, he also as-
sumes a great responsibility; an error either way will give
an excuse for the rendering of a dangerous verdict. Now,
in the face of the argument given in the medico-legal
blending of opinions, as to the mental state which may be
classed under the nomenclature of the criminal insane, the
delicacy of making a scientific diagnosis in such cases and
the great responsibility attached to the diagnosis made, I
will allow you to ask yourselves this question, namely :
Does the acceptance of expert testimony from the general
practitioner in lunacy cases give rise to dangerous verdicts i.
DISEASES OF THE URINARY APPARATUS.
By JOHN W. S. GOULEY, M. D.,
SURGEON TO BELLEVUE HOSPITAL.
( Continued from page 38.)
PART I.— PHLEGMASIC AFFECTIONS.
Section II. — SPECIAL CONSIDEPvATIONS.
VI IL
Urethritis ; its Nature, Causes, and Diagnosis.
Urethritis, the most common of all the affections of
the uro-genital apparatus, is a phlegmasic process, beginning
generally in the mucous membrane of the urethra and ordi-
narily characterized by pain, ardor, dysuresis, and a more
or less abundant muco-purulent discharge. In many cases
it is contagious, but in the great majority it is non-conta-
gious.
This phlegmasia was named urethritis, in the year 1802,
by Bosquillon, because he regarded the word urethritis as
expressing the locality and the phlegmasic character of the
disease, and "gonorrhoea and blennorrhagia " as failing to
convey the idea that the urethra is in a state of phlegmasia ;
the one meaning a flow of semen and the other a breaking
forth of mucus. Therefore it was that he followed the ex-
ample of Sauvages in the use of the suffix itis to denote
phlegmasia, and accordingly constructed the word urethritis
to express a correct idea of the nature and seat of the affec-
tion, i. e., a phlegmasia of the urethra.
" Gonorrhoea " is the most ancient of the designations of
this disease, and was used because of the supposition that
the discharge was semen and originated in the seminal vesi-
cles ; and this erroneous designation is still used almost
universally, although it is more than three centuries since
urethritis wras distinguished from the so-called gonorrhoea.
In the sixteenth century Ambroise Pare spoke of gonor-
rhoea as an involuntary discharge of semen, and of chaude-
pisse (clap) as a purulent discharge which he believed to
originate in the seminal vesicles or, at least, in the prostatic
region of the urethra. William Cockburn was the first
English author to assert that " gonorrhoea " was seated in
the urethral mucous membrane and not in the prostate or
seminal vesicles. The first edition of his work, On the
Symptoms, Nature, Causes, and Cure of Gonorrha a, appeared
in London in the year 171:!, and the fifth edition in 1728.
.Many physicians who are acquainted with these facts still
persist in speaking of the flow of pus in urethritis, in vul-
vitis, and in vaginitis, as "gonorrhoea," which means 1 1 > >t li i n^-
more than a running of semen, because, they urge, the term
has been sanctioned by long usage. Because an error has
been reiterated for three thousand years or more assuredly
does not make it less an error, and the long existence of
this evil in language is certainly no argument in favor of
62
OOULEY: DISEASES OF THE URINARY APPARATUS.
[S. Y. Med. Joitk.,
sanctioning its continual perpetration. Otherwise, how great
would be the inconsistency of those who are striving to
bring the science of medicine to its proper level in this
nineteenth century of progress!
" Blennorrhagia," an outbreak of mucus, was first em-
ployed by the Austrian, Swediaur, in the latter part of the
last century, in preference to "gonorrhoea," which, as he says,
implies a flow of semen, while in reality nothing of the kind
• ever occurs in this disease. But the word " blehnorrhagia "
fails to indicate that the urethra is in a diseased condition.
Even if the adjective urethral were always prefixed to
" blennorrhagia," the two words would also fail to convey
the idea of phlegmasia of the urethra. Although many
different words have been proposed as substitutes for these
two obviously inaccurate terms, the French still adhere to
blennorrhagia," which they originally borrowed from the
eminent Austrian syphilographer.
" Venereal catarrh'1'' is another expression now commonly
used, in Germany and other countries, instead of " gonor-
rhoea." It was suggested in 1806 by Capuron, a French-
man. Venereal catarrh of what particular part or mucous
membrane of the body does not appear in the expression.
But catarrh means simply a downward flow, not even a flow
of mucus. Therefore catarrh fails to designate the true
■character of urethritis.
It is often asked, Is not " gonorrhoea, or blennorrhagia,
-or venereal catarrh " something more than a phlegmasic
-affection ? Sometimes it is, and in that case there is ure-
thral chancre, chancroids, or mucous patches — otherwise,
" gonorrhoea, blennorrhagia, and venereal catarrh " have
never conveyed to the mind of any thoughtful reader and
investigator the faintest notion of phlegmasia, and to such
• the only meaning they express is a flow of semen in the
first case, an outbreak of mucus in the second, and a down-
ward flow from venery in the third case. It is asked also
with equal frequency, Is there not high authority for say-
ing that the terms "gonorrhoea, blennorrhagia, and venereal
catarrh " should be applied to that form of disease which
is contagious, and urethritis to that which is non-conta-
gious ? Yes, high authorities have made the assertion,
without agreeing which of the first three terms should be
used ; but when high authorities misuse words there is no
obligation to follow their bad example.
''Many other names have been proposed to take the place
of " gonorrhoea " ; among them, arsura, pyorrhoea, and syphi-
loid. The latter was used for a time by Ricord. None of
these names had a long survival, for they were most unfit.
But " gonorrhoea, blennorrhagia, and venereal catarrh " are,
so far, examples of the survival of the unfittest. It is to
be hoped that urethritis, answering as it does all present
needs and indicating so clearly the phlegmasic character of
the disease in the male, as do vulvitis and vaginitis in the
female, may survive all those unfit names that always give
-a wrong impression if they convey any idea whatever. Ar-
;sura was spoken of by John Ardern (1320 to 1370) as an
interior heat with excoriation of the urethra, and he spoke
©f this same arsura as occurring in the genitalia of women.
Arsura was also used as synonymous with erysipelas. The
popular saying, "He was burnt" (meaning that he contract- I
ed venereal disease), is likely to have originated from the old
word arsura, which was apparently technical in the four-
teenth century and coined from ardere, arsum, to burn,
burnt.
The names given to urethral phlegmasia by the vulgar
of several nations in some respects are more appropriate
than those employed by the medical profession. These
names, based upon different manifestations, are surely not
worse than " gonorrhoea, blennorrhagia, or venereal catarrh."'
For example, the common people of England and of this
country call urethritis clap, the French chaudepisse, the
German Tripper, and the Spanish purgacidn.
Clap is derived from the old French clapier, which
means a burrow, a hiding place, and is often applied by
surgeons to burrowing abscesses. It means also a filthy
place, a hovel, or brothel. The term clap may have been
adopted on account of this meaning of clapier — a hovel or
brothel where dwelt the women from whom the disease was
supposed to be contracted, or perhaps on account of the
filthy condition of the genitalia of these women.
Chaudepisse was suggested by the great scalding which
is experienced in urination during the second or stage of
increase of urethritis. For the milder cases the people use
the terms echauffement, heating, and coulante, running.
Tripper is taken from trip, which means to drop or.
drip, and has reference to the dripping of the pus from the
urethra.
Purgation, from purgare, purgatum, to cleanse, has ref-
erence to the abundant discharge, which the vulgar imagine
" cleanses the system of a humor." It may also have refer-
ence to the fact that it is sometimes contracted from women
during the menstrual period, for the people call the menses
purgaciones, which they take literally from the Latin.
Antiquity of Urethritis. — There does not appear to be
any historic period when urethritis was unknown. Dujar-
din and Peyiihle, in the history of surgery from its origin
to their day, speak of the great frequency of "gonorrhoea"
in the East, and in alluding to the operation of " circumcis-
ion," which was employed partly to prevent venereal disease,
trace the origin of this operation to a period antecedent to
the time of Abraham. Moses very clearly points out " gon-
orrhoea " as existing in his time, and his sanitary laws tend-
ing to its prevention are admirable, and, if followed fo the
letter, would unquestionably lead very materially to the de-
crease of the disease. Hippocrates, Galen, and Celsus dis-
course upon this disease and its causes, and nearly all the
medical writers of the middle ages make reference to ure-
thritis.
The nature of urethritis was long in dispute, and the
question, Is it an infectious disease, a simple phlegmasic
process, or a contagious affection sui generis? was earnestly
discussed by able physicians, whose conclusions were so di-
verse that, for convenience, they were classed and designated
as the identists and the non-identists. The identists were
those who asserted that " gonorrhoea " and syphilis are iden-
tical diseases, t. e., that " gonorrhoea " and chancres are
produced by one and the same virus, and that " gonorrhoea"
can produce chancres and vice versa. The early authors who
Jan. 16, I892.J
GOULEY: DISEASES OF THE URINARY APPARATUS.
treated of syphilis were, not identists— that is to say, they
made a distinction between the " simple chancre," the in-
fecting chancre, and urethritis, and it was not until about the
middle of the sixteenth century that the distinctions of these
three diseases ceased, and that the doctrine of identism was
promulgated by Musa Brasavola, of Ferrare, and generally
accepted. This doctrine continued in vogue until the latter
part of the eighteenth century, and was first questioned by
Balfour (1767), then by Tode, of Copenhagen (1777), and
by Fabre, a disciple of the renowned Petit, who showed that
he had doubts upon the oiiestion of identism when he as-
serted that the consequences of " gonorrhoea " were not the
same as those of chancre. The first edition of his work on
venereal diseases was published in 1758. Hernandez, of
Toulon, a surgeon of the French navy, published, in 1812,
a monograph of 348 octavo pages to establish the non-iden-
tity of the " gonorrhoea] and syphilitic viruses."
The answer that may now be made to the question re-
specting the nature of urethritis accords with neither that
of the identists nor that of the non-identists, which are so
extreme, but includes all that seems rational from each side.
i. e., urethritis is, in all cases, a phlegmasic process. It is
often contagious, but most frequently it is simple, non-con-
tagious. It is contagious but non-infecting when it arises
from urethral chancroids ; it is styled virulent when it arises
from the contagium of virulent vulvitis or vaginitis, and it
is infecting when due to urethral chancres or mucous patches.
It is not auto-inoculable when simple or when due to an in-
fecting chancre. It is auto-inoculable when owing to a non-
infecting chancre, called chancroid by Clerc.
John Hunter was at the head of the identists, and Ben-
jamin Bell ably and eloquently pleaded the cause of the non-
identists. Hunter declared that " gonorrhoea! " virus was
capable of producing chancre and chancrous virus of pro-
ducing " gonorrhoea." The great master endeavored to set-
tle this question in the month of May, 1767, by making an
inoculation upon the prepuce and another upon the glans
penis with pus taken from the urethra of a patient whom
he believed to be affected with " gonorrhoea," There re-
sulted two chancres which were followed by constitutional
syphilis. He therefore concluded that the two diseases pro-
ceeded from the same virus. A detailed account of this
event with its ultimate result is given by Hunter in his
treatise on The Venereal Disease, London, 1788, pp. 324-327.
It now seems fair to assume that the urethral pus used in
this experiment was the product of a syphilitic sore of the
urethra.
Benjamin Bell took a diametrically opposite view of the
subject, and, to overthrow the doctrine espoused by Hunter,
made an elaborate and strong argument, abundantly illus-
trated by cases, in which his final conclusion was, that the
pus of chancre could never produce " gonorrhoea " and that
the pus of " gonorrhiea " could never produce chancre. This
argument, contained in the first chapter of Bell's work on
Gonorrhoea virulenta and lues venerea, 1793, entitled the
consideration of the question whether " gonorrhoea " and
lues venerea originate from the same contagion, is well wor-
thy of careful perusal by those who may wish to investigate
the question.
Both eminent observers had their adherents, who warm-
ly and ably argued the question which, many years after the
death of the two contestants, continued to be discussed. It
was finally settled by the concurrent labors of three earnest
workers in this field of medicine — namely, Ricord, Basse-
reau, and Cullerier — but they shall now speak for themselves
through the last named, who expresses their ideas substan-
tially as follows : Ricord, who has made inoculations of vene-
real matter on the largest scale, has come to the conclusion
that simple urethritis is never inoculable, that is to say, pro-
duces no specific sore, but that when a specific sore results
from inoculation with urethral pus it is because there exists
in the urethra a chancre which had escaped detection. But
these observations, which at first sight seemed to throw such
great light upon the question, have lost much of their value
since the publication of the work of Bassereau, before which
Ricord believed that chancre and syphilis were the same
thing. From an exhaustive and conscientious clinical study
of the subject, Bassereau was forced to conclude that all
chancres were not of the same nature ; that whenever there
were syphilitic symptoms, these had been preceded by an
indurated chancre ; that the indurated chancre has always
originated from another indurated chancre ; and that a soft
chancre has always been due to another soft chancre and
never caused syphilis. Cullerier at first combated these
ideas, as he had, though rarely, seen constitutional symp-
toms follow soft chancres ; and it was not until the year
1857 that Ricord accepted the doctrine of Bassereau. In
endeavoring to establish the differential characters of the
two chancres, Ricord offered the following proposition : the
soft chancre is inoculable for an indefinite period, while the
indurated chancre can scarcely ever be inoculated— on the
infected individual of course. This is a direct contradic-
tion of his original proposition, which was to the effect that
what distinguishes virulent urethritis, urethral chancre, from
simple urethritis is that the former is inoculable, and that
whenever the inoculation is negative in urethritis there is
no syphilis. On the other hand, Ricord maintains that the
indurated chancre alone gives syphilis and is rarely, if ever,
auto-inoculable, and that the soft chancre has the property
of being inoculated upon the sufferer. Therefore, says Cul-
lerier, whenever an inoculation is made with the pus of ure-
thritis, if this inoculation be successful, it is to be concluded
that there exists in the urethra a soft chancre and that there
will not follow any constitutional symptoms. If the inocu-
lation is negative, this will afford no proof whatever that
there will not follow constitutional symptoms, inasmuch as
the indurated chancre rapidly loses its property of being in-
oculated.
From these statements of the case it is plain that what
has been said of the value of inoculation to serve in distin-
guishing the two species of urethritis should be blotted out,
or at least should be given another signification, for it is
evident that the most inoculable is the least dangerous. The
evidence furnished by inoculation is therefore not to be ab-
solutely depended upon in the distinguishing of simple,
chancrous, and chancroidal urethritis. The more rational and
tenable position in regard to the nature of urethritis, SO far
as it is related to chancre and chancroid — and this position
64
GOULEY: DISEASES OF THE URINARY APPARATUS.
[N. Y. Mkd. Jouh.,
is based upon a careful analysis of the propositions of both
the identists and non-identists and upon clinical observa-
tion— is that urethritis may be simple, or contagious, or it
may be the consequence of a non-infecting, or of an infect-
ing chancre, either of which being accidentally situated in
the urethra, and acting, so far as the urethra is concerned,
as a local irritant. The primary lesion of syphilis per se
possesses no inherent property which, other than as a local
irritant, may cause urethritis, the two diseases being entire-
ly distinct. The same may be said of the third disease, the
non-infecting chancre. From what precedes it may be con-
cluded that a man can contract urethritis from a woman who
has a chancre, chancroids, or mucous patches of the geni-
tals. Many experienced and sound observers have encoun-
tered cases of urethritis so contracted, and the patients have
not had the slightest indication of chancre or chancroids.
Cullerier thus explains the phenomenon : In the primitive
ulcer there are two things — a phlegmasia product and some-
thing special; therefore the individual may take that only
which is simply phlegmasic and escape syphilitic or chan-
croidal infection, the pus acting only as an irritant. He
quotes, from Benjamin Bell's work, the case of a medical
student who placed some chancrous pus between the glans
penis and prepuce, and this caused a simple balanoposthitis,
while others, after introducing chancrous pus into the ure-
thra, had only non-virulent urethritis.
It has happened that, from the same woman, a man has
contracted a chancre on the glans penis, and nothing else,
and that another man, almost immediately after, has only
caught a simple urethritis. It has also happened that a
man has contracted, from one woman, a " gonorrhoea," an
infecting chancre, and non-infecting chancres ; the woman
being affected with all three diseases.
It may now be said that the proposition, contained in
the answer to the question respecting the nature of ure-
thritis, is sustained and may be summed up as follows : Ure-
thritis may be non-contagious, it may be contagious and
non-infecting, or it may be due to the presence in the ure-
thra of an infecting or of a non-infecting chancre, and the
same patient may contract a non-infecting urethritis simul-
taneously with a chancre or a chancroid in the urethra.
This may have happened in the case cited by Hunter to
prove the identity of the two diseases.
Causes. — Urethritis is said to be infecting when due to
the presence of an infecting chancre or of a mucous patch
in the urethra. It is non-infecting when owing to a ure-
thral chancroid. It is named virulent when it arises from
a contagium capable of reproducing itself indefinitely under
proper conditions, as exemplified in the cases of urethritis
commonly designated " gonorrhoea," contracted from viru-
lent vulvitis or vaginitis, or by mediate contagion. It is
called simple when non-contagious,, whether originating
from sexual commerce or from local irritants.
Infect hi <i urethritis in followed hy distinct, manifestations
of syphilitic infection in the course of from six weeks to
three months. The physicians who judge from observation
of the effect of chancre at the urinary meatus deny that
urethritis is produced by urethral chancre, for in such cases
there is little if any tendency to the backward extension of
the phlegmasic action, which is commonly of short duration,
and the mucous membrane of the urethra behind the sore
remains intact. That a chancre seated within the urethra
does produce urethritis was exemplified by John Hunter's
well-known experiment. The urethritis caused by a ure-
thral chancre, besides generally being slight and of short
duration, is accompanied by little or no pain during urina-
tion. A case of urethritis which gets well, without treat-
ment, in a week or in two weeks, needs to be viewed with
suspicion and to be kept under close observation for at least
three months.
The following is given in illustration of the clinical his-
tory of a case of infecting urethritis : The patient, finding
it necessary to invoke medical assistance owing to certain
symptoms which had caused him some anxiety, gave a part
of this account of his complaint. Three months before he
had contracted for the first time what he supposed to be an
ordinary urethritis which gave him very little inconven-
ience and was well in a week. He had never had any other
vevereal disease. There was no visible sore or scar upon
any part of his sexual organs. In the course of six weeks
after the cessation of the urethral discharge he had a well-
marked roseola, which was observed by a medical officer of
the navy, and in six weeks more — that is, three months after
the disappearance of the urethritis, when he applied for
treatment — he was suffering from mucous patches in the
fauces, and showed other unmistakable symptoms of syphi-
lis. When this supposed simple urethritis began he was at
sea (had sailed from New York several days before), and
for the next eighty days was on board a man-of-war and in
no way exposed to the contagion of syphilis. Assuming
the veracity of the patient's story, it is fair to conclude that
his urethritis was caused by an intra-urethral chancre.
Urethritis due to mucous patches in the urethra, though
of rare occurrence, has been repeatedly verified by careful
observers. It is characterized by a discharge which is at
times sanious and which continues as long as the mucous
patches exist. During urination there is some scalding pain.
A patient who has never contracted urethritis, but after im-
pure sexual commerce becomes infected with syphilis and,
several months after the initial lesion, is affected with mu-
cous patches in the fauces and a purulent sanious urethral
discharge, may fairly be regarded as suffering from ure-
thritis due to the existence of urethral mucous patches, pro-
vided that, in the mean time, he had abstained from sexual
commerce.
Non-infecting urethritis due to urethral chancroids is not
followed by lesions such as those which characterize the in-
fecting, syphilitic variety, but it has its own special virus
which acts locally and possesses the property of reproduc-
ing itself indefinitely in proper soils. The same observers
who deny that urethral chancre produces urethritis also
assert that chancroids do not give rise to this phlegmasia,
and probably for the same alleged reason. That chancroids
of the urethra do cause urethritis is a fact which few physi-
cians now dispute. These chancroidal ulcers are prolific
sources of cicatricial strictures in the fossa navicularis and
even in the phallic region of the urethra. Chancroidal ure-
Jau. lti, 1892.]
GOULEY: DISEASES OF THE URINARY APPARATUS.
65
thritis continues until the ulcer is healed and sometimes
long after the healing process. The discharge is often pro-
fuse and sanious. When a douht arises as to its nature, the
question is decided by inoculating with it the patient.
By virulent urethritis, improperly styled "gonorrhoea"
is meant the urethritis resulting from sexual contact with a
person suffering from a species of vaginitis or vulvitis char-
acterized by a purulent discharge capable of reproducing
itself, even when applied artificially to any of the mucous
membranes that are susceptible to venereal phlegmasia.
The mucous membranes which are most susceptible to ve-
nereal phlegmasia are those of the glans penis, the prepuce,
the urethra, the prostatic utricle, the urethral crypts, the
anus, the mouth, and the conjunctiva.
The mucous membranes which are refractory to venereal
phlegmasia are those of the ducts of the bulbo-urethral
glands, the prostatic ducts, the ejaculatory ducts, the semi-
nal vesicles, the spermatic canals, the bladder, the rectum,
the nose, and the lacrymal canals.
Bonnieres, who has compared the histological characters
of these two groups of mucous membranes, describes the
first as being supplied with papillae and covered with pave-
ment epithelium, with an underlying network of lymphatic
capillaries whose parietes are constituted by epithelial cells,
while the second group is covered by cylindrical epithelium
with an underlying network of red blood-capillaries instead
of lymphatics, and concludes that the venereal phlegmasia
acts primarily upon the lymphatic capillaries and the epi-
thelium, and that the phlegmasia of the neighboring tissues
is only secondary thereto. In the prostatic region, for in-
stance, there is a close subepithelial network of lymphatic
capillaries which anastomose with the lymphatic capillaries
•of the spongy portion of the urethral mucous membrane
and terminate abruptly at the urethro-vesical orifice, the
bladder mucous membrane being entirely destitute of lym-
phatics ; hence it is that the bladder is refractory to phleg-
masia such as might otherwise be propagated through the
urethra (Perrin).
The Nature of the Contagium of Urethritis. —
It has been asked what evidence is offered in support of
the assertion that there is such an affection as a sui-generis
virulent contagious urethritis \ Many writers have endeav-
ored to answer this question; among them, Dr. Thiry, of
Brussels, and Mr. Hutchinson, of London.
Dr. Thiry enumerates three kinds of urethritis — the
first, simple; the second, syphilitic; and the third, having
a virus of its own which he calls the granulous virus, and
which, he says, is the distinctive character of true conta-
gious urethritis whose morbid elements are granulations.
But granulations exist in the vagina and cervix uteri in
many women who seldom give urethritis to men who are
accustomed to lie with them or, to use Ricord's expression,
whose genital organs are acclimated. This fact is unde-
niable, and overthrows Dr. Thiry's doctrine. If Dr. Thirv's
views were correct, urethritis should he the rule and not the
exception in these cases.
According to Mr. Hutchinson, the contact of dead pus,
whose corpuscles are in an advanced state of fatty degenera-
tion, such as that from an abscess, causes but little irritation,
while living pus, recently formed, is contagious and likely
to cause phlegmasia when in contact with tissues similar in
structure to those whence it originated. But this also fails
to establish the character of the contagium said to be pecul-
iar to non-infecting contagious urethritis. In accordance
with the light thrown, of late years, upon phlegmasic pro-
cesses, pus consists of dead leucocytes that have failed to
destroy the morbific materials they have attacked ; there-
fore there are no living pus-corpuscles. Pus is a dead
substance to be ejected or encysted and rendered innocuous
until transformed. That urethritis is often contagious is
fully and frequently demonstrated clinically. A man af-
fected with acute non-infecting virulent urethritis who de-
posits his urethral pus into the healthy vagina of a wroman
contaminates this vagina, and there follows vaginitis, and
this same vaginitis causes urethritis in another man who ex-
poses himself to the contagion. What, then, is the element
of contagion, and where does it reside ? Is it in the pus-cell,
in the serum of the pus, or in the mucus contained in the
morbid discharge ? These questions have not yet been sat-
isfactorily answered, although several theories have been
advanced respecting the nature of the contagium, the latest
being the microbic.
Among those who regard the contagium of urethritis as
microbic is Dr. F. P. Jousseaurae, who, in his inaugural
thesis on the vegetable parasites of man, Paris, 1862, de-
scribes an alga of urethritis, to which he gives the name of
genitalia, and whose habitat, he says, is subepithelial. He
believes urethritis, as well as vaginitis, to be caused by the
presence of this parasite. This is here recorded only as a
part of the history of the doctrines relating to the con-
tagium of urethritis.
Many of the modern pathodiistologists assert that in
the discharge of simple urethritis no micro-organisms are
present, while in non-infecting virulent urethritis, " gonor-
rhoea," the pus-cells contain a specific diplococcus, named
" gonococcus," and discovered in the year 1879 by Neisser.
It is further asserted that whenever this contaminated pus
is conveyed to the urethra there follows a urethritis with
the reproduction of the " gonococcus " in the pus-cells of
the new urethritis.
Since the announcement of Neisser's discovery several
other organisms have been detected in the pus of virulent
urethritis. In some cases of. virulent urethritis no "gono-
cocci " have been found, while in many cases of non-viru-
lent urethritis " gonococci " abound.
Diplocoeci undifferenced morphically from " gonococci "
have been seen repeatedly in pus from different parts of the
body and in abscesses distant from the genital and urinary
organs of patients in whom there were no traces of venereal
disease.
It has been suggested that the contagium resides in the
mucus of the urethral discharge, with the implication that
this contagium may be a toxalbumin destructive to the
epithelium. But whence this particular toxalbumin which
selects the genitalia with such nefarious intent .'
Since several different micro-organisms have been found
in the pus of urethritis, may not any or all of these organ-
66
GOULEY; DISEASES OF THE URINARY APPARATUS.
[N. Y. Med. Jocu.r
isms be capable of acting as irritants, and give rise to super-
secretion of mucus, to blood stasis, plastic exudation, the
emigration of leucocytes, and exfoliation of epithelium ;
some irritant being essential to the development of phleg-
masia ? Or is the irritant of urethritis likely to be a virulent
ptomaine ? This is certainly not impossible, since urethritis
has been experimentally induced by the injection of dilute
liquor ammonias.
Nothing so far discovered has sufficed to explain the
nature of the contagium of that variety of urethritis mis-
called " gonorrhoea."
By mediate contagion of urethritis is meant the trans-
mission of the disease without coitus, but by contact with
objects impregnated with the urethral or vaginal discharge of
a diseased individual. The question of mediate contagion is
of great consequence. Much ridicule has been cast upon it,
and honest and veracious patients have often been dis-
credited when they have declared that their urethral dis-
charge was not the result of sexual commerce. Neverthe-
less, the possibility of contracting contagious urethritis
mediately — that is to say, without sexual approach — is a
fact which has been attested by excellent observers for a
century past, and which was recognized even in the time of
Moses, as indicated in Leviticus, chapter xv, verses 2, 3, and
4 :" The man that hath an issue of seed shall be unclean . . .
when a filthy humor, at every moment, cleaveth to his flesh
and gathereth there. Every bed on which he sleepeth shall
be unclean, and every place on which he sitteth." That
patients contract purulent ophthalmia by using towels soiled
by a person affected with contagious urethritis or vaginitis,
or by the affected individual himself carrying a soiled hand
to his eye, is of constant occurrence. What, then, is to pre-
vent contagion if this pus be applied to the orifice of the
urethra instead of the eye ? That in these days patients do
contract urethritis in unclean places without sexual contact
is not a very uncommon occurrence, and that a healthy man
sleeping in the same bed with a man suffering from con-
tagious urethritis is liable to contract the disease is also a
very reasonable assertion, as it is only necessary for an al-
most infinitesimal quantity of infected pus to make its way
to the urethra to insure contagion, and contact with freshly
soiled bed-linen during sleep is not unlikely. Nurses af-
fected with contagious vaginitis or vulvitis have communi-
cated purulent ophthalmia to infants in their charge entirely
through soiled hands, and in the same way have given
urethritis to children. Contagious urethritis engenders con-
tagious vaginitis and vice versa. Such are among the ways
in which the disease is propagated and perpetuated.
By simple urethritis is meant a phlegmasia which has
no specific virus and is not contagious, but which arises
from the action of mechanical or chemical irritants to the
urethral mucous membrane, from sexual excesses, from mas-
turbation, etc. It is characterized by symptoms similar to
those of virulent urethritis. It has the peculiarity that the
phlegmasia process often begins in the prostatic, membra-
nous, or perineal region of the urethra, and gradually extends
forward, an<l finally invades the whole canal, but it also fre-
quently begins in the fossa navicularis, extends backward,
and is attended with nearly all the complications and sequels
of the contagious form. In some cases there is much
febrile reaction, and the discharge is very profuse ; in other
cases the urethritis is superacute, while in the majority it
is subacute.
Oouty patients are sometimes affected with a purulent
urethral discharge, which is often attended with scalding
sensation during urination. This discharge usually disap-
pears on the cessation of the gouty symptoms. In certain
cases, however, the discharge lasts many weeks. Urethritis
is frequently one of the first manifestations of an attack of
gout, and thus shows itself each time the patient is newly
attacked with "the gout." This occurs so commonly in
some cases that the patients are able, two days before, to
announce the advent of a gouty seizure, and they base their
prediction upon the ardor urinae, which they had noticed as
so regularly preceding former attacks. The urine of these
sufferers is loaded with uric-acid sand, and the ardor urinae
is caused by minute punctures inflicted upon the urethral
mucous membrane in its whole extent by the sharp points
of the uric-acid crystals. The mucous membrane thus
wounded yields more or less blood, which passes away with
the urine, and there soon follows a flow of pus which does
not cease until the urine is free from crystalline matter. It
sometimes happens that a number of uric-acid crystals are
cemented together and form concretions of various sizes,
from one to six millimetres in mean diameter, which, when
carried along in the stream of urine, have been known to
block up the urethra, cause retention of urine, and phleg-
masia, and even ulceration of the urethral mucous mem-
brane. Several such concretions have been found lodged
behind urethral strictures, causing retention of urine, be-
sides a copious purulent collection.
Stone in the bladder, particularly the phosphatic, is some-
times an indirect cause of urethritis. The ammoniacal urine,
loaded, in such a case, with prismatic crystals, being ex-
tremely irritating to the urethral mucous membrane, at
length causes a urethritis which, though subacute, is at-
tended with inordinate sensitiveness of the canal.
Urethritis is known to arise from the ingestion of sub-
stances which, being eliminated by the kidneys, render the
urine acrid and irritating. For example, the free and con-
tinuous use of asparagus as an article of food is not an un-
common cause of urethral phlegmasia. There are many
persons who can not make use of this succulent delicacy for
two or three consecutive days without being inconvenienced
by a very considerable smarting sensation in the urethra
during urination, and even by a purulent urethral discharge.
Soon after eating asparagus, their urine emits a character-
istic strong odor, and often contains innumerable crystals
of oxalate of calcium, and this continues so long as they
persist in indulging their desire for this luxury.
Among the many who have complained of the ill effects
of asparagus is a young man who, during three consecutive
summers, was annoyed by profuse urethral suppuration w ith
much scalding in urination. On each occasion he believed
himself affected with contagious urethritis, from which,
however, he had never suffered, but during these periods he
had been indulging very freely in asparagus, lie was ad-
Jan. 16, 1892.J
GOULEY: DISEASES OE THE URINARY APPARATUS.
67
vised to abstain from this his favorite dish, and the dis-
charge always ceased soon after his compliance with the
advice.
New ale, beer, cider, and other fermented liquors, even
when used in moderation, are known to excite urethritis.
These beverages exert an evil influence upon the imperfect
digestion of elderly men, and their use should be forbidden.
The abuse of all alcoholic stimulants is a potent factor in
the production of urethritis.
Free doses of cantharides given ignorantly or with ma-
licious intent have led to the gravest consequences besides a
free flow of pus from the urethra. Large Spanish-fly blisters
applied to the trunk or extremities have been followed by
the same ill effects.
Urethritis may be due to any obstruction which favors
stagnation and fermentation of urine in the bladder. Those
patients who have long suffered from obstructed urination
caused by urethral stricture or prostatic enlargement, and,
in consequence thereof, have been obliged to urinate with
undue frequency, nearly all suffer from urethritis as a result
of the great irritation produced by putrid, ammoniacal
urine.
Urethral phlegmasia is sometimes the outcome of fre-
quent or of violent catheterism. Sufferers from enlargement
of the prostate, who are obliged to use the catheter four or
five times daily to relieve their bladders, are, in the begin-
ning, much inconvenienced by urethritis. In some cases
the first catheterism excites an acute urethritis which
renders subsequent catheterisms painful, but as it would be
unwise to suspend the use of the instrument, measures are
taken to mitigate the phlegmasia and relieve the pain, and
they are ordinarily successful. Many cases could be cited
where the first catheterism caused acute urethritis which, in
a few days, yielded to rest and mild local treatment, and
did not recur after the urethra had become habituated to
the passage of the catheter. There are, however, many
cases in which the urethral discharge becomes chronic and
is maintained solely by the irritation to which the catheter
gives rise, notwithstanding the most careful antiseptic pre-
cautions. In other cases, and unfortunately they arc n<>t
few, the patients, from an unwise sense of economy, allow
themselves to use worn-out, defective, or improperly con-
structed catheters, which seldom fail to cause local mischief.
Others again, from carelessness or ignorance, use more or
less violence, or catheterize themselves with undue fre-
quency, and urethral phlegmasia, if not a more serious in-
jury, is the almost invariable result.
When the external orifice of the urethra happens to be
narrower than natural, and the patient is in the habit of
catheterizing himself frequently and clumsily, there some-
times follows a phlegmasia of the extremity of the penis,
with more or less induration, which renders the use of the
instrument difficult and distressing. In a patient so affect-
ed, the induration had involved such a considerable portion
of the glans penis that it was at first suspected to be of
a malignant nature; but, after the more careful use of a
smaller catheter and the local application of acetate- of- lead
solution, the induration subsided, and the meatus was incised
so as to allow the easy passage of ordinary-sized catheters.
Exploring catheterism, even with a sterilized instrument,
may cause urethritis. The following is a fair illustration
of this point : A., sixty-five years of age, who applied for
treatment on account of an attack of acute urethritis, with
copious purulent discharge, and was not as frank and out-
spoken as a patient should be with his medical adviser, be-
trayed so much anxiety as to the probable cause of his ail-
ment and asked questions of such character as to lead his
hearer to the surmise that he might have exposed himself
to contagion. However, after the summing up of a con-
siderable amount of cross-questioning, this did not seem
likely. At length it was incidentally learned that he had
been catheterized, with due precaution, a few days before,
with a view of discovering the cause of obstruction to uri-
nation, of which he had been complaining. The instrument
did not penetrate the urethral canal more than two inches,
and in two days the discharge of pus had begun. A cau-
tious exploration revealed a very narrow stricture in the
phallic region of the urethra, and the conclusion arrived at
was that, if the patient had illicitly indulged his sexual de-
sire, he surely had not contracted virulent urethritis, but
that the acute phlegmasia was the result of the catheterism
perhaps violently practiced upon an already diseased and
sensitive urethra. The discharge ceased a few days after
the urethra was properly enlarged.
Foreign bodies of various kinds introduced from without
into the urethra and retained for a certain length of time give
rise to urethritis. Among these foreign bodies may be
mentioned broken ends of catheters or bougies, fragments
of wood or straw, pudendal hairs, and many other objects.
Several cases of urethritis caused by the accidental passage
of pudendal hairs into the urethra have been observed, the
purulent discharge ceasing soon after the removal of these
foreign bodies from the fossa navicularis urethra'.
A catheter retained a few days in the urethra excites
phlegmasia of the mucous membrane, and has been known
to cause ulceration at certain points, such as the navicular
fossa, the peno-scrotal junction, and the bul bo- membranous
region, particularly in those cases of urethral stenosis treated
by continuous dilatation where the instrument is sometimes
unwisely retained a week or two wreeks.
Sexual excess appears to be the most common cause of
urethral phlegmasia. Fournier expresses the opinion that
by excessive sexual indulgence men give themselves ure-
thritis oftencr than they receive it. He further asserts that
seventy-five per cent, of all cases of urethritis are non-
contagious. The majority of women from whom urethritis
is supposed to have been contracted had not vaginitis or,
at least, hail not contagious vaginitis or vulvitis. The ure-
thritis so developed is, of course, simple, non-contagious.
There are women whose vulvar and vaginal secretions are
so acrid as to give urethritis to all those that have sexual
commerce with them. A case often quoted in illustration
of this point is that of a noted and very attractive cour-
tesan, whose genital organs were in a perfectly healthy state,
hut who, nevertheless, gave urethritis to all the men who
won her favor.
The occurrence of urethritis from sexual contact during
immediately before, or too soon after, the menstrual flow, or
68
nor LEY: DISEASES OF TEE URINARY APPARATUS.
IN. Y. Med. .Joub.,
during the early period of lochial discharges, lias been very
frequently verified, and such urethritis, although ordinarily
mild, is often as obstinate as it is severe, and is sometimes
followed by many of the evils of virulent urethritis, but it
is never contagious.
Urethritis is often caused by sexual contact with persons
suffering from /eucorrhaea, or from uterine cancer, or tuber-
culosis. Excessive sexual indulgence with a woman affected
with leucorrhcea is likely to cause urethritis in the man, who,
when he discovers his infirmity, is too apt to accuse of infi-
delity his partner in the se xual debauch. This has fre-
quently happened in the case of the newly married and has
led to connubial infelicity, to much misery, to ill treatment
of the innocent wife, to divorce, and to utter ruin. Other
sad consequences, particularly to an oversensitive man who
may have been suffering from an old gleet, are self-accusa-
tion, despondency, and perhaps even suicide, under the er-
roneous impression that he had infected his wife with a
" disease of which he wras not properly cured." It is al-
most needless to say that chronic urethritis is not contagious.
The following case illustrates another point of medical
and legal interest. A medical man who had been under
treatment for faucial diphtheria went away alone for a few
months, and shortly after his return called to say that he
had urethritis, from which he had never before suffered.
In two weeks he was well without having had recourse to
the ordinary internal treatment. The urethra was daily ir-
rigated with mild astringent solutions, and a glass of Vichy
water was taken thrice daily. It was ascertained that his
wife had, at the time and long before, been suffering from
leucorrhoea, and that such was the cause of the urethritis
which had attacked the husband. In a year after this the
wife went on a visit to her relatives in the country. On her
return in three months her husband became affected with
urethritis, and again on a third similar occasion. This last
did not so rapidly yield to treatment, though it was milder
than the first two attacks. The wife had so far refused to
submit to treatment ; at length, consenting, she was relieved
of her local affection, and her husband never again contract-
ed urethritis even after an absence of several months. A
point of much interest in the case is that after recovery from
each of the attacks of urethritis the patient had no trouble
until the first sexual approach several months after a forced
separation from his wife. The case corroborates the asser-
tion of Ricord in regard to what he terms " acclimation " of
the genitals.
That some men are less susceptible to urethritis than
others is a fact which careful observers have repeatedly veri-
fied. Of two men, of the same age and of equally sound
body, indulging themselves sexually, within two or three
hours, with the same woman, untouched meanwhile by oth-
ers, one has escaped unharmed while the other has con-
tracted urethritis. In some instances it happens that the
first becomes diseased ; in other cases it is the second that
becomes affected.
Men contract urethritis from women suffering from ma-
lignant or from tubercular ulceration of the cervix uteri.
That women affected with ulcerated uterine epitheliomata, f
emitting acrid discharges, give urethritis to their husbands
is a fact which bears the attestation of physicians of extern
sive experience. The discharge from tubercular ulceration
of the uterus is not only capable of causing urethritis, but
of producing tuberculosis of the urethra. Some cases of
tuberculosis of the male genital organs have been traced to
this cause.
Masturbation as a cause of urethritis requires more than
a passing notice. Those addicted to the vice of masturba-
tion are, in consequence, attacked with urethritis with great-
er frequency than is generally supposed. This urethritis
usually has the characters of chronicity from the outset, and
the discharge is so slight that it at first escapes observation,
or otherwise it is thought to be of little consequence by the
patient, the sensitiveness of whose urethra has perhaps been
blunted by long-continued abuse; hence the many cases of
stricture, the origin of which is not satisfactorily traced, ex-
cept by those physicians whose attention has been fixed upon
such cases and who have been able to extract the truth from
patients regarding early habits of masturbation. The com-
mon story of these patients is that they had noticed a con-
stant urethral discharge which they had regarded as diurnal
emissions of semen. In rare cases this urethritis becomes
acute and even superacute.
Almost any sort of mechanical irritation of the urethra is
likely to lead to phleymasic action. Infant boys sometimes
suffer much from urethritis by being fingered by vicious
nurses desiring to gratify their own depraved instincts, or,
as they often pretend, " to prevent the child from crying."
Young boys are not infrequently attacked with urethritis
during dental evolution, or during affections which lead to
errors in nutrition, the consequent hyperlithuria being the
chief factor in the causation of the urethritis.
Urethritis occurring in elderly men is often a source of
much anxiety and suffering. A question often asked is, To
what extent are elderly men liable to urethral phlegmasia,
and does this differ from the urethritis of youth ; if so, in
what particulars? This question may thus be answered:
While urethritis is generally simple, non-contagious, among
elderly men, and is less frequent than among young and
middle-aged men, it can not be regarded as an infrequent
affection in advanced life. For instance, it occurs to a
greater or less extent in a very considerable proportion of
cases of enlargement of the prostate, and of gravel and
stone in the bladder. It is not denied that elderly men are
sometimes affected with contagions urethritis, for some
among them are so unwise as to expose themselves to con-
tagion, but happily they are comparatively few, and those
who commit sexual excesses are not many. Urethritis is
generally not so violent in elderly men as in youth or mid-
dle life. Only very exceptionally is it severe in the acute
type, and it is very rarely superacute. Most frequently it
is subacute and soon passes into the chronic state. It is
characterized by less pain, less ardor, less dysuresis, and
generally less purulent discharge than in youth, but it is
more persistent and less amenable to treatment. In youth,
in the great majority of cases, urethritis begins in the an-
terior extremity of the urethra, while in advanced life it
very often begins at the posterior extremity or at once in-
vades the whole canal.
Jan. 1G, 1892.)
GOULEY: DISEASES OF THE URINARY APPARATUS.
69
Diagnosis. — For diagnostic, prognostic, and therapeutic
purposes it is essential to bear in mind the following points :
Contagious non-infecting urethritis, "gonorrhoea," and sim-
ple non-contagious urethritis may be benign, subacute,
acute, or superacute, and may be primitive, in cases where
the urethra was never before diseased, or secondary in cases
where the urethra had been the seat of phlegmasia at some
more or less remote time. Primitive contagious urethritis
is said to incubate from four to seven or even fourteen
days, while primitive simple urethritis has a very short
period of incubation, and sometimes declares itself a few
hours after the action of the irritant which has been its
cause. Secondary urethritis, whether contagious or non-
contagious, has also a very short period of incubation.
Urethritis ordinarily begins in the balanic region and
gradually extends backward, sometimes even to the vesical
orifice.
The adjective benign, applied by some authors to ure-.
thritis, is intended to signify a type characterized by mild
symptoms, such as a little ardor in urination, an itching
sensation in the fossa navicularis, and a slight mucous dis-
charge, all of which disappear in a few days. Though be-
nign urethritis may thus rapidly resolve, it is frequently in
reality the first stage, the close of the period of incubation
of the other types. That is to say, what for three or four
days may appear to be a simple benign urethritis may be-
come a subacute, an acute, or a superacute urethritis, or the
discharge may become slightly purulent and persist as a
chronic urethritis.
Subacute urethritis is characterized by a free muco-puru-
lent discharge with but little redness of the urinary meatus
and slight scalding sensation in urination. Its periods of
increase, stasis, and decline are sometimes all ill defined or
scarcely perceptible. Resolution occurs in from four to five
weeks, or the discharge lessens, but persists and becomes
chronic.
Acute urethritis, as before stated, begins as benign ure-
thritis, which is its first stage, lasting thiee or four days.
After this the discharge becomes purulent and soon thickens
into a creamy state, yellowish at first and later greenish
from an admixture of blood ; the phlegmasic action daily
augmenting until about the tenth day, when it reaches its
maximum of intensity. During this time there is much
scalding in urination, the lips of the meatus are red and
pouting, and nocturnal erections of the penis are frequent
and painful. This is the second or stage of increase, which
has been termed the acute stage of acute urethritis, the
adjective acute having already been used to qualify the type
of a phlegmasia. The acute type, for instance, has its stages
of incubation, of increase, of stasis, and of decline. Then
comes the third stage or static period, during which the
phlegmasic process neither increases nor diminishes. This
period may be short, lasting one or two days, or may last
from seven to ten days. It is followed by the fourth or
stage of decline, which is the beginning of resolution. The
discharge is then thin and pale, ceasing ordinarily between
the fourth and sixth week. Among young and healthy sub-
jects the first acute urethritis often resolves within three
weeks. In some cases resolution is incomplete and the dis
charge persists indefinitely. The phlegmasia is then said
to have passed into the chronic state.
Superacute urethritis is characterized by a superabundant
flow of pus mixed with blood, all the other phenomena of
acute urethritis being greatly intensified. There is often
the complication of balano-posthitis with much oedema of
the prepuce ; the whole penis is swollen and the larger
lymph vessels thereof are inflamed. Nocturnal erections of
the penis are almost uncontrollable, extremely painful, and
attended by what is commonly called chordee, which is a.
curvation of the distended penis toward the perinteum.
This curvation is caused by a superabundant plastic exuda-
tion in the meshes of the submucous tissue and corpus
spongiosum. The corpora cavernosa are gorged with blood,
but, the corpus spongiosum being blocked by the exudate,
complete erection of the penis is impossible. Retention of
urine is of frequent occurrence in this type of urethritis.
Resolution is generally incomplete, and the exudate be-
comes imperfectly organized, undergoes sclerosis, and strict-
ure ensues.
Chronic urethritis is characterized by a slight muco-
purulent discharge, often to the extent of a few drops only
each day, but this discharge is persistent, and increases in
quantity after a debauch or after sexual excess. Chronic
urethritis is consequent upon any of the types to which
reference has been made, or begins with the essential char-
acters of chronic phlegmasia. Men suffering from chronic
urethritis are much more liable to contract acute urethritis
than those whose urethras are sound.
The site of the urethritis due to chancre, mucous patches,
or chancroids is the fossa navicularis, but in rare instances
it has been discovered in the phallic and even in the peri-
neal region of the urethra.
Contagious non-infecting urethritis begins in the fossa
navicularis, and there remains stationary ordinarily for sev-
eral days ; then, if it do not speedily resolve, gradually ex-
tends itself as far as the sinus of the bulb, there to lin-
ger and become chronic, or on the third or even the
fourth week may reach the urethro- vesical orifice, with-
out, however, passing this limit — a fact which seems to
justify the assertion that acute urethritis is a spreading
angeioleucitis, terminating, as it does, abruptly at the neck
of the bladder, beyond which no lymphatics have been
discovered.
Simple non-contagious urethritis, like the contagious,
often begins in the fossa navicularis and gradually extends
backward, as was so well illustrated by Swediaur's experi-
ment. He injected into his own urethra some diluted
liquor ammonias, and soon thereafter experienced the most
excruciating pain, followed by an acute urethritis which be-
haved very much like acute contagious urethritis and last* <I
six weeks, beginning in the fossa navicularis and ending at
the urethro-vesical orifice.
As there are many exciting causes, so there are many va-
rieties in the phenomena of urethritis. The phlegmasia
may be mild and transitory, or it may be mild and per-
sistent. It may be violent and transitory, or it may be
violent and persistent.
It may begin and end in the balanic and phallic regii . s.
70
BENSEL: COMPOUND DEPRESSED FRACTURE OF THE SKULL. (N. Y. Med. Join.,
or in the prostatic and perineal regions, or may invade the
whole canal.
Its course may he benign or subacute for ten days or
two weeks, and suddenly it may assume the characters of
the acute or of the superacute type. As a general rule, this
sudden change is provoked by some irregularity, such as a
debauch, coition, etc., but sometimes the cause is not ap-
parent.
The discharge throughout an attack of acute urethritis
may be purulent and creamy, muco-purulent and glairy, thin
and serous, or sanious.
An acute urethritis, at the expiration of four or five
weeks, may seem to be cured, and in a week there may be
a relapse, all the phlegmasic phenomena returning. It may
then again yield to treatment, and in a week or ten days
after the cessation of the discharge a second recrudescence
may occur, and this second may be followed by a third re-
lapse. Thus, the phlegmasia may continue several months.
In a case observed long ago it lasted one year. The patient,
a medical man, from that time suffered with cystitis, of
which he was not well fifteen years afterward.
(To be continued.)
A CASE OF
COMPOUND DEPRESSED FRACTURE OF
THE SKULL,
WITH VERY EXTENSIVE LACERATION OF THE BRAIN
AND H/EMORRHAGE FROM THE SUPERIOR LONGITUDINAL SINUS.
By WALTER BENSEL, M. D.
L. L., aged thirty-eight years. Early in the evening of Sep-
tember 28th, while engaged in a bar-room brawl, patient was
struck in the forehead with a heavy beer glass. lie lost con-
sciousness for a few moments only, ami then recovered suffi-
ciently to walk, unaided, to a police station, and was thence
transferred to Bellevue Hospital in an ambulance. On admis-
sion to the hospital he seemed to be perfectly conscious but
was very nervous and irritable. His pulse was slow and fall,
pupils dilated, skin warm and dry, and respiration normal.
Bleeding From the nose was slight, but there was such an ex-
tensive subconjunctival hemorrhage on each side that the
patient could only with difficulty close the eyelids. A wound
about two inches long extended transversely across the middle
of the forehead immediately above the supraciliary ridges. At
the bottom of the wound could be made out a very extensive
depressed fracture. The patient obstinately refused hi3 con-
sent to any operation until the next evening, when the subcon-
junctival haemorrhage bad become so great that it was impossi-
ble for him to close bis eyelids over the protruding eyeballs.
This caused him such pain aud distress that he consented to an
operation in the hope of being relieved. His temperature at
this time was 101 2°, pulse was 78, but beginning to show the
■effect of the loss of blood from the epistaxis, which had con-
tinued steadily all day. As soon as possible after his consent
Jiad been obtained I operated, assisted by Dr. Gwathmey, Dr.
Berkele, and Dr. Titterington. Anaesthesia was obtained by
Chloroform. The skin in the neighborhood of the wound was
thoroughly scrubbed with soap and water and then washed
with alcohol, and finally with a solution of bichloride of mer-
cury, 1 in 2,000. The hands of the operator and assistant-
Vere cleansed in the same way. The wound was then enlarged
and a careful examination of the fracture made. The de-
pressed portion of bone, which is exceedingly well represented
in the drawing (for which I am indebted to Mr. J. A. Beimel),
Remains Of frontal suture.
Supraorbital arch.
Sketch shewing actual size and shape of the depressed portion of bone which
was removed.
was found to be almost completely detached from the surround-
ing bone and depressed for about half an inch, tearing the
meninges very extensively. The removal of the detached bone
was followed by a tremendous luemorrhage from the superior
longitudinal sinus. The haemorrhage being too considerable
to be controlled in the usual way by packing, I was obliged to
think of some other expedient, and it then occurred to me to
apply the principle of a lever. For this purpose I used the
sliding catch of a Langenbeck artery clamp, which, it will be
remembered, is a flat piece of steel about an inch and a half
long, half an inch wide, and a sixteenth of an inch thick.
One end of this catch I placed under the open end of the su-
perior longitudinal sinus, beneath the edge of the opening in
the skull ; the middle of the catch rested on the edge of the
opening, which formed the fulcrum of the lever; the other end
of the catch, which projected out of the wound, I fastened
firmly to the skin by two sutures. This controlled the haemor-
rhage perfectly. On examining the frontal lobes of the brain, I
found a laceration in the right, an inch and a half deep and half
an inch wide, and one in the left nearly half an inch deep. I
packed the wound very lightly with bichloride gauze (1 in 5,000)
and dressed it with bichloride gauze (1 in 2,000), absorbent cot-
ton, and bandages in the usual way.
At the end of forty-eight hours the dressings were removed.
The metal catch had remained in place and checked the haemor-
rhage completely. The bulging of the eyes was somewhat
lessened, and there bad been only slight epistaxis since the
operation. The catch was carefully removed, and, no haemor-
rhage following, the wound was packed lightly and dressed
as before. From that time the patient made an uninterrupted
recovery. The exophthalmos and pain in the eyes disappeared
in a few days. There was no rise of temperature which
amounted to anything during the whole convalescence.
Sloaxe Maternity Hospital.
The Maximum Dose of Aconite. — " It is reported in a recent case
of accidental poisoning in Shoreditch that a woman died in four hours
from the effects of a nine minim dose of lin. aconite. This would
efpial about five grains of the root, or about one thirtieth of a grain of
aconitine, which is said to have been the smallest quantity known to
be fatal, the maximum dose of the tincture of aconite, B. P., being fif-
teen minims. Dr. Stevenson calls attention to the fact, and recom-
mends that aconite should not be administered in full doses at less
intervals than six hours. He has found that its local and constitutional
effects do not disappear till after the lapse of from five to seven
hours." — British <in<l Colonial Druggist.
Jan. 16, 1892. J
HAG AN: A CASE OF GENERAL ATHETOSIS.
71
A CASE OF GENERAL ATHETOSIS.
By HUGH HAGAN, M. D ,
ATLANTA, OA.
Though authorities differ as to the correctness of desig-
nating athetosis a disease per se, yet we have sufficient
authority so to do until it is otherwise decided. Taking
advantage of this condition of affairs, I will, by your kind
permission, ask space in your journal for the description of
a case now under my care :
F. B. McL., aged four years, was of normal birth and
healthy extraction. Up to nine months of age a healthy and
well-formed boy. On Friday he was taken ill, and until the
following Monday had continued convulsive attacks, marked by
high temperature. The fever lasted five weeks, and during con-
valescence the mother noticed " the child moved constantly in
all his joints." Further than this she could not describe his
illness. She did not know the diagnosis, as the doctor only
stated "the baby bad fever." The child was brought to me
over two years after the first illness, and having p-issed succes-
sively through the bands of numerous physicians, the must of
whom pronounced it a chorea. I thought differently, and, after
careful study during the past year, am still of the opinion that
the condition is that of a general athetosis. After thorough
trial of the bromides, iodides, arsenic, tonics, consisting of
quinine, iron, cod-liver oil, cerebral and spinal galvanization,
muscular faradization, the status prmens is as follows: The
boy is in a state of constant motion. The movements are
marked by thai apparent volition and rhythm so different from
the jerky, spasmodic character of the choreic. The eyes,
though in a more or less constant state of movement, do not
present the rapid vibratory character of a true nystagmus, but
are more slowly and irregularly drawn up, down, in or out,
as a result of the spasms of the external ocular muscles.
The masseters and temporals close the lower jaw so as to
graphs give a very modified representation of his condition, as
the photographer experienced great difficulty in obtaining even
these. Further examination developed the following: After
many attempts to examine the eyes, I am satisfied they are nor-
mal, especially the discs; further tests than the ophthalmoscope
failed to give any evidence of faulty vision. The other special
senses are normal.
lacerate the tongue, which member is alternately protruded and
retracted by the genio-hyo-glossi, linguales, and palato-glossi.
The lower jaw is depressed by the platysma, the head drawn
back by the trapezii, and these, acting with the muscles of the
back, produce at times a marked opisthotonos. The deltoids
will bring the arms at right angles to the trunk. The triceps,
biceps of both arms, the flexors, extensors, pronators, and su-
pinators of the forearms, and the interossei and lumbricales
of both hands, with their hotnologues in the thighs, legs, and
feet, are at limes in a state of extreme or partial contraction.
The laryngeal muscles are also affected, as the child has fre-
quent " fits of holding his breath." The accompanying photo-
The reflexes, both superficial and deep, though not as de-
cided as in health, are quite marked, considering the marked
muscular atrophy, or rather emaciation, which is due in a
great measure to a lack of proper nutrition, as great difficulty is
experienced in feeding him, his food being entirely fluid.
The electrical reactions are normal, the muscles responding
to both the constant and faradaic currents. The lungs, heart,
and abdominal viscera are normal and per-
form their functions. He had a phimosis,
which was remedied by circumcision. So
great is the muscular inco- ordination that
he can not sit or stand unassisted. He is
totally ataxic aphasic, but, so far as Ids
education will permit, I think not amnesic.
Though not so accomplished as healthy
children of his age, he is very intelligent.,
His cranium is of the bracbycephalic type,
with very prominent parietal bosses. The
scalp is very tight, covered with a very
scanty growth of hair, and the veins very
prominent. The athetoid movements cease
entirely during sleep, which is generally
profound. When at rest the parts assume
their normal physiological positions, no
evidences of contraction or contracture
being present.
Now, as to the cause of this con-
dition I am at sea. Cerebral ha'inor-
rhage, embolism, abscess, or thrombosis,
1 think, we can exclude ; but whether the boy's sickness was
the prime or only the exciting cause I do not know. 1 am
inclined to think, in spite of the pathological conditions
generally enumerated — such as abscess or tubercle in the
optic thalamus, the corpus striatum, the internal capsule,
the cortex, or cerebral sclerosis or infantile cerebral hemi
72
BATES: A CASE OF TRAUMATIC DEAFNESS.
[NT. Y. Med. Jouk,
plegia — that the condition present is due either to a cere-
bellar tumor, in spite of the normal discs, or to meningeal
adhesions over the motor cortical region, as I see no reason
why these conditions could not produce the symptoms as
well as those generally found. If the opportunity offers it-
self for a post-mortem I shall report the results.
211 Peachtkee Street.
A CASE OF TRAUMATIC DEAFNESS.
RECOVERY.
By AV. H. BATES, M. D.
The chief interest of this case was in the recovery from
symptoms of nerve deafness.
The patienr, aged thirty-two, was the engineer of a construc-
tion train carrying a large quantity of dynamite. While travel-
ing at a speed of about eight miles an hour the dynamite ex-
ploded. The effect of the explosion was tremendous. Besides
wrecking the train, destroying the roadbed of the railroad, and
killing many of the employees, bouses two miles away had their
windows broken, chimneys knocked down, etc. The accident
occurred April 19, 1891. The patient was unconscious for a
short time. He was able to arouse himself, however, and walk
several miles to have his wounds dressed.
Sudden deafness with a bloody discbarge from both ears oc-
curred at the time of the accident. He also bad a beating noise
in both ears, lie had a serous discbarge from both ears the next
day which continued and became slightly purulent. The quan-
tity of discharge was never sufficient to run from the ears in a
stream. He also had at times shooting pains through the bead
which were worse about five days after the accident. There
was a scalp wound over the right ear four inches long.
May 28. 1891, began treatment. During the five weeks since
the accident nothing had been done for his ears. The deafness
had remained the same and the discharge had not decreased.
The noise had increased somewhat. Both drum membranes
were perforated, and the size of the perforations was about one
half of the normal drum membrane. Both perforations were
situated in the posterior inferior portion of the drum membrane;
the lower end of the malleus handle was uncovered in each ear.
The external auditory canals, which were large, were much ex-
coriated. The discharge had a slight offensive odor. The hear-
ing distance for the watch with the right ear was about one inch ;
for the left ear a little less. The tuning fork was beard better
through the air than through the bone, and both aerial and bone
conduction were better with the right ear than with the left ear.
Aerial and bone conduction were diminished in both ears. Or-
dinary conversation was heard at about three feet.
After cleansing the middle ear, the deafness and tinnitus were
not improved. Inflation improved the bearing for the watch
about half an inch in both ears for a short time only; after a
few minutes the hearing was the same as before inflation. The
tests of the hearing with the tuning fork, together with the his-
tory of sudden deafness, seemed to indicate disease of the inter-
nal ear.
Treatment was first directed to healing the perforation of
the drum membrane ; later, such measures were employed as
seemed to improve the hearing.
The patient was treated daily for about six weeks and then
less frequently, He seemed still suffering from the effects of
shock, although more than a month bad passed after the acci-
dent. He was listless, easily tired, appetite poor, very drowsy
all the time, with a dull feeling in his head. The drum mem-
branes showed no disposition to heal or the discharge from the
ears to cease. His general condition resembled in some respects
the constitutional weakness of diphtheria.
He began taking ten drops of tincture of iron in a goblet of
water every half-hour through the day. The dose was increased
rapidly and in a few days he was taking a teaspoonful of the
strong tincture of iron every half-hour. The iron was well borne
by the stomach. His appetite increased and became better than
it had been before for years. Bis head became clearer and his
general condition much improved. The drum membranes healed
rapidly and the discharge from the ears stopped. These large
doses of iron were taken for about a week.
With the improvement in his general condition the iron
began to disagree, constipation being the first symptom. At
the end of two weeks he could only take ten drops of iron
three times daily. The patient also took laxatives when re-
quired. Laxatives seemed to lessen the tinnitus.
The local treatment of the drum membranes consisted in
gentle syringing with hot water, and the instillation of peroxide
of hydrogen into the external and middle ear.
Vaseline applied to the drum membranes seemed to act
beneficially in the healing of the perforations and in stopping
the discharge.
There was but little or no immediate improvement in the
hearing or tinnitus from the use of local remedies in the middle
ear; and after the discharge had stopped and the openings in
the drum membranes had healed, the hearing was no better.
The drum membranes were healed at the end of three weeks'
treatment. Cotton worn in the external ears gave the patient
great comfort in the presence of loud noises.
June 9, 1891. — The tuning fork was heard better through
the bone than through the air. Both bone conduction and aerial
conduction had increased, but the gain in bone conduction was
much more than the gain in aerial conduction.
The hearing for the watch and conversation bad not im-
proved. Inflation produced more improvement in the hearing
than at the beginning of treatment. Improvement temporary.
Drum membranes still perforated. Discharge less. Tinnitus
less.
The Eustachian tubes were open. Nares clear; some con-
gestion. No discharge of mucus from the nose or throat.
Although there was very slight congestion of the naso-
pharynx, yet treatment to relieve this slight congestion pro-
duced very great improvement in the hearing and tinnitus. Co-
caine in the nose lessened the noise and improved the hearing
temporarily. The cocaine opened the nose more, and the drum
membrane on the same side became at once less congested-
This action of the cocaine was observed throughout the whole
course of the treatment.
Nitrate of silver applied to the vault of the pharynx im-
proved the hearing.
Politzeration during the early period of treatment, when
there were symptoms of nerve deafness, produced very slight
improvement in the hearing for a few minutes only. At times
inflation had no effect.
Later, when the tuning fork was heard better by bone con-
duction than through the air, inflation produced more decided
improvement in the hearing, and this improvement was more
permanent. Occasionally inflation lowered the hearing tempo-
rarily, or produced no effect in one or both ears.
With increased aerial and bone conduction for the tuning
fork, inflation produced the most marked and constant improve-
ment. The hearing was improved more by inflation than by
anything else.
June 20th. — The tuning fork was heard better through the
air than through the bone. The watch was heard four inches
Jan. 16, 1892.]
LEADING
ARTICLES.
73
with cither ear inflation improved the hearing distance to
twelve inches.
Several days ago the openings in the drum membranes had
closed, the discharge had stopped, and the tinnitus had ceased.
Politzeration and treatment of the vault of the pharynx
were oont.inued until the hearing became normal.
August 15th. — Hearing normal for tuning fork, watch, and
conversation.
December Int. — Patient still has normal hearing.
Summary.
May 28th. — Symptoms of nerve deafness.
June 9th. — Symptoms of middle-ear deafness.
20th. — Symptoms during recovery from middle-ear deafness.
131 West Fifty-sixth Street.
An Opportunity for a Medical Missionary. — Two ladies, Mary and
Margaret W. Leitch, who for seven years have been missionaries in
Ceylon, have issued the following circular :
We are very desirous of finding a fully qualified physician to go as
a medical missionary to Ceylon under the American Board. We would
be truly grateful to you if you could direct us to any one who you
think would be a suitable candidate. He should have had a good gen-
eral and thorough medical education with some hospital or private
practice. He should be a man of earnest piety who would consecrate
his talents to the service of Christ. He should possess sound health
and some executive ability, as the work which he will be called to do
among 316,000 people in the northern province will be a large and im-
portant one. He should be a married man. We are hoping to find
one who, with his wife, would be able to go to Ceylon at least by the
end of this year. He would be expected to take up and extend the
work of the late Samuel F. Green, M. D. — a missionary of the Ameri-
can Board for twenty-two years in Ceylon — who during the last years
of his stay in that island treated, with the aid of his native assistants,
as many as 10,000 patients a year. The salary of the doctor and his
wife ($1,200 a year, the salary usually paid to missionaries in Ceylon),
also the amount required for outfit and passage, have been secured.
In Ceylon there is a large, comfortable mission house ready for their
use, also a dispensary, and a building for medical students ; and the
funds are now being pledged for the erection of a large hospital, the
American Board having authorized us to secure $10,000 for that object.
There will be an income in the country from fees of paying patients
and Government grant which will amount to over $1,000 a year, which
may be used in the conduct of the work. The endowment of ten beds
in the hospital and of ten scholarships has been given or promised, also
the sum of $90,000 is promised, in legacies legally executed, toward a
general endowment. There are at present eight missionary families
in the province working in connection with the American and two
English missions. There are about 3,000 native communicants in the
churches of these missions and about 15,000 children in their mission
schools. There are several higher educational institutions, girls' board-
ing schools, an industrial school, and a flourishing college. Tamil is
the vernacular of the people, but the English language is becoming
widely known. Th_> field is an exceptionally attractive one, and the
outlook hopeful, as the work has been successful among the higher
castes, and it is believed these high-caste converts will take a share in
the work of winning India to Christ. The ladies' address is No. 17
Lafayette Place, New York.
Bequests to Hospitals.— By the will of the late Mrs. Robert L.
Stuart, of New York, the New York Cancer Hospital will receive
$25,00(1; the Hahnemann Hospital, $10,000; the New York Ophthal-
mic Hospital, the Western Dispensary, the Dispensary of the Homce-
opathic Medical College, the Northern Dispensary, and the Northwestern
Dispensary, $5,00(1 each; and the Presbyterian Hospital, the New
York Eye and Ear Infirmary, the Manhattan Eve and Ear Hospital, the
Hospital for the Ruptured and Crippled, and the Woman's Hospital,
each a large share from her estate.
THE
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by Edited by
D Appleton & Co. Frank P. Foster, M. D.
NEW YORK, SATURDAY, JANUARY 16, 1892.
ALBUMINURIA AND LIFE INSURANCE.
At a recent meeting of the Hunterian Society of London
there was a discussion of the relations of albuminuria to life
insurance. The Medical Press and Circular for December 9th
contains an abstract of the debate. Dr. Kingston Fox opened
the proceedings with a paper, which was commented upon by
Dr. Pavy, Sir William Roberts, Mr. Clement Lucas, and others.
Dr. Fox based his paper on his notes of the uranalysis in the
cases of 282 applicants for life policies — all of whom were males
except two. Albumin was found in thirty per cent, of the cases.
This percentage depended on the fineness of the tests em-
ployed ; coagulation by boiling was chiefly relied upon. The
albuminuria of organic renal mischief was found in only eight
cases out of the 86 of albuminous urine. Of another type,
called " permanent albuminorrhcea," there were two cases ; in
one of these albumin was known to have been present at least
two years, with apparently no disturbance of the health, while
in a second case it was said that albumin had been observed
from time to time during a period of seventeen years. The risk
in such cases may be accepted under specially arranged terms,
if the age is under forty, provided the diagnosis is clearly made
out. Under the head of albuminuria from "loaded urine" the
proportion of cases was very high, numbering 22 in 86. This
might be called an albuminuria of " city life," or " civic albu-
minuria." Oxalate of calcium and uric acid are not infrequent
in these cases, and glycosuria is more rarely an attendant
symptom. This disorder is, as a rule, amenable to treatment,
and if it passes away the applicant should not be rejected. Of
cardiac albuminuria the ratio was as high as 20 in 86. The risk
in these cases is to be judged apart from the uranalysis. Dr.
Fox includes under this heading, to which he gives the name of
"albuminuria of unstable circulation," both the functional and
"cyclic" forms of this affection.
Dr. Pavy, who has been officially employed with insurance
questions for many years, stated that he was a firm believer in
the existence of a functional albuminuria which did not lead Dtp
to structural disease. Many cases of cyclic albuminuria were
dependent upon the position of the body, and were not im-
properly styled "postural," the early morning excretion being
usually free from albumin, which appeared in the middle of the
day and was gone again at bed-time. An alteration in the mode
of life will affect the amount of excreted albumin. Dr. Pavy is
in the habit of requiring four specimens of urine — one passed at
the rising hour, one at noon, one at 6 p.m., and the fourth at
bed-time. If the patients are in bed during the day, the charac-
ter of the urine is changed. As has been shown by Dr. Iling-
ston Fox, these persons are known by their mobile disposition.
74
MINOR PA RA OR A PUS.
[N. Y. Med. Joun.,
quick pulse, and irritable heart, with a sharp, ''smacking" im-
pulse. The albuminuric condition may continue long and then
gradually wear away. It is had practice to keep such patients
in bed. These applicants are not to be accepted or rejected on
the results of a first examination; they require investigation.
Dr. Pavy instanced the case of a young collegian who studied
his own condition to some profit. When a youth, aged eight-
een, he was a good athlete and passed a civil-service examina-
tion, but subsequently, albumin having been found in his urine,
it caused his rejection. The case was cyclic and he was after-
ward passed. He then went to Oxford, and from there went up
for a final physical examination before going out to India.
During this time he had read up the literature of these cyclic
cases, and when the examination approached he remained in
bed until just before the time, with the result that he was ac-
cepted, as there was then a temporary cessation of the albu-
minuria. Regarding the albuminuria that is associated with
glycosuria, Dr. Pavy stated that the prognosis was usually
favorable if the glycosuria was amenable to treatment; it did
not lead on to Bright's disease, as had been taught by some of
our recognized authorities.
Sir William Roberts defended the use of the term " physio-
logical albuminuria.'1 The time had gone by when the pres-
ence of albumin in the urine could be regarded as equivalent to
a death-warrant. This condition might follow shock or strain,
the passage of gravel, or the ingestion of a heavy meal. A child
might run a race and come hack Hushed and with a thumping
heart — symptoms that came within a physiological range; so,
too, sharp exercise would cause a temporary albuminuria, which
was not, in his opinion, outside of the physiological range. The
same was true after the application of cold baths. In regard to
the risks of these physiological groups of cases, and others that
were only occasional and transient, there was no longer any oc-
casion to pronounce a sinister prognosis, but the diagnosis must
be definitely made out for the protection of the assurance com-
panies. If the applicant was in early life, the prognosis was, of
course, more favorable than in persons who had passed their
fourth decade.
Mr. Clement Lucas referred to cases where there seemed to
be a family predisposition to show albumin in the urine on
slight provocation. These belonged to a non-hazardous class
of insurers if properly treated. He had found albuminuria in
men who, being about to be married, had applied for insurance,
and the excitement incidental to these undertakings appeared
to have the power to cause the disorder : in one such case, that
of a man of thirty-four years, this symptom had caused the
company to reject the application ; after his marriage his urine
was found to be entirely free from albumin, and he was to all
appearances an eligible risk. Another instance of protracted
ineligibility from this same cause is related by Dr. Sewill in the
above-named journal. The patient is living to-day in his sev-
enty-seventh year, although twenty-six years ago he had been
shown to be markedly albuminuric by the late Dr. Sibson, of
St. Mary's Hospital. The albumin was present in large quan-
tity, and the causation of the attack was thought to be an un-
due indulgence in sea-bathing in chilly weather. The case was
regarded as serious, and a careful regimen was prescribed. The
patient, however, was scornful of medical opinion and did not,
follow directions implicitly. He had a good family history, and
had always been healthy, fleshy, indolent, and a large flesh-eater,
besides taking alcohol in moderate amount. In the course of
four or five temporary illnesses in twenty years, albuminuria
had been several times found, but the general health had not
been seriously threatened until three years before, when an ascites
and an abdominal abscess made their appearance. It was thought
impossible that the man could recover, but he did. He is now
hearty and scoffs at regimen and the wisdom of the faculty.
Nearly all the physicians who at various times gave an unfavor-
able prognosis regarding the state of his kidneys are already
under the sod. Assuming for the moment that this man was
a rejected applicant for insurance, we can readily understand
that an injury was done both to him and to the insuring cor-
poration in consequence of the true value of his urinary symp-
toms having been misrated.
In conclusion, we can not do better than quote the follow-
ing editorial opinion from the November issue of the Canada
Lancet: "In placing an albuminuria in its proper place as re-
gards etiology, and in coming to a conclusion as to its probable
effect upon the patient's future, the physician must take a wide
survey of all the attending circumstances, and keep the patient
for some time under close observation lest a serious error
be made as to prognosis and treatment. There can be no
doubt that hundreds of quite healthy persons are annually re-
jected by insurance companies because of transient and func-
tional albuminuria, thereby entailing much worry and loss, not
only upon the unsuccessful applicants, hut also upon their fami-
lies and friends." A greater amount of labor, care, and respon-
sibility must be entailed upon the medical examiners in order
to arrive at the true significance of urinary signs; hut the same
is true of every department of medicine that is not standing
still.
MINOR PA RA GRA PUS.
TETANUS CURED WITH THE TETANUS ANTITOXINE.
In the Centralhlatt far Bakteriologie und Paras itenkunde
for December 22d, Dr. Rudolf Schwarz, assistant at the surgi-
cal clinic at Padua, gives the history of a case of traumatic
tetanus, in a boy fifteen years old, cured by injections of the an-
titomna del telano prepared by Tizzoni and Cattani from the
blood serum of animals rendered proof against tetanus. He re-
fers to another case treated by Gagliardi and, in a postscript, to
two others treated by Pacini and Nicoladoni respectively.
Tizzoni and Cattani's process is not given by Dr. Schwarz, but
it is probably to be found described in their contributions to the
Riforrna mediea during the year 1891.
THE PHILADELPHIA BOARD OF HEALTH AND LEPROSY.
Tins body, in conformity with the alarmist position it has
maintained for some years past on the subject of leprosy, has
adopted resolutions calling on Congress to establish stations for
the treatment of persons afflicted with that disease. We do not
Jan. 16, 1892. J
MINOR PARAGRAPHS.— ITEMS.
75
believe that Louisiana, that probably has more of such cases
than any other State, will co-operate with this demand or per-
ceive its necessity. Moreover, the number of cases ot' that dis-
ease in the United States does not justify such action by the
General Government. Furthermore, it might be asked under
what provision of our Constitution such patients could be con-
fined in national lazarettos.
DISSECTING ROOMS FOR "THE OUTSIDE MAN."
Our vigorous young contemporary, the New York Journal
of Gynecology and Obstetrics, calls for the renewal of an enter-
prise once successfully undertaken by the Brooklyn Surgical
Society, that of establishing and maintaining rooms where ana-
tomical study may be prosecuted without the necessity of one's
enrolling himself as a pupil in any school. The opportunities
at the schools and hospitals, says the Journal, are excellent,
but confined to a favored few. "Give the outside man a
chance," it adds. The idea is certainly praiseworthy, and we
hope it may be lealized.
THE ANNALS OF OPHTHALMOLOGY AND OTOLOGY.
Tins is the title of a new quarterly journal devoted to the
subjects mentioned in its title, and furthermore, as the supple-
mentary title informs us, to laryngology and rhinology. The
Annals is edited by Dr. James P. Parker, and published in
Kansas City. The first number, dated January, 1892, contains
seventy four octavo pages, devoted mostly to original com-
munications. In its general appearance the Annals bears a
striking resemblance to the American Journal of the Medical
Sciences. We wish it as long and creditable a career as that
journal has had.
PENTAL, A NEW ANAESTHETIC.
Pentai., C6I1 io, is a clear, colorless, thin neutral fluid with a
peculiar sweetish odor and taste. Mering. according to the Cen-
tralblattjur die gasammte Thempie, finds that it has a distinct
anaesthetic action without unpleasant after-effects. It has no
appreciable influence on the pulse or respiration. It is easy of
administration, patients coming under its influence in about four
minutes without any of the unpleasant sensations produced by
either chloroform or ether. For operations taking only a few
minutes to perform, the author thinks that this new ansestbetic
will till all requirements.
IODOPYRINE.
The British Medical Journal for January 2d, referring to an
article by Dr. E Munzer, published in the Prager medicinische
Woehenschrift, describes iodopyrine as a one-atom iodine sub-
stitution compound of antipyrine, occurring in colorless, taste-
less, and odorless crystals, slightly soluble in cold water, but
readily soluble in hot water. Its action is said to have been
studied especially in typhoid fever and in pulmonary tubercu-
losis, in which it lias shown itself an antipyretic of rapid action.
In pulmonary tuberculosis it is reported as having caused pro-
fuse sweating.
THE ACTION OF CHLOROFORM ON BACTERIA.
Tim Gentralblatt fv/r die gesammte Therapie for December,
1891, contains an interesting article by von Kirchner on this
subject, lie has found that chloroform renders the spores of
the anthrax, cholera, and typhus bacilli incapable of germinat-
ing and that pus germs are rapidly destroyed by this agent, lie
thinks that this fact can be put to practical use in the treatment
of these diseases, considering the diff usibility of the substance and
its appearance in the stools and urine after its administration.
HYOSCYAMINE IN LETTUCE.
According to the Lancet, Mr. T. S. Dymond recently read a
paper before the Chemical Society in which he stated that he
had found in the presence of hyoscyamine an explanation of the
mydriatic action of extract of lettuce. The alkaloid was found
in several varieties of the plant, in amounts varying from 0*001
to 0 02 per cent.
THE DOCTORS' WEEKLY.
The first number of a new journal with this title was pub-
lished on the 2d inst. Each number consists of eight large, four-
column pages, containing reading matter and advertisements in-
termingled. Much of the former is chatty in character. Dr.
Ferdinand King, of New York, is both the editor and the pub-
lisher.
THE MEDICAL FORTNIGHTLY.
Tins is a new journal published in St. Louis and edited by
Dr. Bransford Lewis. The first number, dated January 1, 1892,
contains forty- four large pages of reading matter. A novel
feature is that a fac-simile of the author's signature is appended
to each original communication.
THE BACILLUS OF INFLUENZA.
It is stated in the cable reports from Germany that Dr.
Pfeiffer has discovered the bacillus of influenza, and has verified
his discovery by inoculation experiments in six cases. It has
been found both in the sputum and in the blood.
ITEM?, ETC.
The late Surgeon W. H. Long. — Surgeon W. H. Long, cf the
United States Marine-Hospital Service, died recently at Cincinnati. He
was born in Kentucky in 1842, was educated in Louisville, and prac-
ticed his profession in that city until he was appointed an assistant sur-
geon in the Marine-Hospital Service in 1875 ; lie was promoted to the
rank of surgeon in 1878. During his service he was stationed at Louis-
ville, Detroit, Chicago, and Cincinnati. At several of these stations he
was connected with the local medical colleges, and was esteemed an able
teacher of surgery. Several times he was a member of the examining
board for the admission of candidates to the service. In many of the
annual reports of the bureau he published professional papers. He
was actively interested in the work of his profession, and was always a
member of the medical societies of the State and city in which lie was
stationed, and several times was elected president of these bodies. His
death will be regretted both by the officers of his corps and by his
many friends in the profession throughout the country.
The New York Ophthalmologic^ Society. — At the annual meeting
held on Monday, January 11th, the following officers were elected;
President, Dr. J. B. Emerson; vice-president, Dr. Gotham Bacon;
secretary and treasurer, Dr. Frank N. Lewis ; committee on admissions
Dr. H. D. Noyes, Dr. A. Mathewson, and Dr. C. E. Hackley.
The Death of Dr. Horatio S. Hendee, of Lowville, X. Y., occurred
on Tuesday, the 5th inst. He was graduated from the Castlcton, Yt.,
Medical College in 1851, and served as surgeon of volunteers during
two years of the civil war.
The Death of Dr. Colin Mackenzie, of New Yoil<, took place on
Wednesday, the 6th inst. He was graduated from the Western Re-
76
ITEMS. — LETTERS TO THE EDITOR.
[N. Y. Med. Jour.,
serve University, Medical Department, in 1800, and was in his fifty-
third year.
The Death of Dr. Joseph Hilton, of New York, took place on
Thursday, the 7th inst. He was a licentiate of the Medical Society of
the County of New York.
Society Meetings for the Coming Week :
Monday, January 18th : New York County Medical Association; New
York Academy of Medicine (Section in Ophthalmology and Otology);
Hartford, Conn., Medical Society; Chicago Medical Society.
Tuesday, January 19th : New York Academy of Medicine (Section in
General Medicine); New York Obstetrical Society (private) ; Medi-
cal Societies of the Counties of Franklin (annual), Kings (annual),
Otsego (semi-annual — Cooperstown), and Westchester, N. Y. ; Og-
densburgh, N. Y., Medical Association ; Connecticut River Valley
Medical Association (Bellows Falls, Vt.) ; Baltimore Academy of
Medicine.
Wednesday, January 20th: Northwestern Medical and Surgical Soci-
ety of New York (private) ; New York Academy of Medicine (Sec-
tion in Public Health and Hygiene); Medico-legal Society; Harlem
Medical Association of the City of New York ; New Jersey Acade-
my of Medicine (Newark) ; Philadelphia County Medical Society.
Thursday, January 21xt : New York Academy of Medicine ; Brooklyn
Surgical Society ; New Bedford, Mass., Society for Medical Improve-
ment (private).
Friday, January 22d : Yorkville Medical Association (private) ; New
York Society of German Physicians ; New York Clinical Society
(private); Philadelphia Clinical Society; Philadelphia Laryugologi-
cal Society.
Saturday, January 23d : New York Medical and Surgical Society (pri-
vate).
Answers to Correspondents :
No. 369. — The practice is contrary to the letter of the code of
ethics, but it is tolerated in some parts of the country. We should
advise you not to adopt it.
fetters to the drbitor.
QUANTITATIVE TESTS FOR UREA.
Brooklyn, January 2, 189%.
To the Editor of the New York Medical Journal :
Sir: In the Journal for November 21st, page 571, Dr. J. 0.
Bierwirth makes some remarks upon a method of estimating
urea in urine devised by myself, which I desire space in your
columns to correct. He states in one place that the results by
this method are too high, and in another lie states that he ob-
tained with the solution I employ only L65 percent, of the true
amount of urea.
I was surprised to see these remarks in print, as I had
pointed out to him the errors in manipulation at the time his
paper was read. He did not work according to the directions,
because he compressed the air in the tube by forcing into the
open end of the tube a tightly fitting cork, and read the height
of the column of liquid under this pressure. The second read-
ing he made at the atmospheric pressure. Any one who knows
anything of the properties of gases can see that this method can
not give the amount of nitrogen evolved during the effervescence.
The results will vary with the pressure used in forcing in the
cork. In a demonstration of the method of using the apparatus
before the meeting, Dr. Bierwirth himself obtained the theoreti-
cal amount of nitrogen from a standard solution of urea, after
making allowance for the compression by the cork. His second
error of manipulation was in not thoroughly mixing the urine
and the reagent. His tests made at the Iloagland Laboratory
with the solution I have proposed, were made with the appara-
tus of Dr. Doremus, which does not allow of thorough mixing
of the urine With the reagent, and consequently the long time
required and the incomplete reaction. In regard to the objec-
tion to the use of the thumb to close the open end of the are-
ometer. I have only this to say: I have used the apparatus for
about two years and have taught students the use of it, and
have not found any such difficulty as he mentions. After re-
peated trials by myself, my assistants, students, and others, in-
chiding Professor Van Cott, whom Dr. Bierwirth mentions, I
must affirm that this apparatus and solution, when used with
reasonable regard for directions, do give as accurate results as
any method mentioned in the article in question. It is more
rapid, simpler, and more agreeable to operate than any other
method with which I am acquainted. It is inexcusable for the
author to have published his blunders after having them pointed
out to him. E. II. Hartley, M. D.
Brooklyn, January 8, 1892.
To the Editor of the A'ew York Medical Journal:
Sir: It is with surprise that I read a statement published
November 1, 1891, in your journal, in Dr. Bierwirth's paper on
Quantitative Tests tor Urea, regarding the use of a solution of
potassium bromide in chlorinated soda. The doctor states that
with this solution he only gets from a two-per-cent. solution of
urea T65 per cent. ; that " this has been verified by Dr. J. M.
Van Cott, Jr., at the Iloagland Laboratory."
I was present at the meeting of the Kings County Medical
Association when the doctor read his paper. In the discussion
which followed his reading I admitted that this was so, but
pointed out the fact that our failure to obtain the theoretical
amount of urea was due to failure to thoroughly mix the
solutions.
Furthermore, I saw the doctor at this meeting repeat the
test with this solution, and obtain the exact theoretical amount
of urea after thorough mixing of the liquids. This was accom-
plished in Dr. Bartley's tube. At the time I suggested that simi-
lar results might be obtained with the Doremus bulb if the
liquids could be thoroughly mixed : and since then I have veri-
fied this supposition by actual experiment.
In view of these facts, the doctor had no authority to use
my name as he has in the publication of his paper, and I shall be
greatly obliged to you for correcting the matter in your journal.
Joshua M. Van Cott, Jr.
SHALL SUCCESS IN THERAPEUTICS BE IMPERILED BY
ETHICAL CONSIDERATIONS?
Washington, D. C, January 13, 1892.
To the Editor of the New York Medical Journal:
Sir : I have read and weighed the contents of the letter in
your issue of December 19, 1891, on this subject: Shall Suc-
cess in Therapeutics be imperiled by Ethical Considerations?
That certain points in this letter have made a profound im-
pression upon me is the main reason why I now address you,
and respectfully ask that my letter be published in the columns
of the Journal in vindication of the honorable standing to which
all good and true practitioners of medicine aspire.
Dr. Dodge states very clearly a point that is now appealing
to every progressive physician — that in these clays of advance-
ment in the manufacture of pharmaceutical products we should
no longer be confined, as were our forefathers, to prescribing
drugs in their crude form, since there are to-day thoroughly at-
Jan. 16, 18«2.]
PROCEEDINGS
OF SOCIETIES.
77
tested remedies in palatable form which our patients can take
without repugnance and with benefit.
Now, while the code of ethics is an admirable exponent of
the tenets which are acceptable to the great body of practition-
ers in our country, yet it is at least a question open to discis-
sion whether there are not some points which in our progressive
age might be reconsidered and revised. And I would suggest
as one subject tor discussion the question of the approbation and
recommendation of certain proprietary articles which are in
almost daily use by very many ot our ablest practitioners.
Why should those preparations bo condemned simply be.
eause their manufacturers are protected under a registered trade-
mark ? Is it not perfectly legitimate for our medical societies to
elect competent committees to be judges of the therapeutical
value of tried proprietary preparations ? And could not their
recommendation also be secured by their indorsement —
I. In didactic and clinical lectures and private instruct ion
given to medical students ;
■2. In original articles acceptable to the editors of recognized
medical journals ; and
3. In standard medical works?
1 address you particularly on this subject for the reason that
the l eaders of your journal have carefully observed the fearless
manner in which you and your able associates have defended ihe
worthy against the unworthy and given justice where justice
was due. We have also seen that your journal has reviewed
and commended works by others than medical writers. I have
in mind the fact that the very excellent work on the therapeu-
tical application of coca erythroxylon by Angelo Mariani, of Paris,
France, the proprietor of the world-renowned Vin Mariani, was
favorably reviewed in your journal.
William H. Hawkes, M. D.
|)roteebings of Societies.
NEW YORK ACADEMY OF MEDICINE.
Meeting of December 3, 1891.
The President, Dr. Alfred L. Loomis, in the Chair.
Drainage of the Uterus in Chronic Endometritis and
Metritis, with and without Salpingitis.— Dr. W. M. Polk
read a paper with this title. As drainage of the uterus was a
surgical procedure that at present was pretty well recognized,
the author confined himself to a description of his cases and the
details of his method of applying the principle. The operation
of vaginal hysterectomy — which, if called for, could be done
with impunity — had been the means of inciting him to attempt
invasion of the interior of the uterus in the treatment of dis-
eases of that organ. The only class of cases to which the
method of drainage was applied were those of chronic condi-
tions, such as fungous or hemorrhagic endometritis and metri-
tis due to subinvolution. The most obstinate cases were those
of endometritis due to flexions. Those cases which yielded
most readily to the treatment were metritis consequent upon
subinvolution. From his experience he was obliged to differ
with previous observers, whose statements were to the effect
that salpingitis and eircumuterine inflammations precluded
intra-uterine treatment. He advised the early treatment of
endometritis and metritis by drainage, to prevent the extension
of the disease to the tubes. As to the remote and permanent
results of the operation, seven months to a year had elapsed
since treatment in a large number of cases, and there had been
no return of the trouble. Immediately after the operation
there was usually a slight rise of temperature, but it gradually
returned to normal, the patient, with this exception, suffer-
ing no inconvenience. In some cases where perimetric masses
had existed prior to the operation these were in two or three
weeks after treatment found to have become softened and in
some instances abolished. In no case was inflammation set up
by the manipulation or by the presence of the packing. The
author reported in detail the histories of a number of cases to
illustrate the success of his method. In four of these, laparot-
omy had been the primary operation, and, the appendages not
requiring removal and endometritis being found present, the
aut hor had not hesitated to pack .the uterus with gauze at the
same sitting. The requirements for the method were as fol-
lows: 1. Antiseptics, bichloride solutions (1 to 500 and 1 to
2,000). 2. Strips of sterilized gauze about a quarter of an inch
in width and three feet long, from six to eight thicknesses to be
used at a time. 3. A large cervical speculum with a plug. 4.
Forceps, a volsella, and dressing forceps. 5. A Sims specu-
lum. 6. A good dilator. 7. A sharp curette. 8. A long-handled
screw. 9 A fountain syringe and a glass tube. He preferred, as
a rule, general anaesthesia, as the operation was more or less
painful, although in twenty- five per cent, of cases the os was
sufficiently patent to allow of local anaesthesia being used if
desired. The next step was to cleanse the parts with soap and
water, and finally with the bichloride. After dilating the
uterus it was irrigated and the sharp curette thoroughly used.
As to the amount of tissue to be removed, one must be gov-
erned by the individual conditions of the case. Following the
curetting, irrigation was again performed. The gauze was
placed in the l-to-500 bichloride solution, and taken out and
rinsed in hot water, the excess of which was squeezed out and
the gauze then packed in the uterus by means of the long-handled
screw. The patient was then put to bed, to remain there for about
a week. At the end of that time the packing was to be removed,
if it had not been forced out in the mean time by the contractions
of the uterus. The uterus was then irrigated and the patient
allowed to go about her usual vocations. As a rule, but one
application of the packing was necessary to cure the most ob-
stinate case of chronic endometritis or metritis.
Dr. W. T. Lusk had had no personal experience in the meth-
od described by Dr. Polk, but he had been an ardent advocate
of the principle of drainage, and intended henceforth to try and
carry out some such plan as that brought forward by the author
of the paper.
Dr. C. C. Lee had never carried out the plan of Dr. Polk,
but had used a method of his own for drainage of the uterus
after removal of fibromata and retained placenta). This had
consisted of the retention in the uterine canal of a tube which
allowed of free drainage. This tube was frequently left m situ
for ten days and more, and, while giving free exit to discharges,
often corrected flexions and cured dysmenorrhcea. Another
point was that the speaker never used bichloride solution in the
uterus; he preferred hot water for irrigation. He had used his
plan in forty-two cases with very satisfactory results.
Dr.' W. G. Wylie said thai Mr. Poll? must be laboring under
a mistake when he referred to drainage of the uterus as a prin-
ciple only recently recognized. While it might be true that
drainage by means of gauze was something new, drainage as a
principle had been written about and understood as practicable
almost twenty years ago, and for the past eight years had been
taught at the New York Polyclinic, and was being carried out
by many of the younger gynaecologists. As to the value of Dr.
Polk's particular method, the speaker thought that the use of so
large a cervical speculum was impracticable in the majority of
cases; that, as a rule, in cases of dysmenorrhcea there was iraper-
78
PROCEEDINGS OF SOCIETIES.
[N. Y. Med. Jock.,
feet development ; and dilatation to the extent that would allow
of the speculum heing admitted and the uterus packed would
split that organ. The speaker had found that dilatation of the
uterus for half an inch frequently caused rupture. For the pur-
pose ot drainage it « us Ids practice to use a hard rubber bulbous
tube with the opening one third of its caliber ; this u as retained
securely in the uterus and allowed of free drainage. Where
there was pus or inflammation in or around the tubes he con-
sidered almost any manipulation within the uterus dangerous.
As to curetting, this he would never do in the case of large soft
uteri from subinvolution, as perforation of the walls was liable
to occur, until he had reduced the uterus with boro-glyeeride
tampons. In some cases of hardened uteri, with fibrous condi-
tions, it was a difficult matter to say what was the best method
of treatment, as he had found, no matter what plan he had pur-
sued, the condition would return sooner or later. As to drain-
age, he had long been an advocate of the principle.
Dr. G. M. Edebohls thought that as a principle all recog-
nized the necessity of drainage in uterine diseases, lie was
convinced that as yet nothing so practical as Dr. Polk's method
had been suggested, and he, for one, would give it a fair trial,
although he would confine his cases for such operat'on to those
where disease of the tubes could be excluded. Where the dis-
ease w as restricted to tbe endometrium, curetting and drainage
were called for. lie reported the cure of three cases of pyo-
salpinx, occurring in young girls, with repeated attacks of pelvic
peritonitis, by the introduction and retention for three months
of the Outerbridge speculum.
Dr. F. Krug had often wondered why it was that gynaecolo-
gists had hesitated to attack the purulent uterus on surgica]
principles as they would any other pus cavity. It was his prac-
tice to use iodoform gauze for intra uterine packing, a method
he had had no reason to regret, as his results were uniformly
good.
Dr. T. Addis Emmet thought that his previous work bore
testimony to his early recognition of the principle of drainage
in his practice of dilatation of the uterus with sponge tents and
irrigation with hot « ater. Drainage was certainly a good thing
where the tubes contained pus, but doubtless Nature cured a
good many of these cases. As for the diseases called metritis
and endometritis, he would be glad if some one would demon-
strate to him what was understood by these terms, as he bad
never seen a case in the autopsy room. In a woman that was
menstruating there was no true mucous membrane lining the
uterus, the tissues being in a constant state of transition. If the
parts were diseased the trouble was generally confined to the
cervix. For the last ten or twelve years he had never intro-
duced a probe into the uteru-, as a matter of routine, recogniz-
ing the fact that as a rule discharge from that organ was a
symptom of disease lying outside of the uterus — such as pelvic
inflammations or growth-, which could be diagnosticated as
such. He had never seen a case in all his practice where a
woman who had never borne a child required treatment of the
interior of the uterus, lie thought, however, that Dr. Polk's
method had a field, but it must not be forgotten that discharge
from the uterus was a symptom and not a disease.
SECTION IN OBSTETRICS AND GYN. ECOLOGY.
Meeting of December 16. 1891.
Dr. Egbert H. Grandin in the Chair.
Osteoma of the Ovary.— Dr. II. 0. Con presented such a
specimen taken from a woman, thirty years of age, who had suf-
fered for years with excruciating pain in the ovary and finally a
rise of temperature. On removal, the ovary was found to have
undergone bony degeneration, without very much enlargement.
The pressure, however, of the bony mass must have caused the
severe pain
Angeioma of the Liver.- Dr. II. T. Hanks related the his-
tory of a case in which he had made an exploratory incision
into a tumor evidently proceeding from the lower lobe of the
liver, but there was an uncertainty as to what the growth really
was. The incision revealed what seemed to be a cancerous
growth of the entire lower lobe of the liver, which extended quite
a distance beyond the median line and reached down to the
pelvis. The line of demarkation between the healthy and dis-
eased tissue was distinct, but, as nothing could be done, the
wound was closed and the patient allowed to recover from the
operation, when a course of electricity was tried. Puncture was
performed twice, but the patient seemed not to endure it very
well, so that the simple application of the current, with com-
pression with sponges, was continued. It was now several
months since the exploration was made, and the patient was in
much better health and was able to go about and do her work,
the tumor having lessened about two thirds in size.
Several cases of angeioma of the liver had been reported
where the patients had got well without treatment, so that he
could not be sure that the electricity had been the cause of the
improvement. If anything had done good, it was the com-
pression of the sponges, which had been pressed upon the tumor
pretty firmly.
Dr. G. M. Edebohls was able to report recovery in such a
case where he had instituted no electrical treatment. He
thought that the compression of the liver in Dr. Hanks's case
might have had something to do with the improvement.
Expectant Treatment of Intraligamentous Rupture of
an Ectopic Gestation Sac — Dr. G. W. Jarman read a paper
on this subject. He said that, although most writers were
agreed as regarded the main points of diagnosis and treatment
in such cases, yet not a few seemed to have confusing ideas on
the following points : 1. The causation and pathology of rupt-
ure. 2. The cause of hemorrhage after rupture. 3. The diag-
nosis between intraperitoneal and extraperitoneal rupture. 4.
What patients should be operated upon and what only treated
otherwise. I'retty much ail agreed 1 1 1 .■ . t the majority of cases
occurred either in women who had never previously borne chil-
dren or else in those who had had quite an interim since the pre-
ceding pregnancy. That this was due to a diseased condition of
some of the reproductive organs seemed most probable. Recog-
nizing the fact that the mucous membrane of the tube was of
the ciliated-columnar variety, with cilia, which in health had a
constant waving motion toward the uterine cavity, but were
rapidly destroyed by disease, it seemed also probable that the
tube, no longer guarded, might become invaded by the sperj
matozooid and be compelled to domicile it. Added to this,
there was the existence of bands of adhesions constricting
the caliber of the tube at some point, and we found no slight
difficulties which the ovum must overcome if it reached its
proper destination. If it should become adherent to the
tube wall, it either died or else continued to develop so
long as its surroundings *\ ould permit. Undoubtedly the
torn arteries and veins had a share in the production of the
haemorrhage, but. from the quantity found in this class of cases-
after rupture, it had seemed must probable that the opened si-
nuses played the greatest part. The study ot the course of the
hamiorrhage when it had broken into the broad ligament neces-
sitated the study of the arrangement of the pelvic peritonasuin.
The diagnosis between an intraperitoneal and extraperitoneal
rupture should not present marked difficulties. The lact that in
the former the haemorrhage was into a free cavity, while in the
latter it was necessarily limited, should give a rnarkul difference
in the degree of symptoms. Another increment to the severity
Jan. 16, 1892.J
PROCEEDINGS
OF SOCIETIES.
79
of the symptoms was due to the shock attending the introduc-
tion of a foreign substance into the peritoneal cavity. The tu-
mor which had ruptured into the peritoneal cavity was usually
situated in the cul-de-sac. In the extraperitoneal rupture, the
tense elastic broad ligament could be felt bulging into the vagina
and in most instances the uterus would be pushed toward the
opposite side. If the haemorrhage had been extensive, the mass
could ho palpated through the abdominal wall. The diagnosis
between cases of rupture into the broad ligament and those of
broad-ligament haamatoma would offer more difficulties. The
question would at once arise, Did such a thing as a simple haema-
toma ever exist, or was it simply a term handed down from the
time when but little was known of ectopic gestations and their
frequency? Why should the veins of the broad ligament be less
susceptible of dilatation than those of other parts of the body?
And, above all, why should we not be able to find an occasional
rupture in the veins of the pampiniform plexus in the male where
we knew the varicose condition was so much more frequent ?
The expectant treatment, as the term implied, consisted in the
readiness on the part of the physician to meet any indications
which might arise. Hemorrhage either had ceased or else would
cease as soon as the resistance equaled the propelling force. The
author had been unable to find any case reported in which this
extraperitoneal haarnorrhage had caused death. If the anaemia
became alarming and the life of the patient was in actual jeop-
ardy, then, of course, a laparotomy would be indicated and the
bleedinjr point sought. The patients should be forced to remain
in the recumbent posture ; aside from this and looking after the
general functions, but little could be done. In the after-conduct
of the case, should symptoms of sepsis supervene, the most ra-
tional treatment would be the early evacuation and drainage of
the cavity. In case the life of the foetus was not destroyed at
the time of the rupture, but it continued to develop, another in-
dication for treatment presented itself. The great principle was
to operate when it was safest for the mother without regard to
foetal life.
Dr. Coe thought that the danger of an extraperitoneal haarn-
orrhage becoming intraperitoneal was slight. He had seen as
much as two or three pints of blood between the broad liga-
ment, where it had dissected up behind the peritonaeum, hut had
never seen a secondary rupture.
Dr. Hanks also doubted if there was any danger of secondary
rupture into the peritoneal cavity. He advised the expectant
treatment. In a number of cases he had been gratified by good
results under the expectant plan. He thought that irregularity
in the type of menstruation was a good point in diagnosis. This
should always be inquired into. As to the amount of haarnor-
rhage, it was not surprising that it was so profuse when it was
taken into consideration what a vascular organ the uterus was
during gestation.
Dr. Jarman did not think that this reason accounted for the
amount of blood which escaped in rupture of an ectopic gesta-
tion sac of only a few weeks' growth. He felt satisfied that it
came from the sinuses and that it was not arterial blood.
Suppurative Oophoritis.— Dr. H. J. Boldt read a paper
with this title. Abscesses within thickened, inflamed, and hy-
perplastic masses of the pelvic peritonaeum, more especially the
broad ligament, were by no means rare occurrences. Accord-
ing to our modern view of suppuration, we sought its source in
a purulent salpingitis. If the fimbriated extremity allowed the
escape of a drop of pus, we comprehended the subsequent lo-
calized peritonitis, the purpose of which was to shut off the
focus of suppuration from the rest of the pelvic or abdominal
cavity by plastic or formative inflammation around the focus.
Since, we knew that the presenceof the staphylococcus, or rather
its ptomaine, was a requirement to produce suppuration, we
considered this process an infectious one, the micro-organism
being carried from without to the endometrium, from there into
the tubes, and thence into the peritoneal cavity. The process
known by the term of suppurative oophoritis, leading to a par-
tial or total destruction of one or both ovaries, was not quite
so common. Obviously this process in most instances arose
from the contact of the ovary with a focus of suppuration in
its immediate vicinity, the broad ligament. In cases where the
ovary was only partially destroyed we found it, after extirpa-
tion or at post-mortem examination, bordering on an abscess
cavity, and changed to such an extent that it was often not rec-
ognizable to the naked eye. Often there was no difference in
the appearance or consistence of the remnants of the ovary.
Under these conditions the microscope would have to be brought
to bear to ascertain how much of the ovarian tissue was left.
The author had come into posses-ion by operation of a number
of specimens of suppuration of the ovaries, and of these he had
made a thorough microscopical study. According to the differ-
ent tissues involved, the pathological conditions were described
under the following headings: Fibrous connective tissue; in-
flammatory infiltrntion of connective and smooth muscle tis-
sue; myxomatous tissue; changes in epithelial tissue. He gave
a description of the inflammatory changes of all constituents
of the ovaries. To the author's knowledge such had never
been previously described, and he thought they would prove of
great value in proving that inflammation and suppuration in the
ovary were not always based on an immigration of colorless
blood-corpuscles, as had been asserted some twenty years ago
by Cohnheim. It was the author's conviction, from a very
thorough study of the subject, that all constituent tissues of the
ovaries participated in an active manner in the production of
inflammatory corpuscles, which, being broken asunder, fur-
nished that which we knew by the name of pus-corpuscles-
The author gave a description of a number of his cases. They
were selected from those that had not derived their source from
a uterus containing any septic tissue. In many instances a posi-
tive diagnosis could not be made, but constant pain not asso-
ciated with the menstrual period was suggestive of some ovarian
trouble. Where abscess was diagnosticated the abdomen should
be opened in every instance, as patients in such a condition
were in constant danger. If rupture took place into the perito-
neal cavity, and the streptococcus and staphylococcus were
present, the peritonitis was always rapidly fatal. It was rare
for ovarian abscesses to be larger than a hen's egg; in the cases
reported where they were of large size the chances were that
they were some other condition. The author thought that these
cases of ovarian abscess occurred more frequently than was sup-
posed, but that they were confounded with other pathological
conditions. Chronic suppurative oophoritis existed where no
micro-organisms were present. This should not, however, deter
one from operation, as innocuous pus could readily become
noxious.
Dr. Edebohls thought with the author of the paper that the
ovarian tissue was capable of breaking down into pus cells.
One of the factors in the causation of ovarian abscess not men-
tioned by Dr. Boldt was the gonococcus. These micro-or-
ganisms had been demonstrated in ovarian abscess where there
was no break in the ovarian tissue. In regard to diagnosticating
these small abscesses, it was the speaker's practice to pass an
exploring needle through the abdominal wall into the tumor
and demonstrate the character of its contents. Pus had been
frequently found in small tumors where the size and symptoms
had not called for operation, but the demonstration of pus
had. The frequency of ovarian abscesses varied in different
countries. The Germans reported a very inconsiderable num-
ber, while in this country the proportion was very large. Out
80
NEW INVENTIONS.
[N. Y. Med. Joue.,
of thirty cases of operation for diseased ovaries containing
muco-pus, etc., fourteen were purely cases of ovarian abscess.
The rational therapeutic measure in this class of cases was ex-
tirpation. He first emptied thoroughly and then enucleated.
Dr. Coe was glad that Dr. Boldt had made a distinction be-
tween tubo-ovarian and true ovarian abscess. He was also
satisfied that gonococei were a frequent cause, as well as that
contamination could take place from the bowels, which cause
operated through the lymphatics. One of the very serious com-
plications of pregnancy was an unsuspected ovarian abscess.
These ovarian abscesses were usually small, and situated high
up, and it was hard t > distinguish appendicitis from such. In
one case where the author had operated for appendicitis in Mc-
Burney's line be had found an ovarian abscess, and in another
case where the operation was done for supposed abscess of the
ovary appendicitis was found.
Dr. A. H. Buckmastei! thought that the Bacterium com-
mune coli was a more frequent cause of ovarian abscess than
was supposed. He did not think it impossible for it to pene-
trate the wall of the ovary, which was in close connection.
Dr. Jarman referred to the very characteristic odor of these
abscesses, and wondered whether there was any connection be-
tween them and the intestinal canal. In one case where he was
operating he had been almost sure that he had opened the in-
testinal canal, from the very foetid odor which came from the
parts, but he found that it had come from the ovary.
Dr. Hanks thought that the odor was not surprising, as all
old abscesses where the pus had remained encapsulated for a
long time had an intolerable odor. It was his practice to aspi-
rate and enucleate in these cases as soon as possible after a
diagnosis.
The Chairman agreed with Dr. Coe that the vagina was not
the proper canal for drainage, for the reason that the true
ovarian abscess was small and contained only about a drachm
of pus, and was also adherent high up.
Jlcto xilnticntions, etc.
AN INSTRUMENT FOR
THE DETERMINATION OF HETEROPHORIA.
By George T. Stevens, M. D.
In the determination of the various tendencies of the ocular mus-
cles, it is often advisable, and even necessary, to bring to our aid as
many forms of evidence as can be made subservient to our purpose.
While the photometer remains pre-eminently the reliable and effi-
cient working instrument in the determination of beterophoria, auxili-
ary means are often required to confirm or to explain its indications.
We sometimes also require an instrument for making provisional ex-
aminations, more portable than the photometer.
As such an auxiliary and provisional instrument I have devised
the stenopaic lens, which possesses manifest advantages (Fig. 1, A).
The purpose is to present contrasting images to the two eyes.
With the lens, the image of a candle-flame twenty feet distant,
seen through the stenopaic opening, is a large and perfectly defined
disc of diffused light.
If, for the purpose of effecting a diffusion, we employ the uncov-
ered convex lens, a very slight movement of the lens, in or out, up or
down, gives to it the effect of a prism in those various directions.
1 1 .1 convex lens, about 13 D., is covered, except at the optical
center, where a circular opening of three millimetres or less diame-
ter acts as a stenopaic window, the small opening serves the double
purpose of preventing an adjustment of the lens as a prism and of
Cutting off the halo i.i such a manner as to give the impression of an
exact disc of light bordered by a frame. A metal or hard-rubber disc
of the size of the lens of the trial-case, perforated by an opening of
the required diameter and supplied with a perfectly centered lens, is a
convenient form. It may be used with a handle (fig. 1, B), enabling
the patient to hold it in
his own hand, or it can
he placed in the trial-
frame.
In orthophoria the
untransf'ormed image
should be found exactly
in the center of the disc.
In heterophoria it will
tend toward or beyond
the border. If the flame
sinks below or rises
above the center, while
at the same time it devi-
ates laterally, we there-
by discover by a single
comprehensive view all
the elements of a com-
pound deviating tenden-
cy, so far, at least, as
that tendency is mani-
fest (Fig. 2). In this
important respect the
stenopaic lens presents
a feature both unique
and of much signifi
cance. While by other
methods of inducing diplopia or contrast we may discover, at a dis-
tance of some metres, first one and then the other element of a de-
viating tendency, by this instrument all the collective elements are
presented simultaneously to the eye, thus eliminating a very important
source of error.
yi0
c
-D
Orthophoria.
FlG. 2.
Heterophoria.
In respect that it is simple, cheap, and small enough to be carried in
the vest pocket, and that it, more than any of its class, represents the
true relation of the visual lines, it is a useful test. Its disadvantages
are those common to every instrument held close to the eye when in
use in these examinations. This instrument has been manufactured
by E. B. Meyrowitz, 295 and 297 Fourth Avenue, New York.
EDINGER'S DRAWING APPARATUS FOR LOW MAGNIFICA-
TION*
By Joseph Collins, M. D.
With the permission of Dr. Ludwig Edinger, of Frankfort-on-the
Main, I am permitted to demonstrate to you this evening the drawing
apparatus devised by him and presented at the Southwest German So-
ciety for Neurology and Psychiatry, June V. 1891.
The apparatus is based on the projection principle and consists of a
* Presented before the Xew York Neurological Society, October 4,
1891
Jan. 1G, 1862.J
MISCELLANY.
M
stand bearing an upright which supports a tube or cylinder parallel to
the base and in apposition to a piece of canvas board which cuts off all
the rays of light excepting those passing through the cylinder.
The front surface of the upright has a metal groove into which is
fitted at its upper part an arm terminating at the other end in a circu-
lar plate for the support of the object to be drawn. Beneath this is a
second arm, also fitted into the groove, terminating in a small cylinder
for the reception of the lens. Both of these arms are movable, but the
upper one should remain fixed, while moving the other focuses the rays
of light and makes larger or smaller representations of the preparation
according to its distance from the object bearer. The light used may
be either sunlight or artificial. As a rule, an ordinary lamp, with or
without a small reflector, answers all purposes. The light being placed
in the proper position, and the preparation to be drawn on the object
table, a sharply outlined picture of the preparation will be thrown on a
piece of drawing-paper beneath. By regulating the height of the arm
bearing the lens, or by changing the lens, any magnification between
two and fifteen times can be made.
In this way the outlines of an absolutely true drawing can be made
and the details filled in from the microscope, or a precise picture can
be m ide from the apparatus alone, so sharply defined is the representa-
tion.
Of course, specimens colored with dark stains give more clearly dif-
ferentiated pictures than the light ones.
The instrument is made by Meyrowitz, of this city, at my request,
and may be had with two or three lenses. Two are all that are neces.
sary ordinarily, but the third is important sometimes when the object
to be drawn is very small.
1$ i s r c 1 1 a n g .
Influenza from a Veterinary Point of View. — The following paper,
by Mathew Wilson, M. R. C. Y . S., of Wenona, III., appears in the Janu-
ary number of the Journal of Coinjiurii/ire Mi tin-in, mill Veterinary
Archives :
Influenza is a disease that has long beeu known to medical science,
both human and veterinary. Its history can be traced back with cer-
tainty only to the beginning of the sixteenth century, although as far
back as the year 1300 we have accounts of an epidemic among the
horses of Italy that seems to-day to be recognized as influenza. With
the beginning of the sixteenth century we have accounts of epidemics,
the wide distribution of which have been reached by no other acute in-
fectious disease.
Up to the present time a great number of epidemics have been de-
scribed, which generally extended over whole countries and frequently
over several quarters of the globe.
They returned at indefinite periods and affected every season and
latitude, advancing, as a rule, in a great wave.
In some cases they appeared to be preceded by sporadic cases, but
more commonly a large number of the animals would by affected si-
multaneously, the disease spreading with great rapidity.
Among the numerous outbreaks, the following are recorded:
In 1648 an epizootic of this disease appeared in Germany, and from
there rapidly spread to other parts of Europe, and in IV 11 it attacked
the horses of the European armies, causing great losses.
In 1732 the disease appeared in London, and later on in the same
century in Scotland.
In 1766 we have the first attack on the horses of America, but not
making its appearance here in anything like a virulent form until we
have the extensive outbreaks of 1870-72, when it spread over the en-
tire country.
It is to-day an almost permanent disease among the horses of our
large cities, where bad ventilation and want of sanitary arrangements
about the great majority of stables seem to keep the disease alive, and
perhaps predispose fresh animals to it.
Definition. — Influenza is a specific febrile disease, dependent upon a
specific blood poison and prevailing as an epizootic.
It is essentially characterized by a catarrh of the respiratory and
generally also of the digestive organs, by great and rapidly developed
weakness, pains in the head and limbs, as well as by serious nervous
symptoms and fever of greater or less intensity.
It is confounded generally with simple catarrh, but is distinguished
by its wide diffusion, its rapid spread, and the number of cases in the
regions in which it occurs.
We can not lay its cause to atmospheric influences, as we have it
occurring at all times of the year, during different climatic changes and
in countries whose atmospheric surroundings are totally different.
We have it occurring at seasons of the year when climatic changes
are such as do not produce catarrh, and aside from this we have those
lesions of function peculiar to influenza that can in no way be con-
nected with a simple catarrh.
^Etiology. — When we think of the numerous opportunities presented
by this disease for investigation, and to what extent literature has been
published upon it, we are surprised at what few facts have been
gathered together concerning its cause and origin.
A great many theories have been advanced as to the aetiology of in-
fluenza, such as that of atmospheric influence ; others give it a specific
origin, but have never been able to isolate and demonstrate its specific
cause, while on the other hand there are those who claim it has a
spontaneity of origin, due to want of sanitation. This last is, I think,
the weakest of all, as we have it occurring where sanitary arrangements
are the best, as well as where they are almost entirely wanting.
The theory of its specific origin is, I think, conceded by the majority
to be the correct one, although we have as yet been unable to produce
conclusive evidence.
It is due to a living miasm, capable of being carried onward by the
air, but having an independent existence of its own, and which would
find in certain places conditions more favorable for its development
than in others.
Take, for example, the last outbreaks of influenza in the human
family, which seemed to have been developed in Russia and spread in
the direction of human intercourse and the prevailing winds from the
east to the west.
This living miasm is capable of transmission through the air, of be-
ing carried by human beings, or, in fact, by any of the known modes of
infection.
Influenza has been described as the sum of a series of catarrhal
manifestations, which have developed under common epidemic influ-
ences, and the intimate association of the various local affections allows
i is to give them a common specific origin.
Many acute local affections, such as acute catarrh, laryngitis, etc.,
present very much the same symptoms locally as in Ibis disease, but
there is wanting the sudden and general seizure, the severe nervous.
depression, and the extent to which the mucous membranes are in
volved ; all these seem in favor of a general cause which has a Specific
effect upon the whole body.
82
MISCELLANY.
[N. Y. Me». Jour.,
These symptoms are much more severe than in the local affections,
while they remind us more of analogous symptoms in other acute in-
fectious diseases, and for these reasons I think we are justified in
classing it under the same group.
Tltere is a close analogy between the first symptoms of influenza and
measles in the human subject.
Before the eruption occurs on the skin in measles there is found to
be a catarrhal affection of the mucous membranes lining the air-
passages, and also of the conjunctiva. This catarrh is so constant a
manifestation that it has been considered a pathognomonic symptom,
especially in those cases where the eruption can not be seen. Here it
is, as in influenza, one of the earliest and most constant symptoms.
In canine distemper we have another disease whose early symp-
toms coincide with those of influenza.
Here we have the disease ushered in with chills, a dry, irritated
condition of the mucous membranes, where the discharge soon becomes
more copious, great debility, and in some rsisc.-. an extcii.-ion of the
inflammation along the respiratory tract to the lungs and pleura.
In these diseases we have two that are recognized as being due to a
specific organism, presenting characteristic symptoms that almost
coincide with those of influenza; and what more probable to assume
from this, that in influenza we also have a disease whose ravages are
due to a similar cause?
Pathology. — The pathological changes in the body are due to the
absorption of the morbid material by the blood. The alteration
occurs in the blood, where we have a rapid destruction of the red
corpuscles. The absorption by the tissues of these disintegrated
corpuscles gives them a yellowish tint and a congested appearance.
The first sign of this is seen in the early discoloration of the mucous
membranes.
Along with this we always have more or less congestion of the
various organs of the body.
Other pathological changes are due to complications; as, if the
lungs are affected, we have the changes due to pneumonia or pleurisy.
If enteritis or congestion of the liver is the complication, we have the
changes taking place in them.
Symptoms. — The development of the symptoms of this disease, after
a period of incubation varying from four to eight days, may result in a
very mild attack, or they may be very intense.
In a mild attack we have the disease running its course as a specific
fever, with only the alterations in the blood ; but if the attack is
severe, we may have it complicated with inflammatory diseases of the
various organs, aggravated by the already weakened state of the body
and the alterations in the blood, w hich have a tendency to favor a fatal
termination of these complications.
The first symptoms are those of great indisposition, rapidly de-
veloping fever, which may become intense, chills of the body, staring
coat, loss of appetite, and a dry, irritated condition of the mucous
membrane.
The pulse becomes increased in number, varying from 60 to 80 and
even 100 ; it may be at first moderate in volume, but becomes weak.
The discharge from the mucous membranes at first is thin arid
acrid, but as the disease advances it becomes more copious and
thicker.
In the condition that is known as pink-eye we have the discolored
pink condition of the mucous membrane lining the nasal and buccal
cavities and the eyelids, tumefaction of the limbs and eyelids, great
stupor, and the animal very weak.
The fever may run up as high as 105° F. or 10t>° F., and generally
lasts from three to four days.
At the end of this time, if the disease runs a favorable course,
the fever begins to abate, the appetite returns, the various organs
take on their natural function, the pulse falls in number and becomes
stronger, and we have the animal left convalescent in a weakened con-
dition.
Death in these cases may be the result of an excessive fever, with
failure of the heart's action, asphyxia from a rapid congestion of the
lungs, or from the poisonous effect of the morbid matter due to disin-
tegration of the blood-corpuscles.
Coiii/iIini/io/iM. — The complications, as we have before mentioned,
are generally of an inflammatory nature. As a result of the primary
lesion, we have a congestion of the various tissues.
This, along with a distended state of the blood-vessels, a weak
heart's action, and an improper aeration of the blood, is very prone
to be followed by an inflammation, due to the slightest irritating cause.
During some outbreaks we have the majority of cases complicated
with an inflammatory condition of the lungs ; in others we have the
complications arising in the bowels or liver. Why this should be wJ
can not determine, unless it is that local climatic changes or atmos-
pheric influences may be the exciting cause of these local lesions, thd
animal becoming more predisposed, due to the pre-existing disease.
To enumerate the symptoms of the various complications would be
to go into those of pneumonia, pleurisy, enteritis, etc., which 1 do not
think would throw any light upon our subject, and which could only be
thoroughly discussed under their respective heads.
Treatment. — Treatment must, of course, depend upon the symptoms
exhibited by each particular case; but there aie some measures that will
equally apply to all.
Great care must be taken to keep the animal free from exposure to
draughts, and at the same time have ventilation sufficient to provide
him witli plenty of fresh air.
He should be well covered with sufficient blankets to keep up ex-
ternal heat, the legs hand-rubbed and bandaged, and his surroundings
kept clean.
Antipyretics are indicated from the first. Of these we have a great
variety, and selection must depend upon the practitioner.
I have found a combination of digitalis and nitrate of potash a good
remedy, giving it twice a day.
In this we have not only a febrifuge action, but we strengthen the
heart, lower its pulsations, and have a diuretic effect.
If the fever remains high, two or three doses of acetanilide, com-
bined with digitalis, sometimes have a good effect.
If the attack is mild, generally all that is needed is good nursing
ami salines dissolved in the drinking-water.
If there is a tendency to constipation, a powder of sulphur and ni-
trate of potash each day will generally relieve it, along with warm bran
drinks or linseed tea.
The treatment in complications must, of course, depend upon the
accompanying disease, remembering at the same time the weakened,
state of the animal, and let our treatment be such as will keep up our
patient's strength.
On the Use of the Newer Antipyretics in Influenza. — Little progress
seems to have been made, says the University Medical Magazine, in the
treatment of this malady. This is but what would be expected, how-
ever, owing to the obscure nature of the a?tiology and pathology of the
disease. Although there is every indication that the affection is caused
by a specific micro-organism, the particular one remains to be demon-
strated.
As the manifestations of the epidemic influenza are not the same in
different epidemics, or, in fact, in the same epidemic, and as at present
we do not know of any specific, a large field for experimental therapeu-
tics has been offered by the more or less constant prevalence of the
disease during the past two years. This has not resulted in the dis-
covery of any new remedies, but we have learned what not to use.
During the past few years the chemical laboratory has furnished us
with many new drugs, an important series of which possess remarkable
antipyretic properties, and, as ascertained later, some of them are anal-
gesics as well. These qualities seemed to indicate particularly their
use to combat the fever, as well as the local or general pains so fre-
quently complained of in the present epidemic.
Disappointment, however, often followed this method of treatment,
and some of the deaths which occurred in the early part of the epidemic
are charged to the use of these drugs. Evidence has been accumulat-
ing that these new antipyretic drugs are capable of acting as cardiac
depressants. This is, perhaps, particularly the case when the heart is
already weakened from other causes. Bearing in mind the profound
prostration in many cases of influenza, it w ill be apparent that the drugs
in question are dangerous weapons.
It seems that any one of the various systems of the body — the re-
Jan. 16, 1892.J
MISt ELLANY.
83
< spiratory, the nervous, the vascular, or the digestive — may be particu-
' larlv affected by the disease under consideration. This may be ex-
plained by the theory of a locus minoris rtsuterUice, When the violence
I of the disense falls upon the circulatory system, it is very important to
' avoid all cardiac depiessants. This becomes of even greater signifi-
cance if the heart or vessels be already diseased. The same caution
should be ooserved in the ease of children and the aged, among whom
the disease numbers the majority of its victims.
Jt is to be recommended, therefore, that in this disease the new
chemical antipyretics be used very cautiously, or not at all. It must be
remembered that during the prevalence of influenza all diseases are apt
to have an increased mortality, so that the same caution is to be borne
in 1 1 ind. It is, perhaps, superfluous to remark that the same argument
holds good in the cases of the other cardiac depressants.
Some Mooted Points concerning the Vomiting of Pregnancy. — At a
meeting of the Philadelphia County Medical Society, held on December
23, 1891, Dr. T. Ridgway Barker read the following paper:
In discussing the aetiology, symptomatology, and prognosis of the
digestive disturbance associated with gestation known as morning
sickne-s, or the vomiting of pregnancy, it becomes necessary at the
very outset of a comprehensive study of the subject to exclude those
forms of gastric trouble which, while often accompanying this purely
physiological process, are nevertheless not dependent upon it for their
existence, but upon some pre-existing morbid condition which is simply
aggravated by the changes incident to gestation.
From a failure to appreciate and differentiate between these forms
of gastric disturbance is largely due the confusion and misconception
which is so general, hence the existence of such a multitude of views as
to the cause and gravity of the vomiting of pregnancy.
It becomes necessaiy, therefore, that we state clearly that when we
speak of morning sickness we do not include the so-called vomiting m
pregnancy, but confine our remarks solely to the vomiting of preg-
nancy. Without further explanatory remarks, let us proceed to a
consideration of the subject from a scientific standpoint, ever mindful,
however, how easy it is to advance a theory and how difficult to find
evidence to support it. That the occurrence of vomiting without ap-
parent cause in females who have exposed themselves to the risk of
conception is a sign of much importance is generally admitted, since
it so quickly follows cessation of menstruation, and therefore further
tends to confirm the presumptive evidence of pregnancy. With refer-
ence to its aniology, one finds as many views as there are stars in the
sky, each differing from the other in magnitude and brilliancy even as
these distant orbs of light. Let us then turn away from such a merry-
go-round of medical opinion and seek to discover the truth in the
realms of anatomy and physiology rather than in the domain of idle
speculation.
Coincident with conception we find a general rise in the intrapel-
vic blood-pressure resulting in increased activity on the part of all the
viscera therein contained which are concerned in the process of repro-
duction. Cells heretofore carrying on a passive existence now spring
into a high state of activity. Likewise there occurs hyperplasia and
hypertrophy of tissue which is especially rapid in the uterine muscular
[ elements. Nerves, which in the unimpregnated condition possess but
a low grade of sensibility, now become highly sensitive and transmit
readily to their respective centers slight disturbances, which, under
other circumstances, would fail to throw them into a state of activity.
What i elation, one may very properly ask, exists between the vomiting
of pregnancy and this exaltation of the nervous system ? A causal one,
: most assuredly !
Can one fail to realize that this is a symptom of pregnancy due to
f the change in the nervous equilibrium induced by the process of gesta-
tion ? Surely not. Rather are the nausea and vomiting expressions of
a reflex irritation having its origin at the end-organs of the uterine
nerves, which, as we have seen, are in a hyperaesthetic state. As the
growing ovum demands, day by day, an increased space for its develop-
ment, these end-organs are subjected to a varying degree of irritation
which is transmitted to the centers and thence reflected out along the
nerve-filaments distributed to the stomach. Why this affection is of
more frequent occurrence and of greater severity in the first than in
subsequent pregnancies one can readily understand by comparing the
cavities of the primiparous and multiparous organs.
We find in the former that the uterine muscular walls are convex
and nearly, if nut quite, in apposition, hence the capacity of the organ
in these females is relatively less. Not so the multiparous uterus, for
its walls are concave, and the capacity is further increased in length
by half an inch owing to incomplete involution on the part of Nature
after the first pregnancy. Need we seek for more conclusive evidence
than this to support our position ? Is it not plain to be seen that the
resistance in the primiparous organ will be greater and the nervous
disturbance more pronounced than where the cavity is larger, thus al-
lowing the ovum to undergo its development without interference ?
Further, the period when nausea and vomiting are most apt to occur
is in the second month, at a time when the growth of the uterus is
principally lateral and the villi of the chorion are thrusting themselves
into the serotine or placental decidua. As to the character of its on-
set, it is usually gradual and disappears in a similar manner as the
uterus rises out of the true pelvic cavity, thus having quite ceased by
the end of the fourth month.
Concerning the symptomatology of this affection, it has not a few
well-defined characteristics. The primary nausea and oppression ex-
perienced over the epigastrium soon gives place to vomiting, not, how-
ever, preceded or accompanied by any degree of nervous depression as
•s the case with emesis under all other circumstances. The food, if any
;s present in the stomach, is expelled, not violently or with any amount
of retching, but almost as if it were regurgitated. Should the stomach
be empty, then simply 'a little clear, normal gastric mucus is raised,
which, as it usually occurs early in the morning, has given rise to the
popular appellation of moruing sickness. Further, if the matter vom-
ited be food, it will not be found on examination to be sour or to have
undergone- decomposition, but in a more or less perfectly digested state,
depending upon the length of time since its ingestion. As to the sub-
sequent amount of nervous depression, in most instances it is practi-
cally nil, even when the vomiting is frequent and of long duration.
This fact is very noticeable in some cases ; the pregnant female may
have just finished a hearty meal — for impairment of the appetite is
rather the exception than the rule — when almost immediately after-
ward she will be obliged to evacuate the stomach, only to turn to the
piano and find consolation for her lost breakfast. Rarely does one meet
with a case of vomiting of pregnancy where the female's health has ma-
terially suffered, and this is what one would reasonably expect from a
study of the symptomatology of the affection.
That this digestive disturbance is a purely sympathetic one is proved
by the fact that by a strong effort of the will the female can not infre-
quently ward off an attack.
Should she, for instance, have accepted an invitation out to dine
during this period of gestation, she can control the nervous irritability
by a firm determination not to betray her condition to the assembled
guests. It has been repeatedly asked, How can a woman suffer from
morning sickness at one period of gestation and not at another ? In
other words. How is it that the attacks vary in severity in different
pregnancies? Moreover, Why is it that one pregnant woman has morn-
ing sickness and another does not ? Can this be explained on the hy-
pothesis of reflex nervous irritability ? Most assuredly.
The variability in the duration and severity of the affection is due
to two factors: Greater or less irritation, and greater or less irritability.
The question may here be asked, Is vomiting of pregnancy a physio-
logical or a pathological process ?
It has been stated that among women of a strong, robust type,
vomiting of pregnancy is exceptional rather than the rule, as is the
case in Europe and America. But this fact has no direct bearing on
the case; it goes without saying that the stronger and less sensitive
the nervous system, the less general and severe will be the sympathetic
disturbance. One certainly is not warranted in stating that the vomit-
ing of pregnancy is a pathological process, for it is due to a purely
physiological cause. There exists no morbid alteration in structure or
function of the nerves. The irritability is nut pathological but physio-
logical, depending upon the degree of sensibility of the ner vous appa-
ratus. Yet it has been claimed by some investigators that this very
exaltation is evidence of some pathological lesion. Surely not. It
84
MISCELLANY.
[N. Y. Med. Jock.
were, it seems to me, as reasonable to declare a person's brain diseased
because he is irritated by Wagner's music, in which he finds no har-
mony, as to declare that the sympathetic disturbance excited by preg-
nancy is due to some morbid process.
Again, if we select two galvanometers, one registering the weakest
electric current, the other equally well constructed but less sensitive,
we can not say that the former is anymore perfect than the latter;
they differ simply in the degree of their sensibility. Difference in sen-
sibility within certain prescribed limits is a physiological, not a patho-
logical fact. While vomiting, as Austin Flint points out, is not, strictly
speaking, a physiological process, yet under these circumstances it is
far from pathological; rather let us say it is the pathological expression
of a physiological process. The vomiting of pregnancy, unless com-
plicated by some morbid process, never gives rise to alarming symp-
toms or threatens life. If prolonged beyond the period of quickening,
its continuance may be accepted as positive evidence of some complica-
tion which a decided alteration in the character of the vomited matter
will usually indicate.
Cases of pernicious vomiting call for diligent search for organic le-
sions in the nervous system or structural changes in some of the gen-
erative or associated organs. That the vomiting of pregnancy occurs
in health)', strong women almost as frequently as in their less robust
sisters, though in a milder form and of shorter duration, only confirms
the view as to its physiological nature. The view advanced, that the
difficulties of parturition are proportionate to the severity and length of
the morning sickness, one is scarcely prepared to accept. The gravity
of the digestive disturbance is to be estimated by the amount of nerv-
ous irritability, while the difficulties attending parturition may be classi-
fied under two heads — maternal and foetal. The former including uter-
ine inertia, pelvic deformity, and rigidity of the soft parts ; the latter,
abnormal size of the foetus and malpositions of the foetus. Surely
no such conclusions are justified, for the reports from the large lying-
in hospitals of both America and Europe unmistakably prove that no
such relation exists. Females who have suffered great annoyance from
morning sickness have frequently as easy and sometimes more rapid
labors than those who have almost wholly escaped this unpleasant
early indication of pregnancy. Therefore, in conclusion, it would ap-
pear, from a study of this affection : 1. That the vomiting of pregnancy
is due to a reflex irritation produced by the developing ovum acting
upon an exalted nervous system. 2. That it is not an affection of great
gravity and need occasion no anxiety or alarm. 3. That active treat-
ment is rarely demanded, as it is only a disturbance of a few weeks at
the most. 4. That the severity of the gastric trouble is no indication
of the character of the subsequent labor. 5. That where the affection
persists beyond the period of quickening, it is due to pathological
causes which must be discovered and treated accordingly.
The late Dr. William H. Van Wyck. — -The following is from the
minutes of a meeting of the medical board of Charity Hospital, held on
January 2, 1892:
The medical board of Charity Hospital has heard with profound
sorrow of the death of their colleague, Dr. William H. Van Wyck,
which occurred on the lfith day of November, 1891.
Dr. Van Wyck was one of our oldest members, and was endeared to
us all by his geniality and kindliness of heart. He was an esteemed
member by reason of his broad knowledge of medicine and of surgery,
and of his rare talents in practical therapeutics.
The members of the board therefore hereby express their great
grief at the removal of their esteemed colleague by death, and extend
their sincere sympathy to the widow, relatives, and friends of the de
ceased, with the assurance that they will ever cherish his memory.
/ IioREKT W. Taylor,
Committee. -| Henry Goldthwaite,
' Thomas H. Birchard.
The Association of Military Surgeons of the National Guard of the
United State3. — The second annual session will be held in St Louis, on
April 19, 20, and 21, 1892. An interesting programme of addresses
by prominent surgeons of the National Guard and the United States
Army has been arranged, papers on military and accidental surgery will
be read and discussed, and all matters pertaining to the health, useful-
ness, and welfare of the civilian soldiers will receive attention. The
afternoon of one day will be set apart for an object lesson from the
Manual of Drill by hospital corps of the United States Army detailed
for this purpose. The evenings will be given up to entertainments,
receptions, and banquets, for which the medical profession and gen-
erous citizens of St. Louis have pledged $10,000. It is very important
for the committee to ascertain as early as possible who will attend this
meeting, and they ask for the name, rank, and address of those intend-
ing to be present, how many will form the party, and what hotel accom-
modations are desired. The fatigue uniform will be worn during the
day and full dress at all evening entertainments. Full dress is not
compulsory. Those intending to read papers are asked to send the
title to Colonel E. Chancellor, 515 Olive Street, St. Louis, by March
1st. Transportation will be satisfactorily reduced on all railroads and
steamboats to and from this meeting, and all hotels have given a low
and uniform rate. It is expected that not fewer than five hundred sur-
geons and assistant surgeons of the National Guard of the United
States and theii families will be in attendance, to all of whom the com-
mittee of arrangements extend a most cordial welcome. Lieutenant
Ralph Chandler, 135 Grand Avenue, Milwaukee, is the corresponding
secretary.
To Contributors and Correspondents. — The attention of all who pnrjme
favoring us with communications is respectfully called to the follow-
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THE NEW YORK MEDICAL JOURNAL, January 23, 1892-
#rminal Communications.
TARDY HEREDITARY SYPHILIS OF THE BONES *
By G. G. DAVIS, M. D , M R C. S. Eng.,
PHILADELPHIA,
SURGEON TO ST. JOSEPH S nosPITAL ;
ASSISTANT SURGEON TO THE ORTHOP/EDIC HOSPITAL.
Four cases of this not very common affection have re-
cently come under my notice. As its true nature is quite
likely to pass unrecognized and mistakes in treatment
made, and as these cases happen to be so typical, I have
thought them of sufficient interest to be presented to the
consideration of the fellows of the college :
Case I is that of R. B. D., a boy aged fifteen years. He
presented himself at the Orthopaedic Hospital with an enlarge-
ment of the left tibia, accompanied by considerable pain. His
history is as follows: He is one of a family of four-
teen children, nine of whom died in infancy. One
of these nine died of hydrocephalus ; the causes of
death of the others are unknown. One of the five
children left — a girl — lived to the age of eleven years,
and had a similar affection of the legs as is presented
by this patient. She was also at one time deaf and
blind, but these troubles improved under treat-
ment. She is said to have died of membranous
croup. The rest of the surviving children appear
to be healthy.
The mother has had five miscarriages, and the father con-
fesses to having had syphilis, but states that it was contracted
after the birth of the other affected child. There is a history
both of a primary sore and skin eruptions. About eight years
ing, and the pain still troubles him. lie has been rubbing the
leg with liniments, but has never been treated by a physician.
On examination, the left tibia is found much enlarged, par-
ticularly forward, and bent to a slight extent inward. The
thickening begins above the ankle and extends to near the
tuberosity. There is a superficial ulcer on the front of the leg
half way up to the knee. The left extremity, as a whole, ap"
pears to be two inches longer than the right one. The inner
side of the left tibia measures over two inches more than the
right, and its anterior surface is two inches and a half longer
than that of the tibia of the opposite leg. The fibula does not
appear to be at all affected. This increased length of the left
leg has caused the pelvis to be tilted, and produced a curvature
of the lumbar spine with the convexity toward the right and a
compensatory one in the dorsal region with the convexity to-
ward the left. The left knee is bent inward in a genu-valgum
position and the foot is markedly abducted, or in a state of val-
gus. Three years ago be was struck by a stone on the right leg
Fig. 2.
above the external malleolus. The injured part began to pain
and swell, and the fibula of the right side is now enlarged for
the space of six inches above the ankle joint. The enlargement,
however, is not so marked as that of the tibia of the opposite
leg. No other bones are affected, and the teeth are neither
pegged nor notched, although somewhat uneven. The boy is
Fig. 1.
Flo.
Fia. i.
ago, when the patient was seven years of age, he was kicked on , thin, illy nourished, and somewhat nervous. The deformity of
the left shin by a boy. The leg then began to swell and pain
him, particularly at night. This swelling has gone on increas-
* Read before the College of Physicians of Philadelphia, November
4, 1891.
the left leg of this patient is show n in Fig. 1 .
A marked feature of the case was its high and irregular
temperature, varying at times as much as five degrees in twelvo
hours. The boy was treated with syrup of the iodide of iron,
and then bichloride of mercury and iodide of potassium. 11c
86
DAVIS: TARDY HEREDITARY SYPHILIS OF THE BONES.
[N\ Y. Med. Jocr. ,
improved at times, but eventually left the hospital not much
better than when he entered.
Case II.— William P., a boy aged thirteen years, was admit-
ted into the hospital under Dr. Goodman's care. When eight
years of age, during the summer time, he began to have pain in
one of his wrists. He denied having injured the part, and there
was no change in its external appearance. In a week's time he
had pains all over hitn. These pains continued all that fall and
winter. They were present more or less all the time,
but were worse from four o'clock in the afternoon on.
He was also chilly and wanted to be near the fire. The
affection was supposed to be rheumatism, but treatment
for that condition gave no relief. In the following sum-
mer the pains ceased and both tibias began to enlarge.
The ankles and knees at this time were also thought to
be affected. The bones of the left forearm, too, began
to get larger. Since then be has had pain off and on;
it is worse before and after wet weather. He has never,
at any time in his life, had any eruptions on his body
or any trouble with his eyes or ears. His teeth are
good, strong, and even.
His mother gave the following family history : She
has had fourteen children, the patient being the sev-
enth; of these, ten are living; the other children are
all healthy. Of the four who are dead, one was killed
by a gunshot wound at the age of three years, and
another died of some disease of the stomach at the age of
five. The remaining two died at the age of two and four
days, respectively. The physician in attendance said that there
was something wrong with their hearts. A year and a half ago
the mother had a miscarriage at five months. She does not
know of any cause for it, and it is the only one she has ever had.
The father is a strong and hearty man. He has never had any
eruption of the skin, and the only illness he has experienced
enlargement, as shown in Fig. 2 ; both legs were likewise en-
larged, as seen in Fig. 3, of the left leg. The foot of this leg
also showed some valgus. Before he entered the hospital he
fell and burt'himself, and a purple spot showed itself above the
right ankle. He remained in the hospital four or five weeks, and,
after leaving, this spot broke down, and his physician, Dr.
Miller, removed a large sequestrum, after which the limb was
left as seen in Fig. 4. A year and a half later the swollen part
FfG.
Fig. fi.
was six years ago, when he was very sick for four weeks. He
was very hoarse, and the attack was thought to be bronchitis.
The children did not suffer in infancy from snuffles or eruptions
of any kind, nor from sore eyes.
On the admission of^the patient into the Orthopaedic Hospi-
tal both bones of the left forearm were the seat of a fusiform
Fig. 8.
below the knee of the right leg got quite red and painful and
looked as if it was about to suppurate. While in the hospital
this patient was treated with iodide of potassium and phenacetine
and salicylate of soda at times for his fever. On leaving the
hospital his acute symptoms had somewhat subsided, but other-
wise he was about the same.
Ca9e III. — Willie S., a boy, aged eleven years, had been ail-
ing for five years. lie has had pains in his arms and legs, par-
ticularly the latter. These were thought to be rheumatic. He
has been steadily getting worse, and now his legs are very much
deformed, as are also his forearms. He has limped for the past
two years. There is a valgoid condition of both feet, the left
being the more marked, lie complained while under treat-
ment of a cold in the nose and throat. The cervical glands en-
larged enormously, but after three or four weeks again sub-
sided. Later on a large node appeared in the course of a single
week on the left fibula just above the external malleolus, but
immediately began to subside. The father admits having had
gonorrhoea when young, but denies ever having had any symp-
toms of syphilis.
The mother states that there are two other children, now
aged fourteen and sixteen years ; they are and have been per-
fectly healthy. She has had three other children; two of these
died of " water on the brain" — one at the age of three months
and the other at seven weeks ; the third was still-born. The
head of this last child was also said to have been larger than
was natural. She has had no miscarriages. Her husband has
never had any trouble excepting rheumatism, from which he is
getting better. The patient has a lupoid scar under the right
eye, said to be from an abscess, and another on the side of the
head measuring three quarters by an inch and a half. His legs
increased gradually in size until they presented the appearance
shown in Figs. 5 and 6. His forearms are shown in Figs. 7 and
8. The legs are the only parts that now pain him. He was
never affected with snuffles in infancy, nor had he any eruption.
This patient was placed on the use of syrup of iodide of iron,
twenty drops three times a day, and later was given iodide of
potassium, five grains, and bichloride of mercury, one thirty-
second of a grain after meals, and compound syrup of the hypo-
phosphites, U. S. P., before meals. Improvement has been
Jan. 23, 1892.]
DAVIS: TABBY HEREDITARY SYPHILIS OF THE BONES.
ST
marked and satisfactory. The arms have been reduced nearly
to their normal size, and the size of the legs has also decreased.
Febrile disturbances have never been marked in his case.
Lately, however, a new node made its appearance on his left
fibula, as already described, but has decreased much in size.
Cask IV. — William W., a boy aged thirteen. He was well
until four years ago, when he was under treatment at one of our
hospitals for disease of the
right ankle. (See Figs. 9
and 10.) One year later the
left began to swell (see Fig.
11), pain was severe, and he
walked with great difficulty ;
at times he could not walk
at all. He has also had pains
in the left knee and hip,
both in winter and summer.
There is one scar on the
outer side of the left tibia
and two on its inner pos-
terior surface. These were
discharging eight months
ago. The inner side of the
right tibia is three eighths of
an inch longer than that of
the left tibia, causing the foot
to assume a position of ex-
treme valgus. (See Fig. 9.)
Ilis mother has had eight
children, our patient being
the fourth. Six are living,
one died of scarlet fever, and
one was still-born. No syph-
ilitic history could be traced in either parent. The patient was
placed on the use of iodide of potassium, and in about six weeks
the left tibia was reduced to its normal size, and all pain in it
Fig. 9.
Later on one thirty-second of a grain of bichloride of mercury
was given in addition to the iodide of potassium.
These cases are well-marked examples of an hereditary
syphilitic taint which is tardy in its manifestations. The
affection is to be distinguished from ordinary inherited
syphilis because in it the manifestations of the disease oc-
cur usually during the first three months after birth, while
Pig. JO.
ceased. The right tibia, however, soon after suppurated and
discharged three or four minute granules of bone, and still later
an ulcer appeared on the right heel, near the tendo A chillis;
Pig. 11.
in tardy hereditary syphilis the symptoms may show them-
selves in childhood, youth, or even early adult age. In
these cases the signs first showed themselves at the ages of
seven, eight, six, and nine years, respectively. Founder
(Si/p/iilis hereditaire tardive) describes one case, that of a
young man who was attacked at the age of twenty-six
years. Of course tardy hereditary syphilis can manifest it-
self by affecting other tissues than the bones, but they are
the second most frequently affected. Eye troubles are the
most common, embracing nearly half of all the cases, while
the bones, according to Founder, are affected in thirty-eight
per cent.
The tibia is the bone most commonly attacked, ami was
affected in all the four cases here given.
In cases in which a syphilitic taint is suspected we
naturally turn to the previous history of the patient if he is
an adult, and to that of the parents if a child. The tardy
or late manifestations of syphilis appear to be the last evi-
dences that can be definitely attributed to the syphilitic in-
fection. When it is attempted to attribute such lesions as
are commonly regarded as scrofulous or rhachitic as being
the result of a hereditary syphilitic taint, then we simply
wander about in a speculative region about which nothing
definite is known. It is, 1 think, a recognized fact that, as
the duration of a disease is extended, so does the efficacy of
purely specific remedies diminish, and certain it is that
purely antisyphilitic treatment has not demonstrated its
value in scrofulous or rhachitic affections.
88
DAVIS: TARDY HEREDITARY SYPHILIS OF THE BONES.
[N. Y. Med. Jour.,
While the peculiarity of the manifestations of the dis-
ease in the patient may establish the diagnosis positively, it
still often occurs that a typical syphilitic history can not be
traced in the parents. This is only to be expected, because
we should remember that we are dealing- with the manifes-
tations of a disease that is on the point of losing its specific
characteristics, and therefore does not exist in a virulent
form. As the disease varies in intensity in different indi-
viduals, so we are apt to find the history to be a more or less
typical one. In some, the more we search, the more numer-
ous do we find the evidences of tbe syphilitic taint, and in
nearly all some corroborative facts can be discovered. In
tbe first case we find nine out of fourteen children dying in
infancy ; in the second, two out of fourteen ; in the third,
three out of six ; and in the fourth, only one out of eight.
A large infant mortality is characteristic of syphilitic par-
ents, and in the first case this is markedly shown, but not
so in the others, although three out of six in the third case
is certainly suspicious.
Examining into the causes of death of these eleven in-
fants, we find that, of the first five, one died of hydrocephalus,
while the causes of the death of the other four are un-
known. Of the second case, we find that the attending
physician said the two infants died of heart trouble ; they
lived to the ages of two and four days, respectively. Of the
three children of the third case, two died of water on the
brain, and the third was still-born. Of the last case, the
one that was lost was still-born. Haase (AID/, med. An-
nal., February, 1829) and Lanceraux (Syd. Soc. Transl., vol.
ii, p. 162) state that hydrocephalus is occasionally associated
with hereditary syphilis, and here we find three out of
eleven children dying of it. and even one of the still-born
children bad a head larger than normal. It suggests the
possibility of some of the cases of hydrocephalus which
live much longer than these did as being due to a similar
specific poison, although perhaps in a more attenuated and
less virulent form.
Miscarriages are also symptomatic of the affection. We
find that the mother of the first patient had five ; of the
second, one ; and each of the other two had one child still-
born. A clear syphilitic history of primary sore and skin
eruption was obtained from the father of the first patient;
but he claims they appeared after the birth of a sister of
our patient, who was similarly affected, but he is probably
mistaken. There was no syphilitic history on the mother's
side. In the second case there was no specific history on
either side, the father's only ailment having been an att ick
of what was supposed to be bronchitis, which disabled him
for four week<. It is possible that this may have been a
specific sore throat. The parents of the third child deny
all specific symptoms, the father admitting only that he had
had while young an attack of gonorrhoea. No evidences of
a syphilitic history could be obtained from the parents of
the fourth child. The occurrence of osseous lesions such
as are present in these cases has so frequently been ob-
served in connection with other manifestations of the dis-
ease, and in cases in which the whole chain of evidence is
complete, that there can not be the slightest doubt as to
their cause. Such cases are given by Fournier, Hutchinson,
and others, and that of the first patient here presented ig
also one of that character. I have lately had referred to me
a young married woman, aged twenty-seven, who, at the age
of ten years, had an undoubted syphilitic ulceration of the
throat, the soft palate being destroyed. This was followed
later by syphilitic disease of the eyes, and from the age of
twelve she has had trouble with one of her shins. It is
tender and roughened even yet, and has probably been the
seat of a syphilitic node.
The pain which exists in these cases is an important
symptom. It begins when the patient goes to bed, and
is less or altogether absent when he is up and about. It
is said to be caused by the warmth of the bed-clothes,
and that if the patient sleeps in the daytime he will have
the pains at that time, instead of during the night. In
Case II the pains began to get worse from four o'clock
in the afternoon. The pains usually precede the enlarge-
ment of the bones, and at this stage the disease is very
ant to be considered as being rheumatic. This occurred
in some of these cases. The disease may either affect
the bones near the epiphyseal cartilage or else the shaft.
When the neighborhood of the cartilage is affected, the
growth of new though not healthy bone is rapid — in fact,
so rapid as to produce very marked deformities. The
tibia being often affected while the fibula remains healthy,
causes the foot to be thrown into a position of valgus.
This was markedly the case with the left foot of patient
one, the left foot of patient two, the left foot of patient
three, and particularly the right foot of patient four. Mr.
Hutchinson (Med. Times and Gazette, March, 1879, p. 348)
details the case of a girl, aged seventeen, who had an en-
largement of the middle of the femur which caused length-
ening of the member. This shows that the increase in the
length of the limb in these cases is not due to an increased
activity of growth solely at the region of the epiphyseal
cartilage, but that it likewise takes place in the diaphysis.
Spontaneous fracture of the bone occurred in this case.
It is natural to look for other evidences of s' philis~in
the patient, such as notching of the teeth, but one should
not necessarily expect to find them. Of course, some cases
occur in which there has been a variety of lesions. Thus,
the sister of our first patient had had both ocular and aural
affections in addition to the bony lesions; also, in the
case I have already mentioned, there were lesions of the
throat, nose, and eye, in addition to the trouble with the
tibia, but this is not commonly the case, and we are not
apt to find the teeth affected. None of these four cases
showed it.
A valuable diagnostic point is the multiplicity of the
lesions, these being often symmetrical. In the first case
the tibia of one extremity and the fibula of another were
affected ; in the second, the ulna and radius of one arm and
both tibia' ; in the third, both tibia' and one fibula and the
ulna and radius of each arm; and in the fourth case, both
tibia-.
The pathological processes occurring in the bones is
usually chronic, but at times it presents exacerbations, with
marked sthenic symptoms. Severe pains, tenderness on
pressure, increase in size of the part, redness, oedema, high
Jan. 23, 1892.J
DAVIS: TABBY HEREDITARY SYPHILIS OF THE BONES.
89
fever, and even suppuration followed by necrosis — all may
occur.
The first patient, a boy aged fifteen years, had all these
symptoms, and his fever was both high and irregular, vary-
ing from two to five degrees on an average. The second
patient also, a boy aged eleven years, had marked febrile dis-
turbances, the daily variation being from two to four and
four fifths degrees. The third and fourth cases pursued a
more chronic course, with very little febrile disturbance.
The nodes appear sometimes to be started by an injury
as occurred in the first case, but this is not a usual occur-
rence. The disease affects both the periosteum and the
bone itself. The rapid appearance of some nodes, as seen
in the one occurring on the fibula of the third patient, and
those shown by the unevenness of the crest of the tibia in
some of the others, demonstrates the fact that the perios-
teum is markedly enlarged together with the superficial
layers of bone. The body of the bone itself is also often
affected. This at first is the seat of a rarefying osteitis ; the
bone becomes softened, and may even, as in Mr. Hutchin-
son's case above mentioned, break spontaneously. The skin
is not unfrequently discolored, and large blue veins can be
seen wending their way beneath it. (See Figs. 5 and 6.)
As the activity of the disease ceases, if the bony changes
have not been too marked, much of the deformity may dis-
appear. The forearms of the third boy mentioned have
almost, if not quite, returned to their normal condition, and
his legs likewise have much improved, but the bones of the
forearm of the second case retain their deformed condition ;
the disease, however, was still at times active. Later on a
condition of sclerosis of the bones may occur, and further
change in their form will only be such as is due to their
subsequent growth.
When suppuration occurs, it may either take place with
considerable or little disturbance. If the first is the case,
the swelling is apt to occur quickly, the skin becomes red,
fluctuation occurs, and spontaneous opening takes place
with not much discharge of pus ; the bone quickly becomes
bare and exfoliation of a superficial scale is apt to be rapid,
although, if the bone is deeply involved, the necrosed piece
may long remain attached at one of its extremities. If, on
the other hand, the process is more chronic, a regular cold
abscess forms with a scanty amount of pus, spontaneous
perforation soon occurs, and small granules of bone are dis-
charged, as in the fourth case mentioned, and healing soon
takes place, leaving a scar. The process differs consider-
ably in its course from that of tuberculous or strumous dis-
ease. In the latter, the course of the carious or necrotic
disease is much slower and a larger, thicker mass of bone
is involved, and the sequestrum comes more from the body
of the bone. The sinus may also keep discharging for
months, and even years, the disease remaining apparently
/;/ statu quo. In these syphilitic affections, however, the
course, both in its unset and decline, is more abrupt. Of
course, as mentioned above, exceptional cases do occur
where, from the depth to which the hone is affected, sepa-
ration of the sequestrum is much slower than is ordinarily
the case. There is a difference also in the appearance of
the two patients. The syphilitic ones are usually thin, pale.
ill-nourished subjects, while those with ordinary necrosis
are often in quite good general health, and certainly have a
much better appearance than that of the marasmic-looking
subjects of hereditary syphilis.
In regard to the treatment of the affection, mercury and
iodide of potassium are certainly the most useful medicines.
The rapidity with which the bone troubles of acquired
syphilis respond to the administration of iodide of potas-
sium has caused it to be looked on with deserved favor,
and, if one were to estimate its value in the hereditary
form solely by that fact and what Fournier says of it, one
would expect no trouble in the treatment of these affections
after they had once been properly diagnosticated. It remains
true, nevertheless, that in many cases the readiness with
which an affection responds to treatment is inversely pro-
portional to the amount of time that has elapsed since its
acquirement, and, as might be expected, these cases of tardy
hereditary syphilis are not so readily curable as the affec-
tions caused by the acquired form are. Mr. Hutchinson
recognized this when he said (Illust. of Clinical Surg., vol. i,
1875, p. 47) of the nodes of hereditary syphilis that they
were not very definitely influenced by the iodide of potas-
sium. The first two cases here detailed both received at
some time antisyphilitic treatment, but I was unable to
keep sufficient trace of them to definitely determine its
value. The first patient was not much improved, while the
second was, after a few weeks, bettered to the extent that
his acute symptoms subsided, only to reappear later on. In
the last two cases antisyphilitic treatment has been more
continuous and more satisfactory ; both patients have
markedly improved, although neither is by any means cured.
Mr. Hutchinson says that these nodes, after having lasted
a while, may disappear spontaneously, and therefore one
should not be too ready to attribute any favorable change
that may occur to the action of our remedies. Antisyphi-
litic treatment certainly offers the best hopes of cure, and
the physician should pursue it faithfully. Personally, I
like to give the bichloride of mercury in tincture of chlo-
ride of iron with some syrup, and iodide of potassium in
solution of the strength of a grain to the drop. Syrup
of iodide of iron, syrup of the hypophosphites, and tonics
may also be found of service in the intervals when it is
desired to suspend the administration of the more specific
drugs. I hardly think the treatment should be solely and
continuously an antisyphilitic one, but rather combined
with one suitable for strumous affections. Maenamara (Dis-
eases of the Hones and Joints, p. 151) holds that, while the
iodides tend to relieve the pains in the bones, they are not
curative, and therefore he orders iodide of potassium and
bichloride of mercury together in some syrup. He also
advises surgical intervention at times. He states that a
subcutaneous incision into a painful node is frequently at-
tended with the greatest relief to the patient, and, when
the pains in the bones persist in spite of treatment, he ad-
vises exposing them and making a linear incision with a
Hey's saw. I did not have an opportunity of trying this in
the first two cases, where it would almost certainly have heen
of service, and in the last two the symptoms improved under
treatment to such an extent as to render it unnecessary.
90
WERDER: SOME MOOT POINTS IN ECTOPIC GESTATION.
\N. Y. Med. Jouk.,
SOME MOOT POINTS IN ECTOPIC GESTATION*
By X. 0. WERDER, M. D.,
PITTSBURGH, PA.
On the 10th of May of this year there came under my care
at Mercy Hospital, Mrs. R., aged thirty-eight years, married sev-
enteen years, mother of five children, the youngest over four
years of age. She also had four miscarriages, the last one two
years ago. Her menses were somewhat irregular, sometimes
appearing every three weeks, sometimes going over time, also
more profuse and of longer duration than previous to the birth
of her last child. She always iiad good health until three months
ago, since which time she was subject to irregular pains referred
to the lower part of her abdomen and over to the right iliac
fossa, of a bearing-down nature, like labor pains. April 10th,
just a month ago, she had a very severe attack of these pains
a scompanied with a feeling of faintness, so that she was com-
pelled to go to bed. In two or three days she had improved
sufficiently to be able to go about, but she had repetitions of
these paroxysms at irregular interv als of a less severe character.
During the last four weeks she was compelled to spend half of
her time in bed. and was unable, when up, to attend to her ordi-
nary household duties. For the last six weeks she lias had a
constant bloody discharge, never profuse, and at no time we're
there any shreds of decidua passed, as far as she was able to ob-
serve.
Mrs. R. is of medium height, well nourished, but rather pal-
lid and anaemic. She complains of some pain in the lower part
of her abdomen, extending over toward her right side, with bear-
ing-down sensations. There is some tenderness on pressure over
tiiis region. Vaginal examination reveals a marked bilateral
laceration of the cervix with erosions and cervicitis. Pushing
my finger up toward the fornix vagina?, it encountered a mass
filling up Douglas's pouch, causing the latter to bulge down
somewhat, which I at first mistook for a retrofiexed gravid
uterus, but, on making a more careful bimanual examination, I
discovered the fundus uteri pushed out of its median position
over to the left side of the pelvis by this mass, which was very
closely connected — in fact, almost continuous — with it on its right
side, but the fundus was found projecting over it. The uterus
was considerably enlarged and slightly movable ; moving it also
imparted some very slight motion to the tumor. The mass was
situated in Douglas's cul-de-sac and extending over toward the
right side, but was not attached to the right pelvic wall : in
fact, my finger could easily be pushed up between it and the
pelvis. It was soft, almost giving the sensation of fluctuation,
at least at its upper surface, and seemed almost immovable : it
was of the size of a large orange and slightly tender.
A positive diagnosis was not made. It seemed most proba-
ble that this tumor was either an ovarian cyst with firm adhe-
sions to the posterior pelvic wall, or an intraligamentous or
broad-ligament cyst. The possibility of extra-uterine pregnancy
was also considered, the symptoms pointing to it being the men-
strual discharge keeping up for six weeks and the paroxysms of
pain
Laparotomy was performed on May 23d. After pushing up the
intestines and omentum, which covered the tumor and had formed
loose and soft adhesions with it, dark blood appeared in the in-
cision and my hand filled up with a soft, friable substance, which
when brought to the surface was found to be semi-organized
blood coagula. Several handfuls were emptied out and then the
tube was brought up, which was dilated and ruptured and filled
* Read before the American Association of Obstetricians and
Gynaecologists, New York, September 18, 1 89 1 .
uith blood-clots and the, at least at one place, firmly adherent
placenta. The foetus was not. found. This blood tumor was
situated principally in Douglas's cul-de sac. and partly also to the
right of it, but did not fill up the whole right side of the pelvis.
It was bounded in front by the right broad ligament and the
uterus (which also formed the boundary line on the left side,),
above by intestines, and posteriorly by pelvic wall. There was
no membrane surrounding it which presented the least resist-
ance to the finger; after separating the intestines it broke right
into the mass. The abdominal cavity itself, before the ruptured
mass had been broken into, was entirely free from blood. Nei-
ther was there any sign of inflammation, the only abnormal con-
dition being a marked congestion of the peritoneal lining of in-
testines and abdominal walls. The abdomen was washed out
with distilled water, a drainage-tube inserted which was left
forty-eight hours, and the abdominal wound closed. The pa-
tient made an ideal recovery and is now in excellent health.
This case is of great interest, because it proves to my
mind the fact that not all cases of tubal pregnancy are fatal.
Rupture in this case undoubtedly had occurred on April
16th, almost six weeks before operation; the haemorrhage
evidently was not very profuse, probably a slow oozing, be-
cause the symptoms at no time were of an alarming nature.
The bloody serum in the abdominal cavity became absorbed,
the coagula bv the natural law of gravitation found their
way to the lowest portion of the peritoneal cavity, the
Douglas's pouch, when the protecting hand of Nature sur-
rounded them by lymph, encysting them there and shutting
this foreign body out from the general peritoneal cavity.
That Nature's conservative efforts would have succeeded in
restoring the patient's health in time is more than probable.
Simple as this matter seems, some of our best and ex-
perienced operators in this field doubt or even deny the pos-
sibility of this occurrence. Tait says that " intraperitoneal
ruptures seem to be almost uniformly fatal." " I have never
seen a case of suspected rupture, or one in which we sus-
pected intraperitoneal effusion of blood, recover if left
alone." * Joseph Price, whose experience with ectopic ges- j
tation has been equaled only by Tait himself, seems to share
this opinion. Their teaching seems to be that the only hope
of recovery is in an operation. The only cases of tubal preg-
naucy which, according to Tait, recover spontaneously, are ,
those rupturing between the folds of the broad ligaments,
and such cases he regards apparently as quite common — so
common that he has been able to see from fifty to eighty
cases of this condition.
Price's experience differs from Tait's in this regard : in
his opinion, rupture into the broad ligaments is extremely
rare. He says : " Mr. Tait's position in regard to haemor-
rhage into the broad ligaments differs from the rest of the
world. I have operated fifty-four times for ectopic preg-
nancy, and I have failed to find haemorrhage between the
leaflets of the broad ligaments." f
The opinions of these two men should, by means of their
unexcelled experience, be regarded as authoritative, but they
disagree in a matter pathologically of great importance.
There is no doubt that Tait's singular experience in regard
* Tait on Diseases of Women and Abdominal Surgery.
\ Transactions of the Philadelphia Obstetrical Society, February 5,
1891.
JHn. 23, 189-2. J
WEJ&DER; SOME MOOT POINTS IN ECTOPIC GESTATION.
91
to intraligamentous rupture of tubal pregnancy has not
been verified by other observers, nor can his statement in
regard to the uniform fatality of intraperitoneal haemor-
rhage be borne out by facts. T am of the opinion that
■ many of these cases recover, and in this I am supported by
■ Olshausen, Veit, and other authorities. My own experi-
ence, which, it is true, covers only six cases, has proved
this to my own satisfaction. In addition to the case with
which I introduced this paper, I have seen two other cases
in consultation in which there could be no reasonable doubt
about the existence of ectopic gestation with rupture into
the peritoneal cavity, in which operation was refused
and still the patients recovered. The first patient when
seen by me was profoundly collapsed and exsanguinated
and seemed to be on the verge of death. Both the attend-
ing physician, T)r. J. J. Buchanan, and myself urged lapa-
i i rotoinv as the only hope of recovery, but this the patient
refused. As tins patient was very thin and the abdomen
I. not tender, the examination was very easy. The fluid in
the abdominal cavity could distinctly he made out. Bi-
I manual examination discovered the uterus of but little more
than normal size, movable, and pushed to the right by a
■ [ boggy mass in the position of the left Falloppian tube.
This mass was of about the size of a large orange, but some-
what more elongated. The sac of Douglas was filled with
a doughy mass. The patient gradually rallied and im-
, proved, but very slowly, and her recovery was very tedious.
Three months afterward I had an opportunity to examine
1 1 her and found a mass in her pelvis of the size of a large
i lemon, and even then she was unable to attend to her house-
hold duties.*
The history of the third case is almost identical with
the one just narrated, with this exception, however, that
her condition had never become extremelyr alarming and
; i threatening as the other. She also recovered without
l 1 operation ; but though rupture occurred last April, her
family physician, Dr. J. J. Buchanan, reported to me a few
I ! days ago that there was still a mass in her pelvis and that
she was so very tender that examination could only be made
i with great difficulty. It is needless to say that though over
five months have elapsed since her intraperitoneal haemor-
rhage, she is still suffering from its effects.
Of the four cases in which T performed laparotomy, in
one case reported in this paper the operation was made
almost six weeks after rupture, when the patient was slowly
i recovering from an intraperitoneal haematocele ; in two oth-
ers rupture had occurred five days previous to operation;
both patients were rallying from their condition of collapse
and there were no signs of any renewal of haemorrhage, and
as the foetus in both cases had escaped from the tube into
the abdominal cavity, it is at least probable that recovery
I would have taken place without operation. We have,
therefore, five cases out of a total of six in which there is
1 a strong probability of recovery, though undoubted rupture
into the peritoneal cavity had occurred. Ordinarily we
could hardly expect such favorable results, but 1 feel conti-
! dent that the percentage of recovery is much larger than
we have been led to believe. Granted, then, that this be
the case, should we change the method of treatment of this
affection now generally advocated — namely, laparotomy as
soon as this condition is recognized \ I would say em-
phatically. No ! There is too m;ich uncertainty in this
matter, and while undoubtedly many would recover without
operation, there is a very large percentage which only
prompt operation can save ; unfortunately, we have no
means of knowing which are the fortunate cases that would
escape a fatal termination. Within a year T have had an
opportunity to see two specimens of tubal pregnancy re-
moved post mortem from cases unknown to me, which
probably could have been saved by prompt operation. One
of these, whose ovisac was not larger than a raspberry,
died in a little over five hours. Promptness in operating
should, therefore, be our rule ; trusting in Nature to avert
the fatal termination is illusory and is apt to be disappoint-
ing. 1 would advise, therefore, with Dr. Charles A. L.
Reed,* to operate — 1. Before rupture as soon as the con-
dition can be presumptively diagnosticated. 2. In cases
after rupture, as soon as evidences of internal haemorrhage
become apparent.
I think we all subscribe to this treatment, with the
exception of those, perhaps, who still pin their faith to elec-
tricity. We are probably not so unanimous in the cases
which have passed the most critical period, danger of death
from haemorrhage — i. e., cases in which the haemorrhage
has ceased and the patients begin to rally and improve.
Most authorities, I believe, counsel conservatism and advise
against operation, but I doubt whether such a course would
serve the best interests of our patients. On the one hand
we have the danger of recurring haemorrhage (cases in
which bleeding returned at intervals of days and weeks have
been reported by Veit, Olshausen, Price, Tait, and others)
and an accumulation of blood in the abdominal cavity,
which, in spite of the well-known digestive properties of
the peritonaeum, is liable to produce sepsis and peritonitis.
Even if the haematocele has formed, there is still danger of
sepsis and suppuration. If the patient survive all these
dangers, her convalescence will be slow and tedious, as has
been shown in the two cases referred to in this paper, and
the tube which was the seat of the rupture will not only be
a useless organ, but it may prove a source of ill health and
possible danger to life at some future period. On the other
hand, laparotomy should be, and has proved to be, a perfect-
ly safe operation in skilled hands, especially in these cases,
as they have already recovered from their collapsed condi-
tion ; by it we are able to remove all present and future
danger. In none of my abdominal work have 1 seen such
ideal recoveries and such rapid convalescence as in the four
cases in which I operated. The patients gained strength
during the two weeks they spent in bed. One, in whom
the pulse had been from 120 to 160 during the five days
previous to operation, had a pulse of 90 the morning
after operation. I would therefore, in the interest of the
patient, advise laparotomy, though all present haemorrhage
had ceased and even if an intraperitoneal haematocele had
* Reported in Pittsburgh Medical Review, 1891.
* Indications for Operation in Ectopic Pregnancy.
92
GOULEY: DISEASES OF THE URINARY APPARATUS.
|N. Y. Med. Joub.,
formed, provided, of course, the operator has the necessary
skill and the surroundings are favorable for an aseptic oper-
ation.
In closing this already too lengthy paper, permit me a
few words in regard to a danger referred to by Olshausen,*
Reed,f and others, which patients with ectopic gestation
are liable to encounter — namely, a recurrence of such an
accident in the other tube. To avoid this danger it has
been suggested to remove both tubes in operating for tubal
pregnancy, justifying this course by the assumption that
ectopic pregnancy is almost invariably due to salpingitis,
which, in the large majority of cases, is bilateral. It is not
my purpose at present to go into the aetiology of this affec-
tion, but to simply look at this matter in its practical bear-
ings. Where the tube not the seat of feetation is seriously
diseased, its removal is plainly indicated ; but where no
such marked disease is present, such a course, in my opin-
ion, would hardly be rational. Of my four cases, in two
the tube and ovary were perfectly normal ; in one (the case
reported in this paper), the left ovary was slightly adherent
but the tube and ovary otherwise normal ; in one only was
the removal of the other tube indicated for disease. The
result of this conservative course of treatment was preg-
nancy in two cases ; one patient has been delivered of two
living children since, and the other is in her seventh month
of pregnancy.
DISEASES OF THE URINARY APPARATUS.
By JOHN W. S. GOULEY, M. D.,
SURGEON TO BEI.LEVUE HOSPITAL.
(Continued from page 70.)
PART I.— PHLEGM ASIC AFFECTIONS.
Section II.— SPECIAL CONSIDERATIONS.
IX.
Treatment of the Acute Types of Urethritis.
Urethritis, liable to divers accidents, complications,
and consequences, may be regarded as a stricture in posse,
the germ of a stricture — in other words, urethritis and the
consequent stricture may be considered as a continuous
process whose evolution begins at the inception of the
phlegmasic action and ends with the confirmed stricture.
Therefore the general indications of treatment of urethritis
are — 1, to remedy the phlegmasia; 2, to guard against ac-
cidents and complications ; 3, to prevent the formation of
stricture ; and 4, to minister promptly to other conse-
quences of this phlegmasia. The special indications vary
with the types, stages, and complications of the affection,
with the peculiarities and general condition of the indi-
vidual, and with his hygienic environment.
Abortive Treatment. — The treatment of acute urethri-
tis was for a long time based upon erroneous notions of
its nature, and directed to the substitution, as it was be-
lieved, of a simple, inoffensive, for a specific phlegmasia.
* Exlrauterinschwangerschaft mit besondercr Berueksiehtigung der
zueiten lliil fie der Se/neangi rxrhaft.
\ Indications for Operation in Eetopie Pregnancy.
This treatment, suggested in 1780 by Simmons, and after-
ward largely employed by Ricord, Diday, and others, con-
sisted of urethral injections of nitratc-of-silver solution (ten,
fifteen, or twenty grains t<> the ounce), and was named the
abortive, to distinguish it from the methodical treatment.
This supposed quick way was as delusive as it was alluring,
alike to patients and to physicians, for it seldom cut short
the attack of urethritis, and besides the great distress it
caused, was often productive of grave effects upon the
urethra and adjacent parts, the first effect being a super-
acute urethritis, then peri-urethritis, lyinphangeiitis, some-
times prostatitis, trachelocystitis, gonecystitis, orchitis, etc.
Inasmuch as this too heroic treatment is still, though very
rarely, recommended, it was thought necessary to give this
note of warning to younger members of the profession
against the employment of means which not only fail to
remedy but serve to aggravate the affection.
Two other modes of abortive treatment were afterward
employed: 1. The administration of balsamics alone. 2.
The balsamics and urethral injections combined. They also
have proved worse than useless. The balsamics alone were
much used by Cullerier, who gave them in very large doses.
He prescribed from twenty to fifty grammes of powdered
ruin bs each day, alternating with copaiba balsam, of which
he gave from fifteen to twenty grammes a day in divided
doses. Such doses may for a few days be tolerated by
some stomachs, but how fatal they must prove to the faith-
ful kidneys which distill the active principles of these drugs
that, through the urine, they may act upon the diseased
urethra !
The association of astringent injections with balsamics
was extolled by Ricord when nitrate of silver failed. The
substances used for these injections were sulphate of zinc
and acetate of lead, or the two together, three and five grains
to the ounce, repeated three times daily.
Urethral injections with copaiba-balsam emulsion have
also been used, but soon abandoned on account of the great
ensuing irritation. Then were vaunted many "infallible
remedies," used by mouth or applied by injection or
through soluble bougies, all of which have done infinite
mischief. These panaceas were generally prescribed with-
out regard to the particular stage of the phlegmasia.
A complete list of the drugs given for, and the modes
of treatment of, urethritis that have been used and failed
or caused serious harm would more than fill a large and
thick quarto volume printed in small type.
Methodical Treatment. — To treat urethritis rationally
and methodically, it is necessary first to ascertain the na-
ture, cause, type, and precise stage of the phlegmasic at-
tack, and the general condition of the sufferer.
Hyyienic Precautions. — From the beginning to the end
of this treatment the most rigid hygienic precautions should
be taken, if only as prophylactic of accidents and conse-
quences. Among the enjoiuments are continency and
avoidance of all manner of sexual excitation during the
treatment and for a month after the cure, and abstinence
from foodstuffs that may be trying to the digestive process
or that are likely to act injuriously through the urine, which
Jan. 23, 1892.]
GOULEY: DISEASES OF THE URINARY APPARATUS.
93
is one of the most important factors both for ill and for good
in urethritis. For ill, when it is excessively acid and
charged with acid phosphates or with uric acid, or when it
is excessively alkaline and loaded with triple phosphates.
For good, when it can be kept bland and when it can be
made the carrier of medicinal agents. Therefore the phy-
sician should keep a close watch over the urine throughout
the treatment of urethritis. The diet should not otherwise
be restricted, except in quantity, which may be a little less
than in health, but not so decreased as to reduce the vital
powers. An already feeble patient is benefited by a gen-
erous diet, with even a moderate allowance of wine, and is
thus placed in a condition to recover from his urethritis
much sooner than he would under insufficient alimenta-
tion.
The most scrupulous cleanliness should be observed.
The glans penis should be bathed twice or thrice daily in a
solution of mercuric chloride (one to ten thousand), and the
patient cautioned against carrying his hand to the face or
near the eye after touching the genitals, and to burn all
cloths that may be impregnated with pus. The reason for
these precautions should be fully explained to him, for they
are among the most essential of the hygienic observances,
without which virulent ophthalmia is almost certain to
ensue.
The bed on which he sleeps should not be too soft, the
covering should be as light as the state of the weather per-
mits, and the room as little heated as possible. This, in a
measure, tends to prevent erections.
Much walking or any prolonged ■ exertion should be
avoided, as either is conducive to complications and conse-
quences, such as oedema of the prepuce, phimosis, lymphan-
geiitis, orchitis, etc.
General Treatment. — The first stage of urethritis or, as
it is called, benign urethritis, which is the period of incu-
bation of acute urethritis, should be treated with a view of
favoring its early deliquescence. When a patient presents
himself three or four days after a sexual debauch, complain-
ing of a little ardor in urination, and has a slight clear mucous
urethral discharge and some congestion of the mucous mem-
brane at and within the meatus, the physician — after inquir-
ing into the circumstances of the debauch, particularly if
the culprits had both indulged freely in beer, wine, or spirit,
and what was the degree of sexual erethism in both — is ready
to pass judgment upon the question as to whether this is or
is not the beginning of an acute urethritis. If he has a
doubt, he should give the patient the benefit of that doubt
by treating the case as if it were going to be acute urethri-
tis. The treatment should first be directed toward render-
ing the urine as inoffensive as possible. If the urine con-
tains a great excess of uric acid, four or five doses of ten
grains each of sodium salicylate, largely diluted, should be
given during the first day only. Afterward twenty grains
of sodium bicarbonate, also largely diluted, should be given
four times daily, adding the juice of half a fresh lemon to
each dose, thus making a citrate of sodium, which is better
tolerated by the stomach than the salicylate. The deple-
tion produced by a brisk saline cathartic (an ounce of sul-
phate of sodium) is of much service in this stage of the
phlegmasia. Rest at this period is of much consequence,
and may in the end be a great saving of time.
The local treatment of the first stage of urethritis consists
of two daily irrigations of the phallic region of the canal
with a solution of mercuric chloride (one to ten thousand,
or even one to twenty thousand). The quantity for each
irrigation should not be less than a pint of water at a tem-
perature of 102° to 105° F. The greatest care should be
taken against bruising or in any way irritating the urethra
during these irrigations. A smooth, hollow bougie of gum
or glass, not over four inches long, acorn-shaped at its vesi-
cal extremity, not larger than No. 10 English, with three
or four perforations at the base of the acorn, may be used
for the purpose. The bougie, fastened to the long India-
rubber tube of a fountain syringe, is then gently passed
into the phallic region of the urethra for about two inches
and a half and the irrigation begun, the retrograde current
washing all that part of the urethra anterior to the acorn,
and running out into a vessel placed between the thighs of
the patient, who should then be sitting upon the edge of
his bed or chair. If the irrigations are well tolerated by the
urethra, and if the urethral congestion is decreased in the
course of two days, the treatment should be continued sev-
eral more days to insure deliquescence of the phlegmasia.
But if, on the contrary, the discharge increases and becomes
opaque, showing the advent of the second stage, the irriga-
tions should at once be stopped, as otherwise they would
be likely to cause superacute urethritis and its conse-
quences.
If, when a patient first applies for treatment, the dis-
charge, instead of being clear mucus, is already opaque, it
indicates the presence of pus and the beginning of the sec-
ond stage. In such a case the local treatment by irriga-
tions should not be employed. The first part of the treat-
ment— i. e., the citrate of sodium, etc. — should constitute
the principal remedial means.
Patients very rarely apply for treatment until the sec-
ond stage of urethritis is fully established. It is then that
meddlesome treatment and polypharmacy are so often car-
ried to the greatest excess, partly through the solicitation
of the anxious patient, partly owing to misinterpretation of
the phenomena of urethritis, and to the vain search for a
specific, and it is then that the misguided employ blindly
those heroic means which so surely lead to serious con-
sequences.
Subacute urethritis, whose characters in its second stage
are generally a free purulent discharge with little exfolia-
tion of epithelium, comparatively little pain, very little scald-
ing in urination, and no nocturnal erections, notwithstand-
ing its mildness, is persistent and requires careful manage-
ment lest it become acute or superacute. In the sec.. ml
stage of subacute urethritis the same hygienic precautions
should be taken as in the other types, and the same diluent
beverages as those used in the first stage, only it is wise to
vary the drink every few days, substituting uva-ursi, buchu,
or dog-grass tea for the citrate of sodium, ami finally return-
ing to the sodium citrate. In the subacute, like the other
types, balsamics should not be used feu- several weeks, or not
until the stage of decline, and should not be given in as large
94
GOULEY: DISEASES OF THE URINARY APPARATUS.
[N. Y. Med. Jouk.,
doses ; nor should irrigations be employed until very near
the close of the period of decline, when the discharge has
decreased to a few drops each day.
The second or stage of increase, of greatest activity, of the
acute type of urethritis, during which it is steadily extend-
ing backward, attended as it is with much pain in urination,
owing to extensive exfoliation of the urethral epithelium,
and with painful nocturnal erections of the penis, demands
an antiphlogistic medication. During this stage balsamics
and injections are worse than useless, and provocative of
complications and consequences which not only retard the
cure but are in themselves of grave import. They should
therefore under no circumstances be administered during
that period. The amount of food should for a few days be
lessened ; a saline laxative, two drachms of sulphate of so-
dium in six ounces of hot water, should be given every morn-
ing ; thirty grains of citrate of sodium four times daily for
three or four days ; a full bath of half an hour at a tempera-
ture of 102° during these four days, after which a nightly
hot hip bath of five minutes is substituted ; and absolute
rest. Four or five times during the day the penis should be
dipped, for cleansing and for urination, into a small vessel of
warm mercuric chloride solution (one to five thousand). To
combat the nocturnal erections of the penis, ten grains of
camphor and one grain of hyoscyamus extract may be given
at bed-time and once repeated during the night if necessary.
For a fidgety algophobic patient a dose of thirty grains of
sodium bromide largely diluted may be given instead of the
camphor and hyoscyamus.
In this second stage superacute urethritis is similarly
treated. To relieve the excessive pain during erection and
chordee the penis should be immersed in a vessel of iced
water, wherein the patient may then urinate much to his
relief. A full dose of opium during the day and a rectal
suppository of a grain of opium and half a grain of bella-
donna extract at night may be necessary to relieve pain and
induce sleep. The application of ten or twelve leeches to
the perineum often has the effect of relieving extreme pain
and of shortening the period of increase. This of course
is advisable only in the case of strong and robust subjects.
During the third stage, or static period, this active anti-
phlogistic treatment is discontinued. The five-minute hot
hip baths are, however, continued. The quantity of dilu-
ents is diminished or their constituents changed, and the
case is otherwise treated in accordance with such new in-
dications as may arise. The static period is generally of
short duration, and if there be no complications or con-
sequences, such as will be described later, the fourth stage
soon begins.
The fourth stage, or period of decline, is ordinarily the
beginning of resolution, which may be rapid and complete
in two or three weeks, or slow and last four or five weeks,
or incomplete and indefinite and merge into chronic urethri-
tis. During this period of decline the phlegmasic phenom-
ena are absent, and there is only the purulent discharge,
which is less in quantity and very perceptibly altered in
quality. It is no longer creamy and contains more mucus
and less epithelium. There are no painful erections of the
penis, and the urine has ceased to cause scalding pain. It
is at this time that the diluents should be suspended and
that the balsamics may safely be administered, but not in
the large doses so commonly given, such as three drachms
daily of copaiba balsam or one ounce of cubeb powder.
Both of these drugs, thus given, within three or four days
become so nauseating that the most willing patients reject
them. In moderate doses they are longer tolerated, but
finally disturb the digestive process and have to be aban-
doned. About twenty-five years ago sandal-wood oil was
suggested by Henderson as preferable to copaiba. Since
then experience has demonstrated this superiority, and the
sandal oil is now much more extensively used than copaiba,
whose properties it possesses without its disadvantages.
But even this oil should not be given in large doses. Two
capsules, containing each ten minims of sandal-wood oil,
may be taken four times daily for a week, then three times
daily for another week, and during the third week the dose
should be decreased until the patient shall have taken only
one capsule, w hen the drug is discontinued. There are pa-
tients that can not bear even this comparatively mild treat-
ment. Their troubles last longer, but after all get well with-
out it.
Not until the stage of decline is far advanced should
urethral injections be used, and then only if after the use of
the balsamics there is still a slight discharge. Before this
time even mild injections are liable to cause lymphangeiitis
or peri-urethritis. Strong astringents should be particularly
avoided. The ignorant believe that to cure a urethritis the
urethral mucous membrane must be practically tanned. In-
jections, to be effective, should be used in large quantity,
but in weak, unirritating solution, and only once daily dur-
ing this stage of urethritis. The small urethral syringe
containing an ounce of fiuid, used three or four times daily,
does more harm than good, for each introduction of its
nozzle is a hurt to the urethra. Among the most efficient
agents for urethral irrigation in these cases are the corro-
sive chloride of mercury (1 to 10,000) and the sulphate and
chloride of zinc. Of a solution of sulphate of zinc, half a
grain to a grain to the ounce of water, a pint is to be used
at night or in the morning by means of the simple apparatus
and fountain syringe already described, except that the hol-
low bougie should be about nine inches long in order that
it may be carried as far as the sinus of the urethral bulb or
farther if necessary, so that the whole urethra may be
washed. The chloride of zinc, the other precious agent for
urethral irrigation, should be used in even weaker solution
than the sulphate — from a quarter to half a grain to the
ounce. In some cases a solution of boric acid, two grains
to the ounce, suffices to cleanse the urethra and arrest the
discharge.
In the majority of cases this simple treatment, which
can be applied by the patient himself, answers well, and the
urethritis is cured in five or six weeks. Other cases,
whether complicated or uncomplicated, are refractory to
treatment and linger many months or years. These are
principally cases of secondary urethritis, the patients hav-
ing suffered from the phlegmasia once or twice before, or
possibly being affected with granular urethritis or already
with stricture, or perchance with urethral mucous patches
Jan. 23, 18i»2.| HUBBELL: OPTIC NEURITIS AS A FORM OF PERIPHERAL NEURITIS.
95
or tuberculosis. The special treatment required by these
cases will appear in its appropriate place.
Among the medicinal agents that have been used in
Bellevue Hospital for injections in urethritis may be men-
tioned solutions of the violet methylaniline, of permanga-
nate of potassium, of permanganate of zinc, of phenol, of
Hydrastis, and many others, mostly with unsatisfactory re-
sults.
As a general rule, when uncomplicated urethritis is well
cured there are no sequela?. Some patients, however, suffer
for many months after the cure from oversensitiveness of
the urethra, unduly frequent urination, or a superabundant
mucous secretion, due generally to hyperlithuria, and de-
manding a treatment appropriate to that condition. In
other cases a very slight opalescent urethral discharge per-
sists. In these cases the careful introduction of a bulbous
bougie reveals one, two, or three tender spots along the
urethra. These tender spots are places where there has
been a greater degree of epithelial exfoliation than else-
where in the canal, and the denuded spots, though after-
ward covered with granulation tissue, are oversensitive
even to the passage of urine, and it is from them that issues
the slight discharge. The treatment required is an occa-
sional urethral irrigation and the introduction, twice a week
for two or three months, of a steel sound to dilate the canal
moderately, to restore its suppleness, to destroy the granu-
lation tissue, to relieve the sensitiveness, and to prevent the
formation of stricture.
Conclusions. — The study of the nature of urethritis and
of the many modes of treatment proposed for its cure has
led to the following conclusions:
1. There is no specific for urethritis, notwithstanding
the popular belief in its existence.
2. Urethritis can not rationally be dealt with as a single
phlegmasic entity, no matter what may be its cause.
3. The nature, course, and pathic properties of the dif-
ferent stages of the acute types of urethritis indicate that
an exclusive method of treatment can not be carried out in
all cases with a reasonable prospect of success.
Li 4. The treatment that is suited to one type or stage of
urethritis is often hurtful in another type or stage of the
affection.
5. The same therapeutic agent, applicable to a particu-
lar type or stage of the phlegmasia, is not suitable to all
individuals.
6. Balsamics are contra-indicated during the first three
stages of urethritis, and should not be administered until
the fourth or stage of decline is fully established.
7. Urethral injections are contra-indicated during the
second and third stages of urethritis, but may be used in
tlic first stage and toward the close of the fourth stage.
8. Injections of strong solutions of nitrate of silver, or
of strong solutions of any kind, are contra-indicated in all
ii the stages of urethritis.
9. Urethritis is ordinarily too much and too vigorously
treated. The more heroic and meddlesome the treatment,
tlir greater the liability to accidents and complications, and
the longer the duration of the phlegmasia.
1U. Confirmed acute contagious urethritis, under the
most favorable circumstances and the most judicious treat-
ment, rarely gets well in less than four weeks, except of
course in the first attack in young and otherwise healthy
men who are not overtreated. In the last-named cases it
sometimes gets well in ten days or two weeks without
medicinal treatment.
11. Proper hygienic management is all-important in the
treatment of urethritis ; unless it is rigorously carried out,
the medicinal and local treatments inevitably fail.
OPTIC NEURITIS
AS A FORM OF PERIPHERAL NEURITIS*
By ALVIN A. nUBBELL, M. IX,
BUFFALO, N. T.,
PROFESSOR OF OPHTHALMOLOGY AND OTOLOGY
IN THE MEDICAL DEPARTMENT OF NIAGARA UNIVERSITY.
Peripheral neuritis, both clinically and pathologically,
has assumed a recognized position in medicine to-day.
The attention of physicians in the past has frequently
been directed to manifold sensory, motor, and trophic affec-
tions, but until recently the conjectured lesion has been lo-
cated in the spinal cord or brain, or the disease has been re-
garded as merely functional. It was in 1866 that Dumenil f
first established by autopsy and microscopical examination
the existence of extensive disease in the peripheral nerves
as the cause of such manifestations, although Graves, of
Dublin, had, nearly twenty years before, expressed his be-
lief that the spinal cord or brain was not the seat of such
lesions. Ten years after Dumenil made the first demon-
stration, Eichhorst \ recorded a case in which a post-mortem
examination showed the spinal cord to be perfectly sound,
but several peripheral nerves presented evidences, both
grossly and microscopically, of interstitial inflammation.
Then followed Joffroy * in 1879, Leyden || in 1880, and
Grainger Stewart A in 1881, with similar reports. During
the past decade the pathological study of peripheral nerves
has been pursued with commendable zeal, and upon inflam-
mation of them or its results are now known to depend many
forms of paralysis, especially localized ones, numerous sen-
sory disturbances, and various trophic changes in the skin,
bones, muscles, and other tissues whose description in de-
tail I must withhold from this paper.
Investigators have also shown that such inflammations
and degenerations follow upon certain diseases or certain
agencies with a frequency that justifies the regarding of the
latter as aetiological factors in the production of the former.
Among those which thus act as causes may be mentioned
diphtheria, scarlet, fever, measles, small-pox, typhus, typhoid,
and malarial fevers, la grippe, syphilis, tuberculosis, leprosy,
diabetes, rheumatism, locomotor ataxy, beri-beri, etc., and
such substances as lead, arsenic, alcohol, bisulphide of
* Head before the New York State Medical Association at its eighth
annual meeting.
\ Gazette hebdom. denied, ct dc chirwff., 1866.
J Virchow's Arch., lxix, 1876.
* Arch, dephys. norm, et path., 1870.
I Zeitschr. fur kiin. Med., 1880.
A Edinburgh Medi al Journal, 1881.
96
HUBBELL: OPTIC NEURITIS AS A FORM OF PERIPHERAL NEURITIS. [N. Y. Med. J,
carbon, etc. There is also idiopathic peripheral neuritis
whose cause is not apparent, which expresses itself in such
diseases as herpes zoster, Raynaud's disease, circumscribed
selerodermia (Hutchinson), sciatica, so-called rheumatic pa-
ralysis, such as that of the facial, abducens, etc. Again, it
may occur from traumatism and pressure. The relation
which peripheral neuritis is thus shown to hold to other
diseases, both as an effect and as a cause, gives it a far-
reaching importance to the diagnostician, therapeutist, and
pathologist.
I desire at this time not only to emphasize this impor-
tance, but to indicate also that this disease is not confined
to the nerves of motion and general sensation, as is gener-
ally understood by the profession, but includes inflamma-
tions of nerves of special sense as well, having the same
known general causes, as well as arising idiopathicallv or
from unknown causes, and the symptoms of which corre-
spond in character and magnitude with the functions in-
volved. I might with propriety consider inflammations of
the olfactory and gustatory nerves, and point out how they
mav be the sequence of influences not started or found in
their end-organs or in the brain, but arising from the same
causes as inflammations of other nerves. It is only thus
that many affections of smell and taste can be accounted
for. So, also, with the nerve of hearing. Certain forms
of deafness, tinnitus, and vertigo are undoubtedly induced
by typhus and typhoid fevers, measles, scarlet fever, small-
pox, mumps, and syphilis, through a peripheral neuritis of
the auditory nerve. I will, however, limit this part of my
discussion to inflammations of the optic nerve.
The pathology and pathological anatomy underlying
many forms of visual disturbances are subjects of compara-
tively recent study. Before the discovery of the ophthal-
moscope the fundus of the eye was clinically an impene-
trable region. With this instrument the practitioner has
been enabled to reach and study it, and by post mortem
examination has verified the diagnosis of such forms of
neuritis as express themselves at the intra-ocular extremity of
the optic nerve — the optic disc — by swelling, cloudiness,
and change of color. But there are some cases which pre-
sent the subjective symptoms and clinical history of optic
neuritis, but the ophthalmoscope does not show the disc-
picture formerly believed to be a necessary accompaniment.
As early, however, as 1866, von Graefe,* of Berlin, whose
clear insight and acuteness of observation have never been
excelled, suspected that such subjective symptoms were not
due to amaurosis (amaurosis was then, as now, a cloak-word
for pathological ignorance) or to brain disease, but rather
to inflammation of the optic nerve situated behind the ball
and showing very little change within the eye, and there-
fore out of sight of the ophthalmoscopist. He described
cases in which vision became clouded and within a few
hours or days absolute blindness ensued, and yet the oph-
thalmoscopic signs were almost negative. Both eyes were
symmetrically affected, and the blindness was temporary in
some and permanent in others. To this form of disease,
acute in character, he gave the name retro-bulbar or retro-
* Arch, fur Ophthal., xii, 1866, p. 114.
ocular optic neuritis. The diagnosis of the lesion was after-
ward verified by post-mortem examinations. Later, Leber,*
in 1869, expressed the belief that the symptoms in certain
cases of amblyopia with central scotoma, but without any
marked changes in the fundus of the eye, were due to a form
of chronic inflammation in the orbital portion of the optic
nerve. These conjectures were subsequently entertained by
other investigators,, but it was not till Samelsohn,f of
Cologne, in 1880, and Nettleship and Edmunds, \ of Lon-
don, in 1881, made the initial post-mortem examinations of
cases of central amblyopia that demonstration was actually
made of an inflammatory and resulting degenerative procesi
in the course of the optic nerve. In each of these cases
there was found " a tract of chronic interstitial inflamma-
tion and degeneration extending from the optic foramen,
where it was central, to the eyeball, where it occupied the
outer part of the optic nerve." * Similar results were ob-
tained by Vossius, || of Konigsberg, in 1882; Bunge,A of
Halle, in 1884 ; Uhthoff,Q of Berlin, who made seven autop-
sies, in 1884 to 1886 ; and Sachs, J of Innsbruck, in 1887.
Thus it has been conclusively proved that optic neuritis
may exist both with and without objective ophthalmoscopic
signs and with varying subjective symptoms from mild to
aggravated, and in its progress it may be rapid or slow.
These symptoms, objective or subjective, I need not detail
here. They are clearly before the profession.
In diagnosis, however, proper exclusions should be made
in cases where impairment of vision can not be readily ac-
counted for by the ophthalmoscope or other means of ex-
amination. Thus, there are various lesions within the en-
cephalon that affect vision without involving the optic nerve
— for example, disease of the occipital lobe of the brain.
Quinine produces in sufficient doses such disturbance of the
circulation of blood in the optic nerve by vaso-motor irrita-
tion as to greatly contract the field and diminish the acute-
ness of vision, either temporarily or permanently'. Experi-
mental research by De Schweinitz, \ <>f Philadelphia, made
during the present year on animals, goes to show that it
does not produce neuritis. Atrophy of the optic nerve may
undoubtedly take place without a preceding neuritis by
some mechanical or vaso-motor arrest or diminution of
blood-supply to the nerve.
As causes of optic-nerve inflammation there are many
that are common to this and other forms of neuritis. Thus
it may be caused by injury, and injury will produce neuritis
elsewhere. Contiguous inflammations, such as orbital cellu-
* Arrhiv/iir Ophthal, xv, 1869, p. 65.
+ Crlbl f. mcd. Wissemch., Berlin, xviii, 1880, p. 418: also,
Archivfun Ophthal, xxviii, 1882, p. 1.
\ 'J rans. of the Ophthal Sor. of the United Kingdom, i. 1881, p. 124.
* Nettleship. Trans, of the Ophthal Soc. of the United Kingdom,
i, 1881, p. 128.
I Archie fur Ophthal.,' xxviii, 1882, p. 201.
A Uebcr Gesichtsfcld. etc. (Field of Vision and Course of the Fibers
in the Optical Conducting Apparatus), Halle, 1884.
Q Ctrlhl. fur prakt. Augenheilh., 1884, p. 43; and Archie fur
Ophthal, xxxii, 1888, p. 95, and xxxiii, 1887, p. 257.
\ Arehir fitr Angrnln ilk\. xviii, 1**7, p. 21 (translated in Knapp's
Archives of Opldhalmotogy, 1889, p. 133).
| Ophthalmic Review, London, x, 1891, p. 49.
Jan. 23, 1892.]
MAXSON:
VERTIGO.
97
litis or meningitis, may cause it. So may other nerves be-
come involved in the inflammatory processes of surrounding
tissues. Pressure from growths or foreign bodies causes
inflammation of both the optic and other nerves.
It is well proved and generally admitted that certain
substances and poisons produce an inflammation of certain
peripheral nerves (peripheral neuritis), prominent among
which are alcohol, lead, arsenic, and bisulphide of carbon.
These substances, too, produce some form of optic neuritis.
To fortify this statement I will cite some authorities.
TJhthoff,* of Berlin, has clearly shown that alcohol develops
axial or chronic retrobulbar optic neuritis. Hutchinson, \
of London, and Allbutt,J of Leeds, are among several who
have reported cases of optic neuritis and subsequent optic-
nerve atrophy, as shown by the ophthalmoscope, caused by
lead within the system. Among those who have seen optic
neuritis in chronic arsenic poisoning are Da Costa,* of
Philadelphia, and C. L. Dana, || of New York ; Nettleship,A
of London, Fuchs, Q of Liege, Galezowski, J of Paris, and
others have seen " axial " optic neuritis (central amblyopia)
in persons exposed to the fumes of bisulphide of carbon in
the manufacture of certain rubber materials.
Diseases which cause peripheral neuritis also cause optic
neuritis. Hulke, J of London, as early as 1868, recorded
cases of optic neuritis after diphtheria, and Allbutt^and
others have made similar observations. Wadsworth,** of
Boston, and others have seen optic neuritis after measles.
Macnamara,ff of London, has reported cases in which optic
neuritis developed in rheumatism and intermittent fever.
He has also seen this disease in la grippe, \\ and so also have
Weeks,** of New York, and others. The history of the re-
cent epidemics of la grippe furnishes many examples of
" peripheral palsies." Typhoid and typhus fevers, small-
pox, scarlet fever, syphilis, tabes, tuberculosis, and diabetes
stand out more or less prominently in their {etiological rela-
tions to peripheral neuritis. Optic neuritis also is found in
each of them in corresponding frequency. Lastly, both
peripheral and optic neuritis occur alike idiopathically with-
out any assignable cause.
I might multiply illustrations showing the common
origin of both so-called peripheral neuritis and optic neu-
ritis in some of their varieties, but it seems to me that the
evidence already adduced is sufficient to place beyond doubt
the claim that certain astrological influences and pathological
* Archiv fur Ophthal, xxxii, 1886, p. 95, and xxxiii, 1887, p. 257.
f Royal Low/on Oph, Hospital Reports, Part 1, vol. vii, 1871, p. 6.
\ Use o f the Ophthalmoscope, London, 1871, p. 265. See, more re
cently, Oliver, (lulstonian Lectures on Lead Poisoning. British Med.
Jour., Mar. 21, 1891, p. 633.
* Medical Times, Philadelphia, March, 1881.
I Brain. London, ix, 1886, p. 546.
A Trans of the Oph. Soe. of the Un. Kingdom, v, 1885, p. 149.
v Ibid., p. 152.
I Ree. d'ophthal., 1887, p. 30.
I Royal London Ophthal. Hosp. Rep., vi, p. 108.
J Use of the Ophthnlinoseope, 1871.
** Trans, of the Am. Ophthal. Soc, 1880, p. 125.
ft British Med. Journal, March 8 and May 3, 1890, pp. 540 and 100.
X\ Ibid., Aug. 1, 1891, p. 251.
** New York Medical Journal, Aug. 8, 1891, p. 143.
results are common to both, the symptoms varying only in
correspondence to difference of function of the nerve or
nerves affected.
We can not, perhaps, understand why alcohol, bisul-
phide of carbon, tobacco, or diabetes should induce axial
or chronic retro-bulbar neuritis, while lead, arsenic, diph-
theria, tabes, la grippe, or measles should develop a neu-
ritis more generally interstitial, often acute, and showing
ophthalmoscopic signs. Neither can we offer satisfactory
explanation why lead pre-eminently affects the nerves sup-
plying the extensor muscles of the extremities and the mus-
cles of the intestine, or why tobacco has a special affinity
for the nerves going to the heart, or why diphtheria con-
spicuously leaves its impress upon the cranial motor nerves
and some of the spinal. Yet such facts remain, and the
lesson which they teach us to-day is that inflammation may
attack all classes of peripheral nerves alike, those of special
sense as well as those of general sensation and motion, that
the cause is wide-spread and common, and that the princi-
ples of treatment are identical.
Peripheral neuritis in its broadest sense, therefore, be-
comes of intense interest and far-reaching importance to
both the general practitioner and specialist.
VERTIGO*
By EDWIN R. MAXSON, M. D., A.M., LL. D.,
SYRACUSE, N. Y.
Vertigo — from verto, I turn — implies giddiness, dizzi-
ness, swimming of the head, and may be produced by a
variety of causes, operating through different parts of the
system. And hence we have it as a consequence of gas-
tric, epileptic, migrainous, and gouty affections ; organic,
brain, and spinal disease ; and certain affections of the eye
and ear.
Gastric vertigo, being very common, may generally be
recognized, depending, as it does, upon various forms of in-
digestion.
Nervous vertigo usually attends nervous exhaustion, and
generally is, or may be, caused by anxiety, sexual excesses,
tobacco, and tea or coffee.
Epileptic vertigo may occur in a fit of epilepsy, or even
take the place of it ; quite frequently preceding. Hence it
is easily recognized and traceable to the causes operating
to produce that disease.
Migrainous vertigo, usually constituting one of the phe-
nomena of migraine, either attending or following the de-
velopment of the headache, or even sometimes replacing it,
may readily bo understood.
Gouty vertigo occasionally occurs in gouty persons, dis-
appearing, perhaps, when there is the supervention of gouty
arthritis, by which it may readily be recognized through
whatever part it may directly operate.
tint in and spinal vertigo, of an organic character, may
arise from tumors, sclerosis, or other changes of the brain,
cerebrum or cerebellum, or spinal cord. It is generally
* Read before the Syracuse Medical Society, December 1, 1891.
98
MA XSON:
VERTIGO.
[N. Y. Med. Jouk.,
attended by symptoms pointing to the seat of the disease,
cephalic or spinal.
Ocular vertigo, depending, as it may, upon a paralysis
or weakness of one or more of the recti muscles, etc., causes
an incorrect notion of objects. And hence a sense of con-
fusion and giddiness occurs, rendering a fairly plain indi-
cation of the seat of the disease.
Aural vertigo, however, may not be as readily recog-
nized. It has been variously named labyrinthine, apoplecti-
form, and Meniere's disease — this last from his description
of it in 1HG1. Under these headings have been classed
cases in which vertigo, with various other symptoms, is
caused by disease of the labyrinth directly, as conges-
tion, inflammation, or " haemorrhage ; or indirectly by dis-
ease of the middle ear, Eustachian obstruction, spasm of
the tensor tympani, or paralysis of the stapedius, or irrita-
tion or obstruction of the external meatus, and pressure on
the membrana tympani, as by cerumen, foreign bodies, or
by syringing the ears, especially when the membranes are
perforated " (Stephen Mackenzie).
Thus the labyrinthine affection may be either primary
or secondary, " irritative or destructive."
It has been stated by Farrier that the dizziness tends
to falling, in cases not primarily labyrinthine, in one direc-
tion ; and in the primarily labyrinthine in the opposite.
But in all cases the cochlea and semicircular canals are in-
volved, attended with vertigo, tinnitus, and vomiting, with
some degree of deafness in most cases of primary labyrinth-
ine origin. And in these cases the vertigo is related to
the change in the position of the head, being aggravated by
one position and relieved by another, according to the canal
more especially affected. And, in the primary cases, there
may be more generally falling and obstinate vomiting.
In all cases of Meniere's disease there is more or less
secondary visceral disturbance, such as pallor, faintness,
nausea and vomiting, syncope, etc. This is doubtless owing
to the proximity of origin of the auditory nerve (a branch
of which, the vestibular, supplies the semicircular canals) to
the pneumogastric. And, further, the blood supply of the
labyrinth from the vertebral artery comes from the sub-
clavian, near the inferior cervical ganglion of the sympa-
thetic, by which ganglion not only the vestibular artery is
thus supplied, but it also "sends communicating branches
to the pneumogastric and branches to the heart," thus con-
necting, in sympathy, the labyrinth with the heart, stom-
ach, " and other organs," accounting for the nausea, vomit-
ing, faintness, or syncope, etc., as well as tinnitus and dizzi-
ness, characteristic of Meniere's disease, as suggested by
Mackenzie.
Symptoms. — This disease may come on quite suddenly,
perhaps with a noise in the ear, but not invariably.
In one case, that of a gentleman of sixty, he had former-
ly suffered from some aural disease ; and though apparently
in about his usual health (which was habitually feeble), he
may have had a slight congestive chill, perhaps, or incipient
influenza {la grippe). At any rate, he suddenly became un
able to stand with his head erect, and, being tip a flight of
stairs, he had to come down with his head bowed down;
and to walk with his head thus bowed or else lie down, as
he assured me when I saw him three weeks later, being out
of the city. He, as is usual with the dizziness, on raising
his head, had some nausea and vomiting, and he could not
stand erect with stability.
The noise, if heard, is in one ear; and the apparent m
real movements of the body are in a direction opposite to
the affected ear, as I have witnessed ; the falling, when it
takes place, being " more frequently forward, or to one
side," according to Mackenzie.
In another case the patient, a young lady of eighteen,
who had formerly suffered from some slight aural affection^
while having the mumps, being engaged in hard study,
sleeping in, or adjoining to, a recently plastered room, not
entirely dry — having also some symptoms of influenza (la
f/rippe), without any appreciable noise in the ear — became
unable to raise her head without producing vertigo, nausea,
and vomiting, necessitating the recumbent posture, there
being no stability in standing.
Some secondary cases of this disease may be transient,
lasting only a short time. But the vertigo may persist,
with or without the vomiting, or it may recur.
In cases in which the labyrinthine disease is primary,
however, it may continue for many months, reducing the
patient almost to a skeleton, as occurred in one case that
fell under my observation away from this city. The case
had been treated in the main, I believe, as of gastric ori-
gin. I doubt if the patient recovers, from the last ac-
counts, though he may.
In another case, early diagnosticated and properly
treated, the patient has recovered and remains in excellent
health, though apparently more severe than the one above
referred to.
And still another of several months' standing, the pri-
mary symptoms having apparently been quite obscure, the
sympathetic neurotic predominating, terminated fatally,
probably by an extension of the labyrinthine disease to the
brain.
The three cases were evidently primary labyrinthine
disease.
The symptoms of secondary Meniere's disease usually
subside, as the Eustachian, tympanic, and other primary aural
affections and obstructions are relieved and removed, as
they may generally be, one of which I have recently seen
in this city.
Diagnosis. — The diagnosis of Meniere's disease from
the gastric, nervous, epileptiform, gouty, organic brain and
spinal disease, and ocular affections also attended with
vertigo, is not very difficult. For, in addition to the symp-
toms in common, labyrinthine affections in Meniere's dis-
ease have " the vertigo in relation to change in the position
of the head," as claimed by Mackenzie, and as I have wit-
nessed in several cases.
To distinguish between a primary and secondary laby-
rinthine case, the absence of any tympanic, Eustachian, or
external auditory disease or obstruction may generally lead
to a correct conclusion (von Troltsch).
It may be well to remember that deafness and tinnitus
without vertigo, or vertigo and tinnitus without deafness,
may be due to affections of the middle ear, while vertigo,
Jan. 23, 1892.]
MAXSOX,
VERTIGO.
99
tinnitus, and deafness indicate an affection of the labyrinth
(Mackenzie).
Pathology. — As it has now become quite well estab-
lished by experimental observations and research in disease,
by " Flourens, ('yon, Crum Brown, and others " (Quain),
"that the semicircular canals take an important share in
normal equilibration, injury and disease of these parts occa-
sioning locomotive inco-ordination," it is evidently from
this disturbance that the vertigo exists.
There is also in primary eases congestion, inflammation,
or haemorrhage involving the labyrinth, while in secondary
cases there is irritation, at least, from sympathy with dis-
ease of the tympanum, meatus, Eustachian tube, or other
labyrinthine auricular parts or structures.
The vertigo may be caused directly by " variations in
the blood-pressure," as held by Mackenzie, and, together
with all the symptoms of this disease, may be owing to con-
sequent variations in the tension of the membranous semi-
circular canals, changes in the pressure of the endolymph
and perilymph, transmitting an influence through the audi-
tory and sympathetic nerves to the cerebro-spinal and
ganglionic systems, thus accounting for all the phenomena
of this disease, primary and sympathetic.
The membranous vestibule and cochlea doubtless aid
through the same systems of nerves in developing the local
and sympathetic symptoms of this disease, but perhaps in
a less degree, so far as relates to the dizziness.
Promitosis. — In cases in which the labyrinthine affection
is not primary, but owing to some remediable defect in the
tympanum, external meatus, or Eustachian tube, a recov-
ery may generally be expected under judicious treatment
directed to the primary disease.
In primary labyrinthine cases the disease, under judi-
cious treatment, may be greatly relieved, if not cured,
though a degree of deafness and tinnitus may remain in
some cases, or recur. But, if neglected or improperly
treated, suppuration in the labyrinthine membranes may ex-
tend along the vestibular " tubular prolongation " and cul-
de-sac of the uquwductus vestibuli, through the posterior
petrous wall or otherwise, to the cranial cavity, and dan-
gerously involve the brain, as I suspected did occur in one
case that fell under my observation.
Treatment. — The treatment of gastric vertigo involves
a strict regulation of the diet and habits of the patient to
favor digestion. Proper food, with strict regularity and
suitable drinks, must be enjoined, as well as avoidance of
all trash. Tonics to aid digestion may be required, and, in
some rare cases, counter-irritants.
Nervous vertigo calls for prudence in sexual and other
indulgences ; avoidance of alcohol, opium, and tobacco ; and
a strict observance of the laws of health in every respect.
Regular hours for sleep must be strictly enjoined and ob-
served. It requires also good substantial food to be taken
with strict regularity, and may require the substitution of
hot water instead of tea and coffee in some cases.
Epileptoid vertigo requires the general treatment proper
for epilepsy, which consists in regulating all the habits and
administering blood and nerve tonics, the most effectual of
which, according to my observation, are oxide of zinc, car-
bonate of iron, and rhubarb, two grains of each for an
adult, three times a day. And if the epilepsy or tendency
to it is cured, the vertigo disappears.
For migrainous vertigo a regulated diet, tonics, and an
occasional dose of magnesia when there are approaching
symptoms, may do best. Correction of imperfect ocular
action may be attended to if indicated.
In gouty vertigo, colchicum, guaiac, and iodide of potas-
sium ma}' be indicated, and moderation in eating and drink-
ing insisted upon.
In cases depending upon organic, brain, or spinal dis-
ease— as tumors, sclerosis, etc. — a regulated diet and iodide
of potassium, in full doses, may do best. Wet cups may
be indicated to the back of the neck, and blisters back of
the ears, and later to the back of the neck, should be per-
severed in to the last. Mercurials may become necessary
in some cases. If so, I prefer the bichloride in solution
with the iodide of potassium, about eight grains of the
iodide and a twelfth of a grain of the mercurial, well di-
luted when taken — forming, of course, an iodide of mer-
cury.
For ocular eases, in addition to correcting all the habits,
suitable' treatment should be addressed to whatever defect
there may be in the eye, or its muscles or appendages.
Cups to the back of the neck and blisters back of the ears
and to the temples, electricity, and possibly the adjustment
of glasses, may be required.
The indications in the treatment of aural vertigo (Meni-
ere's disease), in which the labyrinthine affection is not pri-
mary, depending upon disease of the tympanum or external
meatus, or obstruction of the I^ustachian tube, should be
adapted to the condition in each particular case.
It may involve cups or blisters to the back of the neck,
leeches or blisters back of the ears and to the temples,
syringing the external meatus to remove wax, or using the
Eustachian catheter to clear that tube, and possibly the
dropping into the external meatus a solution of twenty
grains of boric acid to the ounce of equal parts of gly-
cerin and water, daily, for catarrh of the meatus, and elec-
tricity for paralysis of the stapedius muscle.
The treatment of primary labyrinthine disease includes
several indications. Cups should be applied early to the
back of the neck, and repeated, if necessary ; and at first
leeches to the mastoid process and temples. Later, blisters
may be substituted and repeated, if necessary, while the
vertigo, nausea, or vomiting remains. The ammoniated
citrate of bismuth, in one-grain or two-grain doses, may be
given three times a day, to allay sympathetic gastric de-
rangement. And, to favor digestion, two drops of the
tincture of mix vomica may be required.
In anaemic, congestive, or malarious cases, two or three
grains [not more) of cinchonidine may be required every six
hours, alternating with the bismuth and mix vomica, and
possibly bromide of potassium at evening.
The feet should be set in warm water daily, and mag-
nesia may be given each morning to avoid constipation
and as an antacid ; and, if the tongue is coated, an im-
proved cathartic or leptandrin pill at evening till it becomes
clean. Toast and egg may be allowed at meal time, and
100
hot toast-water and milk given for drink at all hours if
desired.
The worst ease 1 have seen was, under this treatment,
quite well in about four weeks, and has remained so, having
gained ten pounds of flesh in a few weeks, and is enduring
close study.
Another case which was at first, as I learned, regarded as
gastric, and later as " neurasthenia," really an effect of the
uncured aural disease, has now been suffering for several
months, with little prospect, I fear, of a cure or even much
improvement, as nearly as I can learn, emaciation and de-
bility having become extreme, evidently from the non-
removal of the original labyrinthine affection, the aural dis-
ease and sympathetic visceral derangements having evi-
dently seriously impaired digestion, thus in a large degree
cutting off nutrition.
Still another case of longer duration, having been re-
garded and treated as ocular, epileptiform, and organic brain
disease, which it doubtless at length became — suppuration
occurring in the labyrinthine membranes and extending to
the brain eventually led to a fatal termination.
The auricular disease early appears to have been rather
obscure, and in the latter stages, as is usual, very much ob-
scured by the consecutive brain disease and sympathetic
visceral derangements ; and, while a clear diagnosis was not
made, it was the expressed opinion of the last attendant
from the first that there might be an obscure organic brain
disease, and that, if so, it would terminate fatally. And
this was, I believe, concurred in by others at the last, though
opinions may have differed as to the character of the organic
brain disease somewhat.
It may not be improper to add, in conclusion, that since
writing this I have received from a lady of sixty, at a dis-
tance, an account of her having been taken, two years ago,
with " dizziness, some vomiting, finally had to give up, was
in bed several weeks," etc. She adds that since, there is a
" buzzing " (tinnitus) " in the left side of the head, followed
by a whirling, dizzy feeling ; has to stop and hold on to some-
thing and shut her eyes till it passes off, perhaps twenty
times a day."
She further stated that she had not got anything to help
her head, that she " feels weak and trembles all the time,"
etc. She closed by expressing a hope that I could help her.
A later examination confirmed the suspicions her letter had
produced of labyrinthine disease. And I further learned
that it may have originated in influenza (la grippe), consti
tuting the fourth case I have been able to trace to that dis-
ease, more or less directly, of late.
818 Madison Street.
Influenza Colds. — " Few remedies are more reliable, and act bet-
ter as a preventive, or lessen the distressing symptoms of an influenza
told, than the following mixture: ,
lj. Sodii salicylas 3 jss. ;
Liq. amnion, aeet 3 ij ;
Aq. camph ad % vj.
Misce. ('apt. : ^ ss- omnis Stiis horis.
If this be taken every two or three hours when the first symptoms oj
cold come on, it will usually ward off the attack." — British awl Colo-
nial Druggist.
[N. Y. Med. Joub.,
the
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by Edited by
D. Appleton & Co. Frank P. Foster, M. D.
NEW YORK, SATURDAY, JANUARY 23, 1892.
FLOATING KIDNEY AND NEPHRYDROSIS:.
In the September, October, and December numbers of the
Revue de chirnrgie there is to be found an exhaustive article on
intermittent nephrydrosis (hydronep/irose intermittente) by M.
Felix Terrier and M. Marcel Baudouin. There exists, say these
authors, a variety of nephrydrosis, not well understood until
within recent years, that seems to be commoner than has been
supposed; it is an intermittent nephrydrosis. Very often it is
the first stage of a confirmed nephrydrosis. It is due to lesions
of various sorts ; in the great majority of cases it occurs as a
complication of renal displacements, wherefore it is observed
oftener in women than in men. In the former it is met with
especially on the right side ; in the latter, on the left. More
rarely it may be the consequence of a calculus in the pelvis of
the kidney or of temporary compression or obliteration of the
lower end of the ureter. In some cases it is of congenital
origin.
When it is a complication of floating kidney it is produced
in the following way, as shown by experiment and by post-
mortem appearances : An abrupt bending of the ureter occurs,
with or without torsion, at the same time with renal displace-
ment; there is a temporary arrest of the flow of urine, with the
progressive development of a nephrvdrotic sac, which empties
it-el f as soon as the kidney resumes its place; irritation arises
around the renal pelvis, either from embarrassment of the cir-
culation or from infection of the mucous membrane of the pel-
vis; and fibrous adhesions unite the sac to the upper part of
the ureter, and finally lead to the transformation of the inter-
mittent into a confirmed nephrydrosis. These alternations of
distention and evacuation of the renal pelvis, consequent on
temporary obliteration of the ureter, are manifested clinically
by attacks of pain that are well-nigh characteristic, occurring
in the course of a state of health more or less deranged, about
once a month and sometimes oftener. These attacks, which
present three stages — the onset, the acme, and the decline — are
constituted by extremely intense pains, sometimes absolutely
intolerable, coinciding with the appearance of a liquid tumor,
rarely fluctuating, seated most commonly in the right flank, and
with a notable decrease of the amount of urine voided. They
are the result of a sharp bend in the ureter in consequence of
the displacement of a movable kidney. The attack laets for a
number of hours, and ceases suddenly when the kidney resumes
its normal situation. The tumor disappears with the pains, and
a considerable discharge of urine ensues — the pelvis of the kid-
ney empties itself.
At the last meeting of the British Medical Association, be-
fore the Section in Surgery, Mr. R. Clement Lucas made
LEADING ARTICLES.
Jan. 23, 1892.]
LEADING ARTICLES. -MINOR PARAGRAPHS.
101
remarks to much the same purpose. Mr. Lucas's remarks are
published in the British Medical Journal for December 26th.
His conclusions are as follows: Movable kidney is a condition
that during displacement may. and often does, lead to nephry-
drotic destruction, owing to twisting of the pedicle or to press-
ure of the organ upon its duct ; to avoid such danger and to
relieve the patient from pain, all such cases should be treated
by nephrorrhaphy, which is a simple and safe operation; even
when nephrydrosis has already advanced, cases in which it is
clearly due to the mobility may be cured by nephrorrhaphy, and
the remains of the organ saved from further degeneration.
DRUNKENNESS SUCCESSFULLY COMBATED IN NORTHERN
EUROPE.
A fair measure of success has crowned the temperance
legislation of Sweden and Norway. These northern peoples
have been the pioneers in the successful management of that
threatening visitant leprosy, which by governmental effort has
been shorn of some of its harmful powers. They are now
.showing the way in which the baneful drink-habit may be
checked, which has prevailed to an alarming extent among all
classes. The larger towns have been led to put "local option "
in force, and their efforts have been even more successful than
was expected. The Earl of Meath, says the Medical Press and
Circular for December 16th, has lately returned from a visit to
the Scandinavian peninsula, and reports that "the maximum
of good to the community has already been effected with the
minimum of inconvenience to all classes." The system
known by the name of the "Gothenburg system" was first
experimented with, but it was attended with so much
friction and ill-will that it soon gave place to other meth-
ods, one of which is the municipal "trading society " licensing
method.
The municipal council decrees the number of licenses that is
equal to the reasonable requirements of the population. A
monopoly is then given to a society formed by the trading com-
munity, and for a definite term of years. The council retains
full control of the operations of the society. No private person
is allowed to retail spirituous liquors. The retailing of beer
and wine is permitted under a special license. A certain pro-
portion of the profits is applied to pay the shareholders of the
society their preferential interest, after which the surplus must
be assigned to charitable societies and institutions. Last year
there were fifty of these societies in operation. In nearly all of
these localities the same general restrictions exist as to hours
of sale and persons who may buy ; all licensed houses must shut
down from 8 p.m. on Saturday until 8 a. m. on Monday, and no
person under sixteen years of age may be served with alcoholic
drink, no person under intoxication may be served, and no
female bar-tenders arc permitted. The society of the city of
Bergen in Norway has been enabled to show a net profit of
fully one hundred and twenty-five per cent., which is an in-
direct gain to the public in its charitable work and in the re-
pression of inebriety that is found to be incalculable. Brawls,
and wounds, and deaths by violence have been reduced, while
the resources for the hospital treatment of the deserving poor
have been increased.
MINOR PARAGRAPHS.
A BALL OF HAIR IN THE HUMAN STOMACH.
Von Bollinger reports a case in one of the September num-
bers of the Deutsche Medizinal-Zeitung which presents some pe-
culiar features. The patient, a girl sixteen years of age, had
been for three or four years a sufferer from severe pain in the
stomach, with vomiting. These symptoms increased in intensi-
ty until nutrition was so materially interfered with that life
could not be prolonged. Before death a firm tumor in the re-
gion of the stomach could be demonstrated, and a diagnosis of
malignant growth in that organ was made. The autopsy re-
vealed the stomach and duodenum very much enlarged, measur-
ing about twenty inches in length and ten in circumference, and
apparently filled with some hard substance. On opening the
stomach, it was found to be packed with hair, which extended
down into the duodenum for three or four inches, the entire
mass being so firmly wedged into the parts that it was with dif-
ficulty removed in its entirety. The mucous surface of the
stomach was much softened and covered with a thick grayish
fluid which contained fat crystals, sarcina), spores and mycelium
of mold fungus, and also some starch granules. Inquiry into the
history of the case failed to elicit anything that would point to
the patient's having swallowed hair at any time. Schonborn,
in 1883, reported a similar case in which he did a laparotomy
and opened the stomach of a girl fifteen years of age and re-
moved a quantity of hair.
THE DIGESTIBILITY OF CHEESE.
It is the general opinion of the laity that the eating of cheese
after taking food is an assistance to digestion. This view seems
not to be in accord with the result of experiments made by von
Klenze, as recorded in the Allgemeine medicinische Central-
Zeitung, No. 18, 1891. He made very thorough tests of the
various forms of cheese found in the dietary lists. For the ex
periments he used an artificial digestive fluid, to which were
added 50 c. c. of fresh gastric juice and 3 c. c. of hydrochloric
acid. Into this he placed a gramme of the cheese to be ex-
amined. Eighteen varieties were tested, and the following de-
ductions made: Chester and Roquefort cheese took four hours
to digest; genuine Emmenthaler, Gorgonzoler, and Neufchatel,
eight hours; Romadour, nine hours; and Kottenberger, Brie,
Swiss, and the remaining varieties, ten hours. Considering that
in a healthy stomach digestion after an ordinary meal is com-
plete in from four to five hours, it would seem from von
Klcnze's studies, that Chester and Roquefort cheese were the
only kinds that were likely to be digested within this length of
time, and that the other varieties, some of which are largely in
use, not only did not assist digestion, but actually retarded it.
FACET'S DISEASE OF THE CLANS PENIS.
Professor Pick, in the Medicinisch-chirvrgische Rundschau
for December, 1891, reports the case of a patient who came to
him suffering from the following symptoms: For eighteen months
there had been an obstinate eczema of the glans penis. There
was also a tendency to proliferation of the epithelium and to
nodular formation around the glans. An operation for phimo-
sis was called for, and this resulted in temporary improvement
of the eozematous condition. The nodular infiltration, however,
102
MINOR PARA GRAPHS.— ITEMS.
[N. Y. Med. Jocr.,
returned in a short time. Microscopical examination of a po-
tion of the growth showed it to contain cancer cells and numer-
ous psorosperms. With the exception of the presence of the
psorosperms, the whole course of the disease, from the initial
obstinate eczema to the cancerous degeneration, was one of
typical Paget's disease, such as has been described as occurring
in the breasts, the only difference in this case being in the seat
of the disease. What part the micro-organisms played in the
disease it was difficult It) say. but the author thought that they
should be looked for in other suspicious cases of the sort.
HELENIN IX THE TREATMENT OF LEUCORRHCEA.
In the Archives de tocologie et de gynecologic for December
M. Hamonic relates his experience with helenin as a remedy.
He lias found it. worse than useless in gonorrhoea, but capable
of curing cervical leucorrhoea, even without topical treatment.
He prescribes the following formula: Crude helenin, inulin,
each, 15 grains; sugar of milk, q. s. Mix, divide into 100 pills.
From two to four to be taken daily. The inulin is said to have
no remedial power, and to be replaceable by pmvdered licorice
or conserve of roses. Used as an injection, inulin simply irri-
tates the vagina.
IX IIOXOR OF AXTOXIO SCARPA.
Scarpa's place in history has been apparently neglected.
But. according to the Medical Press for January 6th, the people
of Pavia have awakened to the propriety of constructing some
permanent public memorial of their great Antonio Scarpa. The
citizens' committees will receive contributions from foreign
anatomists and others, to the end that Scarpa's space at Pavia
may be appropriately adorned.
THE IXTERX ATIOXAL MEDICAL MAGAZINE.
A new monthly journal of this name has been announced to
appear in January, published by the Lippincott Company, of
Philadelphia. Forensic medicine is to be made one of its special
departments.
ITEMS, ETC.
Infectious Diseases in New York. — We are indebted to the Sanitary
Bureau of the Health Department for the following statement of cases
and deaths reported during the two weeks ending January 19, 1892:
W. i'k ending Jan. 12. Week ending .Ian. 19.
DISEASES.
Cases.
Deaths.
Casec.
Dtaths.
9
■>
9
6
Scarlet fever
223
33
242
33
1
3
4
■1
132
12
152
9
Diphtheria ....
128
46
115
46
0
0
0
0
Erysipelas
2
0
2
0
16
0
9
0
0
8
0
2
1 1
ii
0
0
The New York County Medical Association. — At the recent annual
meeting officers for the ensuing year were elected as follows : Presi-
dent, Dr. S. B. Wylie MeLeod : vice-president, Dr. William T. White;
recording secretary, Dr. P. Brvnberg Porter ; corresponding and statis-
tical secretary, Dr. Augustus D. Ruggles ; treasurer, Dr. John H. Hin-
ton ; member of the executive committee. Dr. Beverhout Thompon.
The association now has a membership of over seven hundred.
The Alvarenga Prize of the College of Physicians of Philadelphia.
— The college announces that the next award of the Alvarenga prize,
being the income for one year of the bequest of the late Senor Alva-
renga, and amounting to about one hundred and eighty dollars, will be
made on July 14. 1892. Essays intended for competition may be upon
any subject in medicine, and must be received by the secretary of the
college on or before May 1, 1892. It is a condition of competition
that the successful essay or a copy of it shall remain in possession of
the college.
The New York Pathological Society. — At the next meeting, on
Wednesday evening, the 27th inst., Dr. Francis Delafield will illustrate
the lesions of the different forms of Blight's disease by photomicro-
graphs projected on the screen.
The New York Surgical Society. — At the next meeting, on Wednes-
day evening, the 27th inst., Dr. Wyeth will read a paper on Ether Xar-
cosis as induced by the Ormshy Inhaler.
A Misquotation.— An esteemed correspondent calls our attention to
the fact that, in an article published in the Journal for January 9th, on
page 42, the expression facilis descensus Averni was incorrectly printed
" facile descensus Averno."
New Remedy for Phthisis. — ' The latest remedy for phthisis is
monochlorophcnol. It is described as a poweiful antiseptic, free from
the disagreeable odor and from the caustic and irritant action of its
related compound, trichlorophenol. It has been introduced by Tac-
chini, a chemist of Pavia, and successfully tried by several Italian
doctors. It is recommended as an inhalation in various affections of
the respiratory passages, and especially in pulmonary tuberculosis.
Monochlorophenol is very volatile, giving off heavy vapors on heating,
which are antagonistic to bacilli." — British and Colonial Druggist.
The Death of Dr. Henry Ingersoll Bowditch, of Boston, took place
at his home, in that city, on Thursday, the 14th inst. The deceased
was in his eighty-fourth year. For many years, as a teacher, as a prac.
titioner, and as a participant in matters pertaining to the welfare of
the profession as a body, he had been a prominent figure. Perhaps he
was best known for bis active part in perfecting and popularizing the
operation of paracentesis thoracis and for his elaborate researches on
telluric conditions as factors in the aetiology of pulmonary consumption.
Nobody in the American profession was more highly esteemed than Dr.
Bowditch.
The Death of Dr. Daniel Ayres, of Brooklyn, in his sixty-ninth year,
occurred on the 18th inst., after an illness of two weeks. As a surgeon
and pathologist. Dr. Ayres held a high rank. He took a lively interest
in the City Hospital and in the Long Island College Hospital at the
time of their inception. He was a liberal donor to the Hoagland
Laboratory and the Wesleyan University, the latter institution receiv-
ing from him gifts of lands and money valued at nearly $375,000. He
was honored with the degree of LL. D. by that institution in 18G5. He
was a frequent contributor to the journals, and was a clear and cogent
teacher of surgery and surgical pathology.
The Death of Dr. Charles Martin, of the Navy, a medical director
on the retired list, took place in Xew York on Thursday, the 14th inst.
He had been a medical officer of the navy since 1848.
The Death of Dr. Colin Mackenzie, on Saturday of last week, de-
prived the X ew York profession of one of its most estimable members.
Dr. Mackenzie w as a graduate of the Cleveland Medical College, of the
class of 1860, but most of his professional life had been spent in Xew
York.
Army Intelligence. — Official List of Changes i)i the Stations and
Duties of Officer* serving in 'lie Medical Department, Cnited States
Army, from January 3 to January 16, 1892 :
Glexxan, James D., First Lieutenant and Assistant Surgeon, is granted
leave of absence for one month on surgeon's certificate of disability,
with permission to go beyond the limits of the department.
Kean, Jeffeksox R., Captain and Assistant Surgeon. The leave of ab-
sence granted on surgeon's certificate of disability is extended three
months on account of sickness.
Patzki, Jri.it s II., Major and Surgeon, and Birtox, Henry G., Captain
and Assistant Surgeon, having been found incapacitated for active
Jan. 23, 1892.1 ITEMS.— LETTERS TO THE EDITOR.— PROCEEDINGS OF SOCIETIES.
103
service by the •Army Retiring Board, will proceed to their homes,
and on arrival there report by letter to the Adjutant-General of the
army.
Kimball, James P., Major and Surgeon, is granted leave of absence for
six months, with permission to go beyond ihe sea, to take efTeet on
or about January 27, 1802.
O'Reilly, Robert M., Major and Surgeon, Fort Logan. Colorado, is
granted leave of absence for twenty-one days.
KlLBOURNE, Henry S., Captain and Assistant Surgeon, is relieved from
duty at Willett's Point, New York, and will report in person to the
Superintendent of the D. S. Military Academy, West Point, New
York, for duty at that station, relieving W. Fitzhv.gh Carter, Cap-
tain and Assistant Surgeon. Upon being relieved by Captain Kil-
bourne, Captain Carter will report in person to the commanding
officer, Willett's Point, for duty at that station.
Patzki, Julius H., Major and Surgeon, having been found, by the
Army Retiring Board, incapacitated for active service on account of
disability incident to the service, is, by the direction of the Presi-
dent, retired from active service, to take effect January 9, 1892,
under the provisions of Sec. 1251, Revised Statutes.
Fisher, Walter W. R., Captain and Assistant Surgeon, is granted leave
of absence for one month.
Wood, Marshall W., Captain and Assistant Surgeon, now on leave of
absence, will report to the commanding officer, Fort Columbus, New
York, for temporary duty at that post during the absence of Cap-
tain W. W. R. Fisher.
Naval Intelligence. — Official List of Changes in the Medical Corps
of the United States Navy for the two weeks ending January 16, 1892:
Pigott, M. R., Assistant Surgeon. Detached from the Naval Hospital,
Mare Island, Cal., and ordered to the U. S. Steamer Baltimore.
Stitt, E. R., Assistant Surgeon. Detached from the U. S. Steamer Bal-
timore, ordered home, and two months' leave of absence granted.
Guest, M. S., Assistant Surgeon. Ordered to the Navy Yard, Nor-
folk, Va.
White, C. H., Medical Inspector. Detached from the U. S. Steamer
Charleston, to proceed home, and two months' leave granted.
Parker, J B., Surgeon. Ordered to the U. S. Steamer Charleston.
Parker, J., Surgeon. Ordered to the U. S. Steamer Charleston.
White, C. H , Medical Inspector. Detached from the U. S. Steamer
Charleston and ordered home.
Lung, George A., Assistaut Surgeon. Ordered to examination for
promotion.
Bryant, Patrick H., Assistant Surgeon. Ordered to examination for
promotion.
Von Wedekind, Luther L., Assistant Surgeon. Ordered to examina-
tion for promotion.
Society Meetings for the Coming Week :
Monday, January 25th : Medical Society of the County of New York ;
Boston Society for Medical Improvement; Lawrence, Mass., Medi-
cal Club (private) ; Cambridge, Mass., Society for Medical Improve-
ment ; Baltimore Medical Association.
Tuesday, January 26th : New York Academy of Medicine (Section in
Laryngology and Rhinology) ; New York Dermatological Society
(private); Buffalo Obstetrical Society; Medical Societies of the
Counties of Onondaga (semi annual — Syracuse) and Putnam (semi-
annual), N. Y.; Boston Society of Medical Sciences (private).
Wednesday, January 27th: New York Surgical Society; New York
Pathological Society ; Metropolitan Medical Society (private) ;
American Microscopical Society of the City of New York ; Medical
Society of the County of Albany, N. Y ; Auburn, N. Y., City Medical
Association; Berkshire, Mass. (Pittsfield), and Middlesex, Mass.,
North (Lowell) District Medical Societies; Gloucester, N. J. (quar-
tet ly), County Medical Society.
Thursday, January 28th: New York Academy of Medicine (Section
in Obstetrics and Gynaecology); New York Orthopaedic Society;
Brooklyn Pathological Society; Roxbury, Mass., Society for Medical
Improvement (private).
fetters to % debitor.
QUANTITATIVE TESTS FOR UREA.
Brooklyn, January 18, 1892.
To the Editor of the New York Medical Journal :
Sie: Permit me a few words in reply to the letters of Dr.
E. H. Bartley and Dr. J. M. Van Cott, Jr., published in the
Journal of Janu-iry 16th, and referring to my paper on Quanti-
tative Tests for Urea.
Dr. Bartley's criticism of my employing a cork in the n<e of
his apparatus instead of the thumb, as he directs, is a just one,
and I admit that he is right, the readings being too high by just
so much of the scale as is taken up by the cork. I fully in-
tended to make this correction later in connection with a fur-
ther paper on tireametry, which 1 have not had the time as
yet to w rite, and I regret the unintentional injustice done to the
doctor's apparatus. The doctor omitted to state in his letter
that the reason why I found the pressure in the tube too great
to withstand w as because the tube was two or three inches
shorter than it should be and than the ones he is in the habit of
using. I obtained the tube from the original makers, Eimer &
Amend.
His further statement that I only obtained 1*65 per cent, of
urea from a two-per-cent. solution by employing his solution is
erroneous, as this has reference only to the use of a solution of
one ounce of bromide of potassium to three of chlorinated soda
in Doremus's apparatus and not in his. The paragraph in my
paper which contains this statement occurs in the course of the
description of Doremus's apparatus, and has no reference to
Bartley's apparatus.
The criticism of Dr. Van Cott is partly answered with the
last explanation. I only used his name as authority for the
statement that the use of a solution of. one ounce of bromide of
potassium in three of chlorinated soda in Doremus's apparatus
yielded 165 per cent, of urea of a two-per-cent. solution em-
ployed, and this he admits is correct.
The other points which he mentions are not a criticism on
my paper, but they should have been offered as an improve-
ment on the method employed by Doremus. The solution of
bromide of potassium can not be used in Doremus's apparatus
under the instructions as given by its inventor. If Dr. Van
Cott's suggestion, as stated at the meeting where my paper was
read, to fill the bulb of the apparatus with water after the first
evolution of gas has ceased, and then close its opening with the
thumb and thoroughly agitate the fluids in the long arm, proves
to be correct, then this is an improvement and an addition to
my statements, but it is not properly a criticism on my paper.
J. 0. Bierwieth, M. D.
fjroeeebings of Societies.
HARLEM MEDICAL ASSOCIATION.
Meeting of October 7, 1801.
The President, Dr. M. C. O'Beien, in the Chair.
{Dr. Arthur H. Leary. Secretary.)
Longevity of the Tubercle Bacillus ; a Convenient and
Rapid Method of coloring the Organism — Dr. Henky Hei-
man read a paper on this subject. (To be published )
Dr. R. Van Santvoobd said that there was an evident neces-
sity of thoroughly mixing the antiseptic fluid, such as the bi-
chloride, with the expectorated material from a phthisical pa-
104
BOOK NOTICES.
[N. Y. Med. Joir
tient. The tubercle was often inclo-ed in hard and tenacious
masses, which were often with difficulty attacked by the disin-
fecting material. An alkaline solution was of benefit to help
disseminate the masses. He was in the habit of employing a
process in staining the Bacillus tuberculosis with a fuchsin solu-
tion containing five per cent, of carbolic acid, decolorizing and
staining it simultaneously with a thirty-three-per-cent. solution
of sulphuric acid and methylene blue.
The President said that it was his opinion that all tubercu-
lar glands found in scrofulous children should be extirpated and
the parts thoroughly cleansed with disinfecting solutions. This
procedure might prevent general phthisis later in life. He ad-
vised patients suffering frond phthisis to employ powders or tab-
lets of bichloride to make solutions themselves to disinfect the
sputum. It was a noteworthy fact that a large number of in-
ternes of the large hospitals died of phthisis. While he was in
Bellevue Ho-pital it was a custom of some of the young doctors
to employ hypodermics of ether, etc., in patients in the third
stage of phthisis, and then wait to see how long it took to de-
tect the odor in the breath. They thereby had run great risks
of contracting the disease. Three of the young men with him
in the hospital at that time had died of phthisis a few years
later.
Dr. E. L. Cocks said that he frequently pressed the cheesy
material between two slides, so as to distribute it evenly and the
more readily discover the Bacillus tuberculosis. Considering the
ease and rapidity with which this bacillus might be stained and
demonstrated, physicians were placed in very responsible posi-
tions toward their patients. It was their duty to examine the
sputum in doubtful or suspected cases. A child seven years
old had come under his observation with very few symp-
toms except gastric disturbance. She had been able to play-
around the room as usual. Within a few hours, however, stra-
bismus had developed, the head had been thrown backward,
followed by convulsions and death. The post-mortem had
shown acute tuberculosis throughout all the serous membranes.
In the lungs there had been a number of cheesy masses.
Dr. Heiman said, in reply to Dr. Martin, as to whether he
had found the Bacillus tuberculosis present in any case where
there were no physical signs, that he had so found the bacillus
in these cases. He then made mention of a case in which pul-
monary haemorrhage had been the first premonition of trouble;
here a careful search had revealed the bacillus.
Dr. E. Mater said that he would like to mention an interest-
ing case. A middle-aged woman had complained of hoarseness
and slight cough, fever, and general malaise. There had been
no positive subjective symptoms of phthisis. The pharyngeal
wall had been very pale, a condition frequently noted in phthisis,
and was s:iid to be almost pathognomonic. The arytenoid
cartilage had been thickened and (edematous, and in one place
an ulcerated condition had existed. The sputum had been
examined and bacilli had been found. The physical examination
of the lungs had been negative.
Dr. F. von Raitz said that a case had come under his obser-
vation where there had been slight cough and hectic, but ab-
solutely no physical signs of phthisis could he found. But
bacilli bad been found in the sputum and the patient had died
four months later of pulmonary tuberculosis.
Dr. W. F. Martin remarked that it was his belief that boil-
ing water placed in the cuspidor of phthisical patients would
answer a very beneficent purpose. This would disinfect the
mass and keep the particles from being disseminated about the
room.
Dr. E. L. Cocks said that a patient of his had gone under
the Koch treatment for lupus vulgaris. The growth had been
reduced in size, but the bacilli could still be scraped off and
demonstrated under the microscope. The case was now in as
bad a state as before the treatment.
The President said that he also had had a patient who had
a very severe lupus of the face and who had taken the Koch
treatment and had died the next day.
Dr. Mayer said that a case recently under his treatment
would further illustrate the value of microscopic examination of
sputum in doubtful cases. A man, aged forty-four years, of
previous good health, was rather pale and not rugged. He had
been treated for naso-pharyngitis. Examination had revealed a
small cheesy mass in the tonsillar region, beneath which was a
raw ulcerated surface. It had been considered to be either a case
of syphilis or one of lupus. A nti syphilitic treatment had been
employed, but to no purpose, as the ulcerated condition had
spread rapidly. Various physician" who had also seen the case
had likewise suspected syphilis, but no history of that disease
could be obtained, either past or present. Now for the first
time the sputum was examined and the bacilli were found in
large numbers. The patient had died three months later with
general tuberculosis.
Dr. M. Einhorn remarked that in manipulating sputum for
examination it was advisable to heat the mass and pour off the
liquid which would rise to the top. The solid material would
sink to the bottom and would contain the bacilli. We little
realized the virulency and extreme vitality of this bacillus.
Successful inoculation had been practiced on rabbits after keep-
ing the bacillus eight years.
Dr. Heiman said that it had been found to be a fact that a
large number of patients had been attacked with tubercular
meningitis a short time after the extirpation of tubercular glands.
The method of preparing the specimen for examination was
so rapid and simple that it could be done in a few minutes<
almost while the patient was dressing after a physical examina-
tion. It had been stated that ten per cent, of the internes of the
large hospitals died of phthisis a short time after leaving them.
|iooli ftoticcs.
A Practical Treatise on the Diseases of Women. By T. Gail-
lard Thomas, M. D., LL. D., Professor Emeritus of Diseases
of Women in the College of Physicians and Surgeons, New
York; Consulting Surgeon to the New York State Woman's
Hospital, etc. Sixth Edition, enlarged and thoroughly re-
vised by Paul F. Munde, M. D., Professor'of Gynaecology at
the New York Polyclinic and at Dartmouth College; Gyuae-
cclogist to Mount Sinai Hospital, etc. Containing Three
Hundred and Forty-seven Engravings on Wood. Philadel-
phia: Lea Brothers & Co., 1891.
When the popularity of Dr. Thomas's book is recalled, and
it is remembered that it has been translated into all the conti-
nental and into some Oriental languages, it seems strange that
since 1880 no new edition of it should have appeared. Clinical
teachers become, through their writings and instruction, to a
large extent the molders of professional opinion in the branches
cf medicine to which they devote themselves. Especially is this
true in the department of gynaecology, where repeated clinical
observation becomes the source of knowledge. The readers of
medical literature will therefore appreciate the reappearance, in
handsome form, of Dr. Thomas's book, revised by so careful an
observer and so facile a writer as Dr. Munde. In his preface
Dr. Munde states that it was at the request of the author of the
book that he undertook the revision, not without misgivings, as
the task involved a labor equal to the writing of an original
Jan. 23, 1892.]
BOOK NOTICES.
105
book; and because be might find it impossible to subordinate
bis views to tbose of Dr. Thomas. The Litter difficulty has been
obviated in the text by placing the initials of either writer in
brackets where individual opinions clash. Considering the deli-
cacy of his task, Dr. Munde can felicitate himself upon bis
achievement. Indeed, so thorough is his revision and so nu-
merous are his interpolations that the book might almost be
called his own.
It is impossible in so short a space to review the work ac-
cording to its deserts. Only the most important points can be
touched upon. Dr. Munde has brought the description and
classification of gynaecological diseases up to the most approved
pathology of the day, and the treatment advocated is of the
same standard. For instance, a new chapter is included in the
book on electricity as a therapeutic agent in gynaecology, in
which a middle ground is taken by the writer. He advocates
the use of the galvanic or faradaic current in some cases, but
seems to prefer the knife where electricity is sometimes indi-
cated. The chapter on congenital malformations has been re-
written and much new and valuable material added. Dr.
Thomas's belief that the perineal body represents "the inverted
keystone of an arch " is corrected in this edition. New opera-
tions are described for the repair of the lacerated perina?um, for
cystocele, and for proctocele. The use of pessaries is recom-
mended with the same fervor as in previous editions, the author
and reviser holding a middle ground here again. In the discus-
sion of uterine displacements, however, the reader familiar with
Dr. Thomas's former works will find marked changes. Dr.
Munde says, for example, in opposition to the views of the au-
thor: " At the present day anteflexion is generally consider ed
to be, in its minor stages, a physiological (even congenital) con-
dition, only productive of evil under accidental complications,
and retroflexion is usually looked upon as a sequel to or com-
panion of retroversion, and of no special consequence in itself."
Dr. Munde, in the discussion following, attributes the patho-
logical effects of displaced uteri to backward displacements rather
than to forward displacements. This is a different view from
the one Dr. Thomas takes, as is Dr. Munde's belief that retro-
flexions, apart from retroversions, have no distinct pathological
and clinical aspects.
Much original work has been expended upon the diseases of
the ovaries, and newly recognized diseases have been included.
The last chapter in the book is entirely new and is devoted to
the discussion of diseases of the mammas. A new form of dress-
ing after the operation for mastitis — the " sponge dressing," not
generally known — is described at length.
Typographically, the book presents a fine appearance ; most
of the cuts are new and well executed. The work is an impor-
tant addition to American medical literature, and will prove in-
dispensable to the student and physician.
Ileafness and. Discharge from, the Ear. The Modern Treatment
for the Radical Cure of Deafness, Otorrhcea, Noises in the
Head. Vertigo, and Distress in the Ear. By Samuel Sexton,
M. D., assisted by Alexander Duane, M.D. New York:
J. II Vail & Co., 1891. Pp. 12-13 to 89.
This little volume, which has afforded us so much gratifica-
tion in its perusal, is practically an embodiment of the author's
well-known papers on the excision of the drum-head and ossi-
c\e< which have appeared from time to time in different medi-
cal periodicals. It presents what li.i.s long been a necessity —
namely, a practical, concise, and careful review of the work
done in this direction of modern aural surgery. A short sketch
of surgical attempts for the relief of deafness* from the earliest
times is given, and our attention is called to the success of mod-
ern operators in this line in Germany and America, as regards
both the permanency of the benefit secured and the satisfactory
character of the immediate effects themselves. Failure in the
final result among operators in former times was largely due to
regeneration of the drum-head, owing to which the good effects
following their operative procedures usually disappeared. The
operation devised and performed by Sexton is more successful
than those formerly practiced, since regeneration of the drum-
head is, as a rule, completely prevented. Should this take
place, a secondary operation is readily performed, resulting al-
most invariably in complete success. In most cases, however,
there seems to be very little or no tendency to regeneration.
Attention is called to the great importance of avoiding every
manipulation tending to injure or irritate the drum, both during
the operation and afterward, and neglect of this undoubtedly
caused many of the failures in former operative procedures.
Dr. Sexton's operation for the removal of the drum-head and
ossicles is now more or less well known in its details and needs
not to be reviewed here. If conducted with care and skill, the
operation yields highly satisfactory results, and offers to the
patient in its performance very little that is formidable. A rest
of a day or so will see him again able to attend to his daily
occupation. For the surgeon, however, the operation is one
which makes considerable demands on his skill, steadiness, and
knowledge — reasons enough, we presume, why it has obtained
but little currency even among otologists.
The operation is held to be indicated in all cases of chronic
catarrhal otitis media which display a progressive tendency
and in which the subjective symptoms are referable mainly
to the obstruction existing in the middle ear, and not to any
marked implication of the labyrinth. Since the longer the dis-
ease is allowed to run its course, the greater the damage result-
ing to the parts, the obvious deduction is that the operation
should be done as early as possible.
A number of instructive histories of cases are given as ex-
amples of the gratifying results of this operation in chronic ca-
tarrh and chronic purulency of the middle ear, a perusal of
which will be found of great interest. Great emphasis is laid
on one point in connection with the after-treatment — namely,
that one should refrain from all meddlesome interference iciih
the ear. Simple cleansing of the parts when necessary is all that
is advisable. The volume closes with a short summary and gen-
eral outline of the author's conclusions in regard to the opera-
tion.
Human Monstrosities. By Barton Cooke Hirst, M. D., Pro-
fessor of Obstetrics in the University of Pennsylvania, and
George A. Piersol, M. D., Professor of Histology and Em-
bryology in the University of Pennsylvania. Part I. Illus-
trated with Seven Photographic Reproductions and Eighteen
Woodcuts. Philadelphia: Lea Brothers & Co.. 1891.
As the authors state, there is no English work on teratology
that is comparable to those of Geoffroy Saint-Hilaire, of Forster,
or of Ahlfeld, and, as those works are comparatively rare and
inaccessible, aside from the disadvantage of an alien tongue,
there is every reason to believe that these volumes will find an
audience more extensive than one composed of anatomists and
embryologists solely.
It seems to us that the authors have been wise in accepting
in general the classification and nomenclature employed by
Saint-Hilaire, thus avoiding the further confusion that would
arise from yielding to the temptation to originate a new classifi-
cation and introduce new and not necessarily better terms.
Klebs's classification of hermaphrodites and Fdrster's classifica-
tion of double autositic monsters are substituted for Saint-
Hilaire's.
106
BOOK XOTICES.
[N. Y. Med. Joub.»
The production of malformations is by variations in growth,
by defective union, by fission, or by artificial means. Regard-
ing the first cause, the authors believe that arrested develop-
ment has its origin in a more deeply seated cause than merely
mechanical apposition ; the insufficient primary growth in the
second cause seems also due to some deeply seated central cause
profoundly influencing development: so with fission, a local
cause is insufficient to explain the variation ; while experiment
has shown that >l violent agitation, marked variations in tempera-
ture, and disturbance of the normal respiratory interchange, are
all forces which, when acting on the early embryonic trace, are
capable oi producing profound alterations in the developmental
processes."
The evident care that has been bestowed upon the prepara-
tion and production of this work foreshadows a second part of
no less interest, and it is to be hoped that the authors will re-
ceive the professional support that they will undoubtedly de-
serve.
The Surgical Treatment of Wounds and Obstruction of the
1 htcxt i ins. By Edward Martin, M. I)., Instructor in Opera-
tive Surgery, University of Pennsylvania, etc., and H. A.
Hare, M. D., Professor of Therapeutics, Jefferson Medical
College. Philadelphia: W. B. Saunders, 1891 . [Fiske Prize
Fund Dissertation, No. xl. Price, $2. J
This essay was awarded the Fiske Prize of the Rhode Island
Medical Society in 1890, and the authors state that their con-
clusions are based upon the results of two years' original research
in the laboratory. The various chapters treat of congenital mal-
formations ; intussusception : internal strangulation; volvulus;
obstruction from foreign bodies; intestinal paralysis; chronic
obstruction; peritonitis; the diagnosis and general, special, and
surgical treatment of obstruction ; and wounds and rupture of
the intestines.
The special treatment of intestinal obstruction is very care-
fully worked out, the authors urging rectal feeding only with
whisky, beef peptoids, eggs and milk, and hot water to relieve
the thirst, hypodermic injections of morphine and atropine to
relieve the pain, and gastric lavage to remove all decomposing
substances in the stomach. On account of the patulous condi-
tion of the pylorus, if the water used for lavage has boric or
salicylic acid added, intestinal antisepsis may be furthered.
They advocate injections of warm saline solutions at a pressure
of two to eight pounds in obstruction, though urging great cau-
tion on account of the number of ruptures that have been re-
ported as resulting from the employment of this procedure.
In paralytic obstruction they have had good results from a
powerful faradaic current. Gaseous or aerial insufflation they
believe to be secondary in value to the use of warm water.
One very important feature they urge that is too often ig-
nored, not only by writers of text-books on abdominal surgery,
but by the surgeons themselves, is the preservation of heat
during operations. Referring first to Brunton's and their own
experiments showing that lethal doses of chloral are not fatal if
the bodily heat is kept up, and to a number of thermometric
observations taken in the axilla and in the rectum of patients
before and after anaesthesia, showing an average fall of tempera-
ture of 2-5° F., they urge that hot- water cans be placed about
the patient during the operation, or, better, that he be placed
on a hi it- water bath.
They have made further experiments, showing that the
water should have a temperature, both in the water bath and
in enemata, of from 105° to 108°, as a higher temperature may
produce heat dyspnoea.
The surgical treatment of these intestinal disorders and
wounds is carefully considered; and the table of cases of cceli-
otomy for gunshot wounds of the abdomen is the most complete
one with which we are acquainted.
The book will prove very valuable to any one interested in
this branch of surgery, and the authors are to be complimented
upon the conciseness with which they have treated their theme.
A Manual of Venereal Diseases. Being an Epitome of the most
Approved Treatment. By Everett M. Culver, A. M., M. D.,
Pathologist and Assistant Surgeon, Manhattan Hospital, of
New York City, Member of the American Association of
Andrology and Syphilology, and late of the Department of
Venereal Diseases of the Vanderbilt Clinic ; and James R.
Hayden, M. D., Lecturer on Venereal Diseases, University
of Vermont, Chief of Clinic, Venereal Department of Van-
derbilt Clinic, College of Physicians and Surgeons, New
York. With Illustrations. Philadelphia: Lea Brothers &
Co., 1891.
In this little volume the authors have attempted to give the
student and practitioner an epitome of our knowledge of the
venereal diseases. They have succeeded admirably. The book
contains nothing foreign to the subjects to be treated, and
abound* in hints and suggestions of practical value. From their
opportunities of observation the authors have had a wide range
of experience, and that they have cultivated these opportunities
a perusal of their work will testify. Tt is not too much to say
that the book is one of the best of the manuals of its kind for
the busy physician and for the student who has not the time to
go more deeply into the subject.
On the Pathology and Treatment of Glaucoma, being a Revised
Publication, with Additions, of the Erasmus Wilson Lect-
ures, delivered at the Royal College of Surgeons of England
in March, 1889. By Priestly Smith, Ophthalmic Surgeon
and Clinical Lecturer on Diseases of the Eye, Queen's Hospi-
tal, Birmingham. With Sixty-four Illustrations by the Au-
thor, and Twelve Photo-zincographs. London : J. & A.
Churchill. 1891. Pp. xi-198.
Since the lectures of which this volume is a revised publica-
tion were delivered, in 1889, several parts of the subject of
glaucoma have been more fully worked out, and the results ob-
tained have been incorporated with the original text. The addi-
tions have chiefly been with regard to the causes of glaucoma-
tous complications after operations for cataract, the connection
between primary glaucoma and certain dimensional variations
in the eye, the condition of the vortex veins in glaucoma, a de-
scription of the secondary changes produced by high pressure
in the eye. and a more complete consideration of the treatment.
The work now furnishes us with a very valuable compendium of
what is at present known with regard to this disease.
Quoin's Elements of Anatomy. Edited by Edward Albert
Schafer, F. R. S., Professor of Physiology and Histology in
University College, London, and George Dancer Thane,
Professor of Anatomy in University College, London. In
Three Volumes. Vol. I, Part ii. General Anatomy or His-
tology, by Professor Schafer. Illustrated by nearly 500 En-
gravings, many of which are Colored. Tenth Edition. Lon-
don : Longmans, Green, & Co., 1891.
Qcain's Anatomy does not need any introduction to the
medical fraternity of this country. It has been considered one
of our most reliable as well as most popular text-books for many
years, and there are few among us who will not welcome it as
an old and tried friend.
The subdivision of each volume of this edition into parts
commends itself as making the work less cumbersome and mor
Jan. 23, 1892.]
BOOK XOTICES.
107
easy of access. The part at present before^us gives a more
thorough exposition of histology than was given in the previous
editions. It is written clearly and pleasantly, and forms by it-
self a really valuable work on this subject. It is profusely
and well illustrated and creditably got up.
A Text-hook of Physiology. By M. Fostee/M .' A., M. 1)., LL. D.,
F. Ii. S.,' Professot of Physiology in^'the University of ^Cam-
bridge, etc. Fourth American, from the Fifth EnglisirEdi-
tion, thoroughly revised, with Notes, Additions, and Two
Hundred and Eighty-two Illustrations. Philadelphia: Lea
Brothers & Co., 1891.
The fact that since this edition has been going through the
American press a sixth English edition has been published suffi-
ciently attests the deservedly high reputation enjoyed by this
work.
In the present volume the author has added some histological
data in order that they may be fresh in the student's mind in
entering upon the consideration of physiological questions; and
he has incorporated into the text those discoveries in physiology
that have been made since his former revision.
The work is fully abreast of the times,"anu will continue to
hold the position that it has won.
BOOKS, ETC., RECEIVED.
Treatise on Gynaecology, Medical and Surgical. By S. Pozzi, M. D.,
Professeur agrege h la Faculte de medecine, etc. Translated from the
French Edition under the Supervision of and with Additions by Brooks
H. Wells, M. D., Lecturer on Gynecology at the New York Polyclinic,
etc. Vol. I. With Three Hundred and Five Wood Engravings and
Six Full-page Plates in Color. New York : William Wood & Co., 1891.
Pp. xxii-581.
Physical Diagnosis : a Guide to Methods of Clinical Investigation.
By G. A. Gibson, M. D., D. Sc., F. R. C. P. Ed., Lecturer on the Princi-
ples and Practice of Medicine in the Edinburgh Medical School, and
William Russell, M. D., F. R. C. P. Ed., Pathologist to the Royal In-
firmary of Edinburgh. With One Hundred and One Illustrations. New
York : D. Appleton & Co., 1891. Pp. xiii-376. [Price, $2.50.] [The
Students' Series.]
Botany : a Concise Manual for Students of Medicine and Science.
By Alex. Johnstone, F. G. S., Lecturer on Botany, School of Medicine,
Edinburgh. With One Hundred and Sixty-four Illustrations and a
Series of Floral Diagrams. New York: D. Appleton & Co., 1891. Pp.
xiv-260. [Price, $1.75.] [The Students' Series.]
Surgical Anatomy for Students. By A. Marmaduke Shield, M. B.
(Cantab.), F. R. C. S., Senior Assistant Surgeon, Aural Surgeon, and
Teacher of Operative Surgery, Charing Cross Hospital. New York: D.
Appleton & Co., 1891. Pp. x-226. [Price, $1.75.] [The Students'
Series.]
Tubercular Peritonitis. By A. Vander Veer, M. D., Albany, N. Y.
[Reprinted from the Virginia Medical Month/;/.]
Report of a Case of Hsematophilia, or a Family of Bleeders. By A.
Vander Veer, M. D., Albany, N. Y. | Reprinted from the Archives of
Paediatrics.]
Report of Cases of Cholecystotomy, with Special Reference to the
Treatment of Calculus lodging in the Common Duct. By A. Vander
Veer, M. D., Albany, N. Y. [Reprinted from the Transactions of the
Association of American Obstetricians arid Gynaecologists.]
Concealed Pregnancy : its Relation to Abdominal Surgery. By A.
Vander Veer, M. D., Albany, N. Y. [Reprinted from the American
Journal of Obstetrics and Diseases of Women and Children.]
Retro-peritoneal Tumors : their Anatomical Relations, Pathology,
Diagnosis, and Treatment. With a Report of Cases. By A. Vander
Veer, M. D., Albany, N. Y. [Reprinted from the American Journal of
the Medical Sciences.]
Deafness and Discharge from the Ear. The Modern Treatment for
the Radical Cure of Deafness, Otorrhuea, Noises in the Head, Vertigo,
and Distress in the Ear. By Samuel Sexton, M. D., assisted by Alexan-
der Duane, M. D. New York : J. H. Vail & Company, 1891. Pp. 12-
13 to 89.
Sixteenth Year Book, containing the Annual Report of the Board
of Managers of the New York State Reformatory at Elmira. For the
Year ending September 30, 1891.
The Hydriatic Treatment of Typhoid Fever according to Brand,
Tripier and Bouveret, and Vogl. By Chr. Siler, M. D., Ph. D., Pro-
fessor of Histology in the Medical Department of the Western Reserve
University, Cleveland, Ohio. Published by Chr. Siler. Pp. 340.
A Practical Resume of Modern Methods employed in the Treatment
of Chronic Articular Osteitis of the Hip. By Charles F. Stillman, M.
Sc., M. D., Chicago. Detroit : George S. Davis, 1891. Pp.118. [The
Physicians' Leisure Library.]
The Improvement of Evacuators for Litholapaxy and the Later De-
velopments of the Operation. By Otis K. Newell, M. D., Boston.
[Reprinted from the Medical Record.]
The Treatment of Urethral Stricture, and a New Divulsor for Rapid
Dilatation. By Otis K. Newell, M. D., Boston. [Reprinted from the
Medical Record.]
How should we proceed when Abdominal Tumors are complicated
by Pregnancy? By James F. W. Ross, M. D., L. R. C. P. Eng. To-
ronto, Canada. [Reprinted from the Transactions of the American
Association of Obstetricians and Gynaecologists.]
Clinical Aspects and ^Etiological Relations of Cutaneous Tubercu-
losis. By James C. White, M. D., Boston. [Reprinted from the Boston
Medical and Surgical Journal.]
A Hint to the Literary Men of the Profession. By Charles Perry
Fisher. [Reprinted^from the Medical News.]
The Application of Sacral Resection to Gynecological Work. By
E. E. Montgomery, M. D., Philadelphia. [Reprinted from the Transac-
tions of the American Association of Obstetricians and Gynaecologists.]
Criminal Aristocracy, or the Maffia. By Arthur MacDonald, Worces-
ter, Mass. [Reprinted from the Medico-legal Journal.]
On the Ferments contained in the Juice of the Pineapple (Ananassa
sativa), together with some Observations on the Composition and Pro-
teolytic Action of the Juice. By R. H. Chittenden, assisted by E. P.
Joslyn and F. S. Meara. [Reprinted from the Transactions of the Con-
necticut Academy.]
The Technique of Cerebral Surgery. By G. Wiley Broome, M. D.,
St. Loins. [Reprinted from the Weekly Medical Review.]
Report of a Case of Spina Bifida, with Partial Motor and Sensory
Paralysis of both Extremities, Complete Paralysis of the Sphincters of
the Bladder and Rectum, Double Equino-varus, and Purulent Bursitis.
By H. Augustus Wilson, M. D., Philadelphia. [Reprinted from the
Transactions of the American Orthopedic Association.]
The Aseptic Closure of Long-standing Sinuses having their Origin
in Tubercular Joints. By H. Augustus Wilson, M. D., Philadelphia.
(Read before the Philadelphia Academy of Surgery, November 2,
1891.)
Scope of Orthopedics — Forms of Club-foot Tenotomy. By H.
Augustus Wilson, M. D., Philadelphia. [Reprinted from the Medical
and Surgical Reporter.]
Hand Disinfection. By Howard A. Kelly, M. D., Baltimore. [Re-
printed from the American Journal of Obstetrics and Diseases of
Women and Children.]
The Ideal Dressing for the Abdominal Wound. By Howard A.
Kelly, M. D., Baltimore. [Reprinted from the American Journal of
Obstetrics and Diseases of Women and Children.]
Osteo-pcnthesis. By B. Merrill Rickets, M. D., Cincinnati, Ohio.
[Reprinted from the Journal of the American Me, Vied Association.]
The Surgica] Treatment of Pyloric Stenosis, with a Report of Fif-
teen Operations for this Condition. By N. Senn, M. D., Ph. D., Chi-
cago. [Reprinted from the Medical Record.]
A Code of Rules for the Prevention of Infectious and Contagious
Diseases in Schools. Being a Series of Resolutions passed by the Medi-
cal Officers of Schools Associations. Third and Revised Edition.
London: J. & A. Churchill, 1891.
The Middlesex Hospital. Reports of the Medical, Surgical, and
Pathological Registrars for the Year 189o. London: H. K. Lewis, 1891.
108
MISCELLANY'.
[N. Y. Med. Joub.,
The Transactions of the Association of Military Surgeons of the Na-
tional Guard of the United States, for the Year 1891. Chicago.
Report of the Health Department of the City and County of San
Francisco, for the Fiscal Year ending June 30, 1891.
Fortieth Annual Report of the Directors of the New York Ophthal-
mic Hospital, for the Year ending September 30, 1891.
Seventh Annual Report of the New York Post-graduate Hospital
(and the Babies' Wards), for the Year ending September 15, 1891.
Twentieth and Final Annual Report of the Philadelphia Dispensary
for Skin Diseases, 1891.
De la methode hypodermique des injections sous-cutanees comme
methode de traitement dans certains cas de chloro anemie et de tuber-
culose pulmonaire. Observationes reoueillies dans sa clientele et a sa
clinique. Par le Dr. E. Boisson.
Ueber Myositis syphilitica diffusa s. interstitialis. Ton Professor
Dr. G. Lewin. Berlin : A. Hirschwald, 1891.
^ jfl i s c c 1 1 it n u .
On Some Painful Affections following Influenza. — Dr. A. Ernest
Sansom,F. R. 0. P., Physician to the London Hospital, etc., contributes
the following article to the Lancet for January 2d :
I propose in this short communication to pursue the inductive
method of reasoning in regard to some cases which at one time caused
me considerable perplexity. I will first mention a case which initiated
my difficulties. A gentleman aged fifty-three, who lor many months
previously had been in fair average health, was taken during the night
with severe pain in the right hypochondrium. The signs simulated
those of hepatic colic. He took a mild aperient, and the attack passed
away after one to two hours and he slept. The following day the bow-
els were properly opened, there was no evidence of absence of bile from
the motions, the urine was in all respects normal and contained no bile
or excess of coloring matter. The attacks of severe 'pain, however,
recurred at intervals — mostly in the night, but sometimes during the
day — for about ten days, treatment by opium and belladonna only re-
lieving them. It seemed that the gall-bladder could be mapped out by
the area of tenderness, but never was there the slightest jaundice. On
one night there was sharp diarrhoea. I could only say that the attacks
were those of hepatalgia of paroxysmal recurrence. In hunting about
for a cause, the only antecedent which seemed at all probable in this
direction was an attack of influenza contracted in Paris at the very
earliest time of the epidemic, and followed by protracted enfeeblement.
I computed that nearly twenty months must have elapsed between the
original attack and these consequences, if they were consequences.
There was no evidence of reinfection, but of course this was possible.
The key seemed to be furnished by a number ol experiences which
came to me just about the same period as this first instance. In all
there was fair evidence of an attack of influenza followed at intervals,
extraordinarily variable, by signs of extreme pain and distress. In
twenty-four such eases the sites of pain could be thus tabulated : 1.
Epigastrium, nine cases ; abdomen generally, two cases ; localized in
hepatic area, 'one case. 2. Head, various sites, seven cases ; supra-
orbital region, one case; right inferior maxilla, one case. 3. Heart
region, seven cases. 4. Extremities: hips and legs, two cases; calves,
two cases; arms, two cases ; right sciatic region, one case; fingers, one
case ; lumbar region, one case.
In Group 1 in some cases the pain at the epigastrium was nearly
constant. For instance, a man aged sixty-six, who had been previously
quite healthy, caught influenza at Christmas, 1890, and had never felt
well since. Six months afterward he had constant pain at the epi-
gastrium, with craving lor food. Food slightly relieved the pain, but
soon after nausea occurred, with pyrosis. In most cases the pain was
paroxysmal, and frequently nocturnal, sometimes attended with vomit-
ing or pyrosis. Peculiar symptoms occurred in some of these cases, as
" a fe.ling as of a cold wind over the chest, and inability to take a
deep breath." In some the si<:ns of colic, as in the first case mentioned,
were closely simulated ; frequently there was retching, but the tend-
ency was rather to diarrlnea than to constipation. In one case, a man
of sixty-three, suffering from intense epigastric pain, with -ense of J
heavy weight preventing sleep, and some vomiting, I found a small
patch of herpes zoster below the angle of the right scapula.
In Group 2 were various neuralgia;. In one man aged thirty-eight
there was intense supra-orbital neuralgia varying from side to side; -'
previously there had been rigor and abdominal pain like colic, and then
sweating and palpitation. Be had suffered from influenza twelve
months previously, but no ailment since. In anotl er case, a lady aged
twenty-five, urticaria followed influenza, and twelve months afterward
attacks of vertigo, with palpitation of the heart a:.d pain referred to the
occipital regions. A lady of thirty-seven, who had suffered from an
attack of influenza in May, 1891, averred that two months afterward
she commenced to have headache, from which she had neier been free
jn her waking hours for three months subsequently; she also suffered
from pain on movement of the right lower jaw. She had tremors and
tinnitus aurium, but no vertigo. In others headache occurred coinci-
dentally with gastric crises.
In Group 3 some of the patients referred the pain which they suf-
fered very closely to the region ol the heart. In a few cases the pain
was persistent, but in most paroxysmal. A lady aged forty-two, who
had suffered from influenza nine months previously, described the pain
as constant and dull, limited to the heart region. A gentleman aged
thirty-six, whose attack dated sixteen months previously, was wearied
with such dull aching; it was rather more diffused than in the former
case. In another gentleman, aged forty-two, the constant pain in the
cardiac region was accompanied by a tingling down the left arm. <
The most important and characteristic cases in this group, however,
simulated angina pectoris. A gentleman aged thirty-one, typically J
athletic, who had never suffered from illness before his attack of in- I
fluenza, which was very severe, was taken five months afterward with
sudden and violent pain at the heart, eventuating in syncope. He was I
standing with his back to the fireplace talking with friends, when the I
attack seized him uith violence, and he fell unconscious upon the ■
hearth-rug. There was no epileptoid sign. Another attack occurred a
week after. There could be no doubt from collateral evidence that
the patient became faint to unconsciousness. In the intervals no
notable deviation from health could be detected ; the left ventricle
was slightly hypertrophied, but not more so than could be expected in
an athletic subject. The patient described the pain as of the charac-
ter of a ''grip" or " screw " at the heart ; he experienced no coldness, |
and repudiated any sense of impending death. There were occasion-
ally, also, some attacks of dyspnira, occurring independently of exer-
tion. Nearly at the same time at which this patient came under my
observation a gentleman came under my care with like symptoms, in
whom there was no evidence of an attack of influenza. He presented
the appearance of typical good health, but suffered attacks of terrible
pain at the heart, ending in complete unconsciousness. On some oc-
casions the attacks were followed by wild excitement, and the patient
had to be restrained from self-violence. I have reason to believe that
in both these cases there was complete recovery. In a lady, aged
forty-one, attacks of intense pain were initiated by exertion. The pain
was localized in the second left intercostal space — presumably over the
superior cardiac plexus — and here was a tender spot. The pulsations
of the heart were painfully felt when in the recumbent position. In
some other cases there was a feeling of impending death, as in true
angina pectoris, though the pain was much less severe. This occurred
in a gentleman aged thirty-three, sixteen months after an attack of
influenza. Pain referred to the heart, however, had occurred at inter- ,
vals ever since his attack. In the case of another gentleman, aged
thirty-seven, the sensation was described as of an arrest of the heart, j
as if the pendulum of a clock had been stopped at one swing. With
this the patient said: "I feel as if I were going to die." In sonie^
cases there was a manifest slowing of the pulse; in others an irregu-
larity. Sometimes a slow alternated with a quick pulse. Fifteen
months after an attack of influenza I counted the pulse of a lady aged
twenty two as fifty-six. In most cases the rate was rapid, and I do
not remember one case in which the arterial tension was unduly pro-
longed. This absence of prolonged arterial tension, in my opinion,
Jan. 23, 1892. J
MISCELLANY.
109
took the cases out of the category of true angina pectoris. I have not
heard that any case was fatal.
It is no part of my purpose to pursue the question of the cardiac
phenomena of influenza. These furnish most interesting lessons, but I
am concerned now only with the manifestations of pain. I turn now
to Group 4, in which there were painful affections of the extremities.
A lady aged twenty-five, who had an attack attended with high fever
four months previously, complained of intense aching in both arms.
This occurred chiefly at night, and she actually wept on account of the
pain. Previously to the manifestation in the arms she had suffered
pain in the calves of the legs, resembling that of neuritis. In another
case of a gentleman, aged forty-one, the pain was referred to the lum-
bar regions more on the left side, to the right shoulder and the left
wrist, to the course of the right sciatic nerve, and to the muscles of
the thigh. There were fearful exacerbations, chiefly nocturnal, so that
the patient, previously a healthy man, actually shrieked on account of
the pain. In the case of a female aged thirty-three pain was localized
in the muscles of the calves of the leg and of the thigh. The pain
was strongly aggravated after food, especially meat. In another fe-
male, aged twenty-three, pain was extremely violent in the thighs and
legs, and there were attacks of faintness. Subsequently the suffering
was localized m the course of the right sciatic nerve. It was subject to
remissions, with severe nocturnal exacerbations : there were also
shooting pains at the epigastrium. The case was of alarming intensity,
but recovered. In a lady aged forty-eight pain was referred to the
right hip and to the right arm ; it extended from the right shoulder to
the fingers, and all movement caused pain.
There could be little doubt that in these cases there was a form of
neuritis. I met with other analogous instances in which there had been
no history of influenza: One case in a child in whom there was severe
pain in the calves, dropped feet, absolute loss of motor power, and, in
fact, all the signs of neuritis of the alcoholic form. Any causation by
alcohol was in this case quite out of the question ; no doubt it was due
to some infectious cause, and resembled the cases of peripheral neuritis,
due to no traceable contagion, recorded by Dejerine and others.
In this summary of my personal experiences I have dealt with no
cases of the earliest manifestations of influenza ; all were in patients
whose attack had passed away and who were not confined to their
homes. The periods between the attack of influenza and the manifesta-
tions of symptoms of pain varied from a few weeks to twenty months.
The evidence appears to me to confirm the view of Dr. Althaus that
the materies morbi of influenza resembles the syphilitic virus in its
tendency to attack many parts of the nervous system after the attack
is over, but surpasses the syphilitic toxine in virulence and in rapidity
of action. Dr. Althaus * has adopted the deductive method in his
reasoning. Starting from certain probabilities, he has worked out the
problems of the effects of the materies morbi if it should specially at-
tack certain areas of the central nervous system. He concludes that
the different forms of influenza are due to irritant poisoning of the
buib and the nerve nuclei contained in it. Adopting a converse meth-
od, that of logical induction, and taking my arguments alone from per-
sonal experience, I have arrived at a similar conclusion to Dr. Althaus
in so far as the proposition is concerned — that the virus of influenza
especially affects the nervous system. Leaving the question of the
acute and early manifestations, however, which I agree wtih Dr. Alt-
haus in considering to be due to involvements of certain areas in the
medulla oblongata, it appears to me most probable that the consequent
phenomena are better to be explained by inflammatory changes in cer-
tain peripheral parts of the nervous system. In regard to the visceral
kewalffice, the hepatalgia, the gastralgia, and cardialgia, there are signs
of localization and, in some instance^ of local tenderness that point to
a local cause. In some such it seems probable that the sympathetic
fibers and ganglia are alone affected. In other cases, as in those in
which there seems to be temporary arrest of the heart's action, retch-
ing, vomiting, and various disturbances of digestion, it is most probable
that the vagus is involved in greater or less degree; but here also the
effects might be due to peripheral irritation. In the sensori-motor
manifestations it can scarcely be possible to avoid the conclusion that
* The Lancet, November 14 and 21, 1891.
there is in existence a form of neuritis analogous to that which is
caused by many other toxines. The conclusion, therefore, which I have
come to is that the various affections I have briefly described are the
remote consequences of the influenza infection, and that their proxi-
mate cause is a peripheral neuritis affecting the sympathetic ganglia
and nerves, the vagus, and the sensori-motor nerve trunks.
Infantile Deformities and Maternal Impressions and Emotions. —
The following presidential address before the Obstetrical Society of
Glasgow, by Dr. George Hal ket, is published in the Glasgow Medical
Journal for January :
There are few things more painful to a mother than to give birth to
a child that is in any way deformed. How often do we hear a mother
say that it matters little to her whether her child is a boy or a girl, or
what it is like, or whom it is like, so long as it is " like the world."
We are apt to look upon these words as an idle tale, and worthy of
little attention ; but I firmly believe that they bear more real signifi-
cance than they generally get credit for.
A deformed child is a lifelong sorrow to its mother, and an object
of pity as long as it lives, yet we not infrequently see children come
into this world deformed as to their face, their limbs, or other parts of
their body, and bearing these deformities along with them from their
cradle to their grave.
The deformities of which I am going to speak are those which have
occurred in children at whose birth I attended, with whose family his-
tory I was acquainted, and, in the case of those who survived, whose
subsequent career I have been able to follow.
I will take first those deformities affecting the head and face, then
those affecting the upper extremities, then the lower extremities, and
then those affecting the trunk.
The case of greatest interest affecting the face and head was the
child of a woman residing in Stobcross Street. It was her second child,
the first being as healthy and well-formed a boy as one could wish to
see, and who is still alive. The child of which I am speaking was also
a boy. Its nose was only partially developed, being very small, and had
only one nostril. It had the appearance as if only half the nose were
there. The right eye was situated considerably further back on the
head and at a much lower level than the left eye. The child could not
close that eye, and, sleeping or waking, the right eye was always wide
open. On the right side of the forehead there was a small growth, half
an inch in length, tipped with bone, and which looked like a small horn.
This I took to be the undeveloped part of the nose. The child was oth-
erwise strong and healthy, and lived till it was fifteen months old, when
it died of acute bronchitis.
There were five cases of hare-lip. Two of these were simple and un-
complicated, and situated on the left side of the median line. These
were successfully operated upon. Two cases, one on the right side and
one on the left, were complicated with cleft palate. One died in in-
fancy from bronchitis, the other was operated upon and is still alive.
The fifth case was a double hare-lip, with cleft palate, and died in the
Western Infirmary, whither it was taken for operation.
I had three cases of children with hydrocephalic heads, all dead-
born. One of these required perforation and the application of the for-
ceps ; another, born at the end of the eighth month, was delivered with
the aid of the forceps. This child had no neck, the head being fixed
directly on the shoulders. The third case was a breech presentation,
and was delivered with great difficulty. The bones of the head in this
case were not united, otherwise craniotomy would have required to have
been performed.
I had one case of complete ossification of the bones of the head.
The mother of this child had had a large family, and all bei confine-
ments were normal. Iu the present case, after the cervix was com-
pletely dilated, the head remained lor a considerable time above the
brim of the pelvis. To aid delivery, I applied the forceps, but, do what
I could, I made no impression on the position of the Lead. The case
being in Crossbill, I got the assistance of Dr. Nairne, but with no bet
ter result. We then decided to turn, and again the head gave trouble.
It was only after efforts which exhausted us both that the child was
brought into the world, with a head as round a ball and as haul ;i>
a stone.
110
MISCELLANY.
[N. Y. Med. Jouu.,
Coming now to the deformities affecting the upper extremities, there
was one ease where the forearms were only partially d( veloped — that is,
they were short and thin as compared with the upper arms, and they
were firmly fixed at right angles to the upper arms, to which they were
attached by a thin web-like membrane of slvin and fibrous tissue. On
each hand only the thumb and forefinger were present. This child was
dead-born, but the mother behaved it was alive at the beginning of
labor.
The next case was a child born at the end of the eighth month of
pregnancy. It had both hands firmly fixed at right angles to the fore-
arms, and resembled the condition which is found in talipes equino-
varus in the foot.
There was one child born in which the index and middle fingers of
the left hand were not developed, and two cases where the child was
born with a sixth finger on the left hand. As the attachments of these
sixth fingers were only slight, I separated them and bandaged the
hands.
In the lower extremities the only deformity I had was that of club-
foot, and of this I had three cases — all of the talipes equino- varus type.
In two of these eases only one foot was implicated ; in the third, both
feet
All were successfully operated upon.
I had one case — a breed) presentation — where one of the feet was
very much twisted by intra-uterine pressure, and had all the appear-
ance of a bad club-foot; but manipulation and bandaging eventually
restored it to its proper shape.
On the trunk I had three cases of spina bifida One was in the dor-
sal region and had no tumor. One was in the lumbar region, and the
third was over the upper part of the sacrum. The first two cases died
within a few days of their birth from convulsions. The third case did
well, the tumor taking on a thick covering of skin. This child, a boy,
is still alive, and about eight years of age. He was three years old be-
fore he could walk, still walks with a stooping and shuffling gait, and
is not intellectually the equal of his brothers and sisters.
These, gentlemen, are the deformities and malformations worthy of
note which have occurred in my midwifery practice, and the question
now arises. Can their appearance in any way be explained?
The belief that maternal impressions and emotions affect the de-
velopment of the foetus has existed from the earliest periods, and, up
to the beginning of the eighteenth century, was generally accepted by
the medical profession. From that date up till now, and more espe-
cially within the last fifty years, writer after writer, and among them
men of distinction, both in this country and America, have expressed
their disbelief iu this theoiy, and have written many articles to contro-
vert it.
They hold that maternal impressions or emotions are exceedingly
common among pregnant women, and that deformities are very rare.
That deformities sometimes occur when there was no history of
maternal impression.
That when deformities follow well-marked maternal impressions,
they are due to coincidences, and are not cause and effect.
That there is no nerve tissue in the umbilical cord, and that mental
emotion can not in this way be carried from the mother to the child.
And, further, that, as the action of maternal impressions and emotions
can not be explained pathologically, they can have no effect whatever
on the fVetus in ufcro.
But, gentlemen, " there are more things in heaven and earth than
are dreamt of in our philosophy," and case after case has been put on
record, substantiated and confirmed by medical men whose names are
sufficient guarantee, that mental impressions and emotions do sometimes
affect the development of the foetus.
One thing is certain : that, knowing the sympathy that exists be-
tween the brain and the womb, if there is one time more than another
when a woman should be treated with gentleness and care, when her
surroundings should be pure and free from anything that is repulsive,
it is when she is pregnant.
If, on the other hand, we see her exposed to everything that is bad
— the fury of a drunken husband and the annoyance of quarreling
neighbors, hearing obscene language and seeing foul sights; if, in ad-
dition to that, we find her addicted to drunkenness and the other evils
that spring from that — there is little wonder that the course of na-
ture in the development of the feet us should sometimes be interfered
with.
Now, what do we find in the cases that I have laid before jrouf
In the first case, where the nose was only partially developed and
where the right eye was displaced, the father of the child was at that
time a confirmed drunkard and frequently assaulted his wife. There
was a history of repeated kicks and blows over the abdomen during
the early months of pregnancy, not discovered only alter the lirthof
the child, but of which I was made aware at the time, and measures
had to be taken on more occasions than one to prevent abortion. In
this case I believe the deformities were the result of external vio-
lence.
Taking next the deformities which were due to arrest of develop-
ment— hare-lip, cleft palate, and spina bifida — there was not, so far as
I was made aware, in any of them any history of particular maternal
impressions, but there weie in every case circumstances which 1 believe
tended to cause these deformities.
In the two worst cases of hare-lip and cleft palate the mothers
were given to frequent and long-continued fits of intemperance: and
from this cause, aggravated by violent emotions, to which every intem-
perate person is exposed, the blood became vitiated and so changed as
to intcifere with the proper nutrition and development of the child.
In two other cases the mother suffered bereavement about the time
of conception, and had long periods of grief and mental depression.
Another was deserted by her husband and left in poverty and sus-
pense, amd the others suffeied in many ways from ill treatment and
neglect.
Now, beaiing in mind the absolute dependence of the foetus on the
blood of the mother, it is not difficult to imagine how mental emotion,
long continued, should so affect the quality of the maternal blood as to
cause it to act injuriously on the child.
In the two cases where the hands and arms were deformed or only
partially developed I did not seek for any history of maternal impres-
sion. I thought it better in each case that the mother should be kept
in ignorance of the deformity of her dead child.
But there was one case that would not hide, and that was where
the child was born alive with the index and middle fingers ..anting
from one of its hands. The mother was a young woman who knew
nothing about maternal impressions, but, when she was made aware of
the state of her child's hand, she stated without hesitation thai she had
to work for some months after her marriage, that the foreman under
whom she worked had lost two fingers through an accident, that when
she saw his hand for the first time she had a "grueing," or shivering,
and that every time she saw him she could not keep from thinking of
his deformed hand.
A few years ago an interesting correspondence was carried on in
the British Medical Journal on the subject of maternal impressions,
and medical men in different parts of the country gave an account of
cases which had come under their own observation. One medical man
had a patient who, in the early months of her pregnancy, wished to
have her ears repierced, that she might wear her ear-rings again.
When she got this done she wished she hadn't, and the matter preyed
heavily on her mind. When she was confined, it was found that the
child's ears were likewise pierced, and a thread was passed through one
of them.
Another related how a patient of his, in her first pregnancy, was
served daily with milk by a boy wdio had lost his middle finger, and
that as he handed her the milk she always observed the absence of that
finger. When her child was born, the middle finger of one of its hands
was wanting.
A third medical man described how a workman was brought into
his surgery with one of his hands cut right off by some machinery. He
narrated this incident to a lady friend of his, who was at that time in
the early months of pregnancy, on whose mind it made a marked im-
pression, and who could not keep from detailing the incident to others.
Her child was born with only one hand.
Another doctor had a patient who, about the time of her conception,
had lost a near and dear relative. Her grief was inconsolable, and she
spent the early months of her pregnancy in weeping and covering her
Jan. 23, 1892.J
MISCELLANY.
Ill
eyes with her handkerchief. When her child was born it was born
blind.
And this brings me to speak of a case that occurred in my own
practice, now a good many years ago, but the facts of the case are as
(irmly impressed on my mind as if they had occurred only yesterday.
It was the saddest case I ever hail, for though the confinement was as
simple a one as I ever attended, the child was born dead, and the
mother died within a few hours afterward, and that from no apparent
cause.
On October 4, 1884, a lady residing in the western district of Glas-
gow called upon me and asked me to attend her in her confinement,
which she expected about the middle of December. It was to be her
third confinement. Both previous confinements had been normal, and
I had attended her in her second confinement, when she made a good
recovery. I remember telling her that I did not think she looked quite
as well as she did when 1 saw her last, and she replied that since the
death of her mother, who had resided with her, she had felt dull and
lonely, and was often in low spirits. Otherwise, she said, she was in
good health.
I may here mention that, though I had been frequently in her house
visiting her mother and her children, I had never been asked to pre-
scribe for herself, and none of her friends ever suspected her to be suf-
fering from any bodily trouble.
I did nut see her again t ill the early morning of December 9th, when
I was called to her confinement. I found her sitting at the kitchen
fire, the very image of despair. On my advice she went to bed, and on
examination 1 found the labor well advanced, the head presenting nor-
mally, and the membranes unruptured. The pains were strong and
regular, and with every pain she etied out in a tone which resembled
that of grief rather than of bodily suffering : " Oh, my poor mother, my
poor mother." I told her that she was not bearing up so well as she
did at her previous confinement, and encouraged her as well as I could.
She paid no attention to what I said, but with every pain kept crying:
"Oh, my poor mother, my poor mother." Shortly afterward the mem-
branes ruptured, and in a few minutes the child came into the world,
but the first view 1 got of it convinced me that it was dead. There
was no discoloration of any part of its body, but it had that soft, white
appearance which indicated the absence of life. I did attempt resus-
citation, and while doing so asked her when she found the movements
of the child last, and she answere 1 that she had felt no "life" since
her mother died. Now, her mother had been dead nearly a year.
After removing the placenta and bandaging her, 1 waited a short
time to see that the uterus was contracting properly, and then left her,
to all appearances well. In about three hours afterward I was called
hurriedly to come back and see her, and was just in time to see her
breathe her last. There had been no undue haemorrhage, internal or
external ; and the only information 1 could get was that she had at-
tempted to sit up, and had fallen back i.i a fainting fit.
I was visiting in the neighborhood the following day, and reference
was made to what had happened. I stated that I had difficulty in ac-
counting for the cause of death, but the lady to whom I was speaking
said she believed the cause of death was a broken heart. And then she
told me how in the summer time she had frequently met the deceased
lady at the coast, and how her whole talk on every occasion was about
her dead mother.
Gentlemen, I have laid before you, for your opinion, every fact of
this sad case with which I am acquainted; but whatever the scientific or
pathological explanation may be, I am firmly convinced, in my own
mind, that the death of this child and the death of its mother are in
some way connected with maternal emotions.
The Function of the Peroneus Tertius Muscle. — Mr. W. Ramsay
Smith, B. Sc., Demonstrator of Anatomy, Edinburgh School of Medi-
cine, contributes the following to the January number of the Edinburgh
Medical Journ-d: Recently, in the course of studying the actions of the
muscles of the lower extremity with the view of determining what mus-
cular movements take place in walking, I was fortunate to meet with
some clinical cases worth recording. In this note I shall confine my
remarks to two eases illustrating the function of one muscle — the
peroneiiH tertirts.
The first case was one in which the peroneus tertius of the left side
was subjected to a continued strain by the patient sitting for an hour
or two in a cramped position, with the heel on the ground, the ankle
joint fully extended, and the toes turned in. '"'hen the patient, in the
;irt of walking, placed the heel on the giound and allowed the weight
of the body to fall on the advanced leg, the sole of the foot came down
all at onee with a flop — :/'<y<, and pain was felt at each step taken with
this foot. The pain was referred to a spot corresponding to the origin
of t he peroneus tertius muscle. The patient found it impossible to stand
on the heel of the left foot; every attempt to do so resulted in the sole
of the foot coming down floj> on the ground, md was accompanied by
intense pain in the part of the leg I have referred to. On carefully
testing the condition of the extensor lougus digitormn, extensor pro-
prius hallucis, and tibialis anticus muscles, 1 could discover no abnorm-
ity ; the power of these muscles to tesist flexion of the toes and ex-
tension of the ankle was as great as usual, and no pain was elicited by
such testing. This condition of paralysis continued for about three
days, when the muscle gradually regained its power. During that time
walking was practiced by keeping the knee slightly more bent than
usual, turning the toes slightly more outward, and placing the sole of
the foot on the ground at each step of the left foot. In this way there
was no pain accompanying the act of walking, and the difference of
gait was scarcely perceptible.
The second case was one in which the patient, on descending from
a high leap, alighted on the ground on his right heel, the ankle being
at the time extended. The symptoms in this case were similar to those
in the former, only they were more aggravated ; and examination
showed that the extensor longus digit or um, particularly the outer part
of it, was also involved in the strain. The power of this extensor to
resist flexion of the toes was impaired, and the pain in the leg was cor-
respondingly increased in its distribution. The act of walking was per-
formed as in the former case.
These two cases illustrate very clearly the action of tlu.1 peroneus
tertius as a muscle of ordinary walking when the heel is the firtt part
of the foot to touch the ground. Acting with the tibialis anticus, and
aided by the extensors of the great and other toes, it prevents the foot
from coming forcibly down on the ground, which it tends to do, as soon
as the weighl of the body bears on the ankle joint; in other words,
these muscles on the front of the leg prevent " spasmodic" extension
of the ankle joint in ordinary walking. The action of this muscle, too,
in In Iping to maintain the erect posture of the body becomes apparent ;
and this action goe< very far to explain, if it does not make perfectly
clear, how the peioneus tertius muscle is ;he peculiar property of the
human subject, no other mammal possessing it.
1 have not yet seen an instance of the absence of this muscle, and
I am unable to sav what the state of matters may lie in such instances;
but it would be instructive to know the condition of the slip of the ex-
tensor longus digitorum to the little toe, and whether any peculiarity
exhibited itself in the gait of persons in whom the peroneus tertius was
absent.
A Physician's Estimate of his Class. — In Dr. S. Weir Mitchell's
interesting "medicated novel," Characteristics, ih&t Is being published
in the Century, there is the following description of varieties of
medical men that will suggest acquaintam es to many of our readers :
"There is no place where goo I breeding has so sweet a chance as
at the bedside. There are many substitutes, but the sick man is a
shrewd detective, and soon or late gets at the true man inside of the
doctor.
" I know, alas! of men who possess cheap manufactured manners
adapted, as they believe, to the wants of 'the sick-room ' — a term I
loathe. According to the man and his temperament do these manners
vary, and represent sympathetic cheerfulness or sympathetic gloom.
They have, I know, their successes and their commercial value, and
may be of such skillful make as to deceive for a time even clever wom-
en, which is saying a great tied for the manufacturer. Then comes
the rdier man who is naturally tender in his contact with the sick, and
wdio is by good fortune full of educated tact, lie has the dramatic
quality of instinctive sympathy, and, above all, knows how to control
it. 11 he lias directness of character too, although he mav make mis-
112
MISCELLANY.
[N. Y. Meii. Joir.
takes (as who does not?), he will he, on the whole, the best adviser for
the sick, and the completeness of his values will depend upon mental
qualities which he may or may not possess in large amount.
"But over and above all this there is, as I have urged, some mys-
tery in the way in which certain men refresh the patient with their
presence. I fancy that every doctor who has this power — and sooner
or later he is sure to know that he has it — also learns that there are
days when he has it not. It is in part a question of his own physical
state ; at times the virtue has gone out of him.
"I had a rather grim but most able surgeon. He seemed to me to
have a death-certificate ready in his pocket. He came, asked ques-
tions, examined me as if I were a machine, and was too absorbed in
the physical me to think about that other we whose tentacula he knocked
about without mercy, or without knowledge that tenderness was need-
ed. Our consultant was a physician with acquired manners. He al-
ways agreed with what I said, and was what I call aggressively gentle ;
so that he seemed to me to be ever saying with calm self-approval, 'See
how gentle I am.' I am told that with women he was delightfully
positive, and I think this may have been true, but he was incapable of
being firm with the obstinate. His formulas distressed me, and were
many. He was apt to say as he entered my room, 1 Well, and how are
we to-day ?' And this I hated, because I once knew a sallow under-
taker who, in the same fashion, used to associate himself with the
corpse, and comfort the living with the phrase, 'We are looking quite
natural to-day.' "
The New York Academy of Medicine. — At the next meeting of the
Section in Laryngology and Rhinology, on Wednesday evening, the
'i^th inst., Dr. II. Hoyle Butts will read a paper entitled A Comparison
of some Recent Methods for removing Adenoids from the Vault of the
Pharynx.
At the next meeting of the Section in Obstetrics and Gynaecology,
on Thursday evening, the 28th inst., Dr. Robert L. Dickinson will read
a paper on The Diagnosis of Pregnancy between the Second and
Eighth Weeks by Bimanual Examination, and Dr. Victoria M. Davis
will read a paper on The Preventive Treatment of Mastitis.
Mortality in Cities in the United States. — The following table
represents the mortality in the cities named, as reported to Dr. Walter
Wyman, Surgeon-General of the Marine-Hospital Service, and pub-
lished in the Abstract of Sanitary Reports for January 15th :
CITIES.
L
1
go
l»
ft
i I
« at
£
New York, N. Y
Jan.
9.
1,515,301
072
Chicago, 111
Jan.
9.
1,099,850
617
Boston, Mass
Jan.
9.
448,477
339
San Francisco, Cal . . .
Jan.
2.
■^'.iS'.iX
Cincinnati, Ohio
Jan.
?C6,!i08
172
Cleveland. Ohio
Jan.
9.
261,353
95
New Orleans, La
Dec.
19.
242,039
125
New Orleans, La
Dec.
26.
242,031)
153
Pittsburgh, Pa
Jan.
238,617
104
Washington, D. C
Jan.
2?0,3!)2
133
Louisville. Ky
Jan
9.
101,129
91
Rochester, N. Y
Jan.
9.
133,8%
79
Providence, R. I
Jan.
9.
132,146
Indianapolis, Ind. . .
Jan.
2.
io.->,««
"60
Indianapolis, Ind
Jan.
9.
iit.->.4:.'i;
60
Toledo, Ohio
Jan.
8.
81,434
42
Richmond. Va
Jan.
81.3S8
46
Nashville, Tenn
Jan
9.
76.108
40
Fall River. Mass
Jan.
8.
74.398
37
Jan.
9.
36,425
17
Binghamton, N Y . . .
Jan
9.
35.00.-.
17
Yonkers, N. Y
Dec.
19.
32 033
12
Yonkers, N. Y
Doc.
26.
32,03a
10
Yonkers, N. Y
Jan.
2.
32,033
22
Yonkers, X. Y
Jan.
9.
32,088
15
Jan.
2.
31,076
21
Mobile, Ala
Jan.
n.
31,076
10
Galveston, Texas —
Dec.
23.
29,«U
17
Galveston, Texas ...
Jan.
1.
21I.OH4
15
Rock Island. Ill
Jan.
1
1:5,634
3
Jan.
11.750
3
DEATHS FROM-
34 311 16
13 32
7 5
• 8
2 12
The Pan-American Medical Congress. — The committee on organiza-
tion of the Pan-American Medical Congress, at its meeting at St. Louis
last October, elected the following international executive committee :
The Argentine Republic, Dr. Pedro Lagleyze, Buenos Aires ; Bolivia,
Dr. Emelio Di Tomassi, La Pa/.; Brazil, Dr. Carlos Costa, Kio de
Janeiro ; British North America, Dr. James F. W. Ross, Toronto ;
British West Indies, Dr. James A. De Wolf, Port of Spain ; Chile, Dr,
Moises Amaral, Santiago; United Stales of Colombia, Dr. P. M. Ibafiez,
Bogota; Costa Rica, Dr. Daniel Nunez, San Jose; Ecuador, Dr. Ki-
cardo Cucalon, Guayaquil; (fuatemala. Dr. Jose Monteris, Guatemala
Nueva: Haiti, Dr. D. Lamothe, Port au Prince; Spanish Honduras,
Dr. George Bernhardt, Tegucigalpa ; Mexico, Dr. Tomas Noriega, City
of Mexico; Nicaragua, Dr. J. I. Urtecho, Grenada; Peru, Dr. J. Casa-
mira Ulloa, Lima; Salcador, Dr. David J. Guzman, San Salvador;
Spanish West Indies, Dr. Juan Santos Fernandez, Habana ; United States,
Dr. A. Vander Veer, Albany, N. Y. ; Uruguay, Dr. Jacinto De Leon,
Montevideo; Venezuela, Dr. Elias Roderiguez, Caracas. Hiwaii, Para-
guay, Santo Domingo, the Danish, Dutch, and French West Indies are
not yet organized. Nominations of local officers have been received
from a majority of all the members of the international executive com-
mittee, and a number of the lists have been confirmed by the commit-
tee on organization. These will be announced as rapidly as accept-
ances are received.
To Contributors and Correspondents. — The attention of all who purpose
favoring us with communications is respectfully culled to the follow-
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Authors of articles intended for publication under the head of "original
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dressed to the publishers.
THE NEW YORK MEDICAL JOURNAL, January 30, 1892.
(Original (Hommunimtions.
THE PROGRESS OF CYSTOSCOPY
IN THE LAST THREE YEARS.*
By WILLY MEYER, M. D.,
ATTENDING SURGEON TO
THE GERMAN AND NEW YORK SKIN AND CANCER HOSPITALS.
Three years ago Dr. Max Nitze, of Berlin, the inventor
of the cystoscope, in his well-known essay, Contribution to
Endoscopy of the Male Bladder, f stated that we could now,
with the help of the cystoscope in its handy and improved
shape, establish a strict differential diagnosis between the
diseases of the bladder. lie further said : u Having seen
with the cystoscope that the bladder is healthy, and that the
morbid process therefore involves the upper urinary pas-
sages, most probably the kidneys, it is tempting to put the
question whether we shall be able to prove with the cysto-
scope which kidney or which pelvis of the kidney is dis-
eased. Either we could attempt to push a thin catheter
under the guide of our eyes into the orifice of the ureters,
to draw the urine directly from each kidney separately, or
we might be able to observe with the cystoscope out of
which ureter the blood escaped in a case of hematuria," or,
I may add, pus or purulent urine in a case of pyelitis or sup-
purating kidney.
It was obvious from the beginning that Nitze's statement
would be sustained by all who practiced cystoscopy — namely,
that our knowledge as well as the diagnosis of bladder dis-
eases would just as rapidly widen, clear up, and improve
with the help of the new cystoscope as our knowledge of
laryngeal diseases, for instance, did after the invention and
introduction of the laryngoscope. But would Nitze's hope
also be realized, or could it be realized, in regard to kid-
ney troubles ? Might we hope to be able to use his cysto-
scope as at least one means of observing the " character "
of the urine in its direct descent from each kidney ?
Reviewing the literature on cystoscopy wddch has ap-
peared since 1887, and the results of my own work in this
line, covering now (December, 1891) a period of nearly four
years, we can unhesitatingly answer this question in the af-
firmative.
Before treating of the progress in the diagnosis and treat-
ment of "kidney" diseases with the help of the cystoscope
— the special object of my paper — any further, I will try to
give a short review of the development of cystoscopy in
general, with reference to the construction of additional in-
struments, made in accordance with the principles laid down
by Nitze, and to its influence upon the diagnosis, prognosis,
and treatment of diseases of the bladder.
I. Instruments.
After three years' careful trial and comparison of the
two chief cystoscopes which have been in the market — viz.,
that of Dr. Max Nitze, manufactured by Paul Ilartwig, of
* Head in part before the Medical Society of the State of New York
at its eighty-fifth annual meeting, Albany, February '■>, 1891.
f V. Langenbeek's Archil) f, liin. Chirwrffie, vol. xxxvi, p. 6(51.
Berlin (Markgrafenstrasxe, 79), and that of Mr. Joseph
Leiter, the well-known instrument-maker of Vienna, manu-
factured by himself (Mariannengasse, 11) — I must slightly
alter my remark, made a few years ago,* that I " prefer "
Nitze's instrument. It is true, I still mostly use it, because
I have become accustomed to it, and because it seems to me
that the picture, as seen through its prism and lenses, is
more stereoscopic. f 1 also believe that, in order to avoid
diagnostic errors, it is better to train one's eyes exclusively
on one instrument. After experience has been acquired, it
is immaterial which instrument is used. And since Leiter
has slightly altered the pattern of his instrument in ac-
cordance with the suggestion of Hurry Fenwick, of London,
he has secured the essential advantages of Nitze's cystoscope
and eliminated the former disadvantages of his own. Inci-
ter's instrument is now most highly finished and perfectly
reliable. J " The length of the beak is reduced to less than
an inch.* The elbow is well rounded ; the length of. the
shaft is seven inches and a half. The ocular end is fitted
with a rotatory plate, carrying the binding screws, while,
instead of the Nitze slot-key, a small screw upon the face
of the plate forms a more convenient switch." || In the
Leiter instrument of 1887 the beak was nearly half an inch
longer, the elbow presented an angle, the shaft was too
short, and the battery wires had to be fastened in the binding
screws, which were immovable upon the instrument, and
thus would twist around it, if the latter was turned around
its longitudinal axis in the bladder. The only difference,
then, which still exists between the two German instruments,
apart from the arrangement of the rnignon lamp, is in
the telescope. That of Nitze slightly magnifies ; that of
Leiter slightly diminishes. The lenses in Nitze's instru-
ment also give a more perspective picture, to my eyes at
least, and cover a larger field — i. e., the observer's eye will
perceive with one glance a larger area.A
The drawbacks alleged against Nitze's cystoscope are :§
* Author. A Contribution to the Surgery of the Bladder. New York
Med. Jour., Feb. 23, 1889.
f That others are of the same opinion is shown by the following
passage in a recent treatise by Cecil-Kent Austin, entitled Sur le diag-
nostic preeoee <lcs neoplasmcs 1/1 In ccssic et <ln rein an mourn tin ri/sto-
scope, Paris, 1890: "Je ferai remarquer en passant que les images
percues au moyen de 1'instrument de Berlin m'ont paru plus nettes,
plus satisfaisantes que celles que donne l'itistruroent viennois."
\ In the new one, which is in my possession, the beak still measures
an inch.
* This alteration, as it appears, was first employed by Leiter in the
old Nitze-Leiter instrument. Neue Beleuehhingsapparate mit Zu
hilfcnahmc des elektruehen Lichtes. Nachtrag zu den von Josef Toiler
verfassten Catalogen, 1890, p. I.
I [ should say here that Nitze demands that Letter's cystoscope
which is practically the same as Nitze's, be called the Nitze cystoscope
manufactured by Leiter.
A Take Nitze's instrument in one hand, turn its prism to the win-
dow, and hold the palmar side of the slightly Hexed lingers of the other
hand at a distance of about two inches from it ; then look through the
telescope: you will see at once the fifth to second fingers and a part of
the ulnar side of the thumb. Do the same with Leiter's cystoscope:
you will see only two fingers and a hall.
v Cf. E. Hurry Fenwick. The Electric Illumination of the Bladder and
Urethra, second edition. London: J. and A. Churchill, 1889, pp. 36
and 43.
114
1. A somewhat less brilliant light.
It is true, that of Leiter is brighter, because the still
longer beak carries a larger, less delicate, and more power-
ful incandescent lamp. Still, the light as thrown from the
Nitze mignon-lamp, if tested as to its strength previous to
the introduction of the instrument (what always should be
done), will be found entirely satisfactory in every case.
Where we can not see with it for special reasons, we shall
most probably also not succeed with the other.
2. The silver tip, the carbon filament of which has given
out or has been destroyed, has to be sent to Berlin for put-
ting in a new incandescent lamp, whereas Leiter has made
the cystoscopist independent. "
This is now easier arranged for cystoscopists on this
side of the ocean, who work with Nitze's cystoscope, as I
have induced the W. F. Ford Surgical Instrument Company,
315 Fifth Aveuue, New York city, to carry a number of
silver tips in stock. Useless tips will there be exchanged
for new ones, which fit upon the instrument. (Difference
of price here and in Berlin, 50 cents.) I should add, al-
though it is self-understood, that it will be necessary to
have a number of these tips, all armed with the carbon fila-
ment', constantly on hand, just as the order sent to Leiter
should include six reserve lamps. The price of the latter is,
however, one fifth of that of the silver tip of Nitze's cysto-
scope. The difference of the two instruments in this respect
is therefore merely a pecuniary one. To replace a burned-out
incandescent lamp by a new one does not require a mo-
ment longer in Nitze's cystoscope — nay (if such a simple,
though important, manipulation is to be compared at all),
is even still simpler than in Leiter's. But there is —
3. Another disadvantage, which became manifest to me
in the course of the last year, since I have been in possession
of three different Nitze cystoscopes. It is that the screw of
the different tips in stock will sometimes be found not to
fit exactly on the thread at the lower end of the shaft. Thus
the screw of the tips now and then overruns the limit of
screwing or does not reach it at all. The surface of the
lamp then points to another direction than the prism, and
the tip is simply useless. It will, however, be seen at once
that this is no drawback to the instrument proper, but a
mistake which can be remedied at once by a greater accu-
racy of the instrument-maker. It is to be hoped that Mr.
Hartwig will yield to the cystoscopists' urgent requests and
pay better attention in the future to this slight but impor-
tant defect, explained to him at length. The screw-thread
of each cystoscope ought to be manufactured accurately
alike, and the tips, before being sent away, carefully fitted
on a standard instrument at Berlin. The arrangement as
now made here in New York also dispenses with this an-
noyance. In cities where a similar arrangement is not or
can not be made, the cystoscopist will soon have his small
stock of fitting tips, and must insist upon having put new
incandescent lamps into these very same tips. I should not
omit to state here that, after some experience and with
proper care and a good battery, the same tip can be used
for nearly a year and perhaps still longer.*
* Still I have to mention —
1. To constantly have Nitze's instrument in good working order, it
[N? Y. Mkd. Jocb.,
In his first essay, and later also in his Text-book on Cy-
toscopy* Nitze recommended three different cystoscopes
for a thorough inspection of the entire inner surface of the
bladder.
Cystoscope No. 1, which carries the lamp and prism
at its concave side (the latter at the junction of beak
and shaft), represents the main instrument, "the" cysto-
scope.-
Cystoscope No. 2, for the inspection of the fundus : The
lamp on the concave side ; the window at the end of the
shaft, through which the observer looks with the telescope ;
of course, no prism.
Cystoscope No. 3, for illumination of the internal orifice
of the urethra and its immediate neighborhood : The lamp
and prism on the concave side of the beak, which latter is
about half an inch longer than in the others, and bent in
nearly a right angle to the shaft. A small mirror, situated at
the convexity of the curve inside the tube, reflects the picture
which is thrown into the telescope from the reflecting plane
of the prism. I have tried this instrument in a number of
cases, and can state that the picture seen with it is utterly
indistinct. It is to be hoped that it will soon be improved.
Although we are able to diagnosticate the hypertrophy of
the prostate "in the picture" with No. 1, yet a thorough
inspection of the internal urethral orifice and its surround-
ings under electric illumination would be very valuable in a
number of cases.
In regard to cystoscope No. 2 I can only repeat what I
said two years ago : f that it is unnecessary to buy it. I have
always succeeded in inspecting the fundus and trigonum, to-
gether with the mouth of the ureters, by simply turning No.
1 180° and depressing the handle, even in cases with hyper-
trophy of the prostate. The inconvenience to the patient
is slight. Nitze himself advised me, when I saw him at the
International Congress at Berlin, to exchange my No. 2 for
a longer No. 1, which would prove very useful in cases of
hypertrophy of the prostate, where the urethra is materially
lengthened. I did so, and can say that I am very thankful
is absolutely necessary to keep clean and dry the two circular grooves
at the upper end of the instrument, as well as the concave surface of
the rotatory handle, which, when attached to these grooves, conveys the
current from the battery to the instrument. This refers especially to
the irrigating cystoscope.
2. The slot key, which, under management of the thumb, serves
for opening and breaking the circuit, may work rather easily after
some time. The light then will be less brilliant. A simple turn of the
screw which holds the key in place will correct this difficulty.
3. If the cystoscope turns too easily in the handle, it will be found
useful to leave the left hand at the upper end of the cystoscope, the
so-called " funnel," during the examination, while pressing the handle
with the other hand tightly against it.
4. If the lamp of a new tip does not burn at once when the current
passes its filament, a slight straightening of the little cork-screw-like
silver wire at the basis of the tip, before the latter is screwed on, will
often be found sufficient to get a bright light.
5. The small bubbles of air which often arise with a peculiar noise
from the junction of shaft and tip in Nitze's instrument are caused by
the decomposition of the water by the electric current. If a bit of wax
is smeared upon the lower groove of the screw at the tip, previous to
its being adjusted, this can always be avoided.
* Wiesbaden, 1889. Verlag von .1. P. Bergmann.
f hoc. cit., p. 203.
MEYER: THE PROGRESS OF CYSTOSCOPY.
Jan. 30, 1892.]
MEYER: THE PROGRESS OF CYSTOSCOPY.
115
to Pr. Nitze for this kind advice. The long shaft will be
found of advantage in many instances.
As a third instrument 1 procured the new irrigating cys-
toscope of Nitze, which permits of changing the fluid in the
bladder without being removed itself.* It contains two
small tubes in its shaft, which is thus increased in size to
25 gauge, French. (The size of the beak is -22, as in
the others.) The one tube ends just in front of the prism
with three small holes side by side. It carries fresh water
iuto the bladder. The water, thrown in with the help
of a hand syringe, passes with considerable force over the
surface of the prism, thus washing it and removing blood
coagula or pus shreds which so frequently settle there and
render a successful cystoscopy impossible. This is a very
clever arrangement. The other tube ends, or rather begins,
with a single oval-shaped opening at one side of the lower
end of the shaft ; through it the water passes out of the
bladder. Both tubes are carried to either side of the
upper end of the instrument, and their current can there
be shut off by a small stop-cock. Both these stop-cocks
! are attached below the funnel to a metal ring, which
also carries the handle with the slot-key. They thus
remain steady in the hand of the observer while the shaft
i can be turned around its longitudinal axis. The irriga-
tion can be effected without regard to the turning of the
shaft. To put the whole into working order, rubber tubes
are attached and tied on the end of the two tubes. It will
be found of advantage to have the one which carries the.
water out of the bladder cut so long as to hang into a basin
under the table. If the water is changed and the examina-
tion continued — which will frequently be of great impor-
tance— an assistant or the patient must pump the water in.
This latter manipulation is best done intermittently by sud-
den brief pressures on the handle of the syringe. A fount-
i ain syringe can also be used. Of course, this arrangement
does not enable us to flush the viscus or wash it out in the
ordinary sense. Still, I have found this irrigation sufficient
and of the greatest value in clearing up an obscure bladder
trouble as well as in the diagnosis of renal disease, pyuria,
and hsematuria. In examining the bladder of patients who
suffer from such troubles, the originally transparent medium
becomes rapidly a:::, suddenly turbid and the outlook is at
once cloud' d Ly a dense fog; nothing can be distinguished.
I succeeded, in one of these cases where I had to perform
nephrectomy for pyonephrosis and cystic degeneration, and
therefore wanted to determine the condition and excretory
power of the remaining kidney, in establishing the fact, just
after fresh water had been thrown into the bladder, that the
urine descending from the other kidney was clear (cf. Case
III, nephrectomy). In another troublesome case also I could
make out only with the help of the irrigating cystoscope
that the large amount of pus which always turned the in-
jected water murky in a few seconds was ejected from one
ureteral orifice only (cf. Case I, nephrotomy). In fact, I
* Cmtralblaltf. Chirurgie, 1889, p. 940. Nitze had two irrigating
cystoscopes made — a " simple " and a " more complicated " one. The
former, oval in shape, only permits of throwing more water into the
bladder; the latter, which is round, enables us to really change the
water. Only the latter is to be recommended,
should prefer to use the irrigating cystoscope mostly were
it not that, on account of the increased size of the shaft, its
use is only practicable when the urethra is of a certain di-
mension.
In vesical luematuria, where the blood more easily co-
agulates, the irrigating cystoscope of the present size will
often be of little or no use, as the blood-clots generally block
at once the canal which carries the water out of the bladder.
Fresh water is then pushed into the vesical cavity, but the
turbid fluid can not get out.* If a tumor is to be examined
and it does not bleed during the examination, the instru-
ment will also prove valuable in determining the insertion
of the growth. The jet of water propelled across the prism
and beak will make a pedunculated growth swing, while it
leaves the sessile growth undisturbed. (The same result
can be obtained in using cystoscope No. 1, by pressing w ith
one hand in sudden short shocks on the epicystic region.)
The irrigating cystoscope will be also found of advan-
age in cases where papillomatous growths, inserted around
the internal urethral orifice, cover lamp and prism of the
instrument as soon as it has entered the bladder, and thus
render an examination impossible. The field of vision then
appears dark. These growths can be easily pushed aside
by the forcibly injected fluid, and will then be suddenly
seen in bright illumination, swaying in the fluid. Concre-
ments and foreign bodies lying in the pouch behind an hy-
pertrophied prostate gland, and not to be detected there by
the examining eye, may sometimes be thrown by the water
out of the recessus, and thus diagnosticated. Lastly, it is
worth mentioning that the irrigating cystoscope enables us
to view the bladder in different degrees of distention. In
a certain number of cases the ureteral openings can be seen
only by this means. (Nitze, loc. tit.)
Having thus carefully compared and tried the cysto-
scopes of Nitze and Leiter, I am ready to say that it is dif-
ficult to give proper advice as to which of the two had
best be bought by the beginner, as both instruments are
equally worthy of being in the hands of everybody who
practices electric illumination of the bladder. But, whereas
Nitze has given us three useful cystoscopes (according to
pattern No. 1), and whereas I deem it of pre-eminent impor-
tance, in order to avoid mistakes, to stick to one pattern in the
beginning, I prefer to advise the beginner to buy the Berlin
instruments. I, personally, have so far gladly incurred the
slight annoyance of sending my few burned-out reserve tips
to Berlin for repair once in a year. The pleasure of being
enabled to work with the three cystoscopes has amply re-
warded me. Still, I also often find advantage in using
Leiter's elegant instrument in its new shape.
The very newest instrument of this class, which has just
been made known to the profession in a preliminary com-
munication, is the opera ti>i</ cystoscope, invented bv Nitze,
and constructed by P. Hartwig, of Berlin {('/>•//>/. f.
Chirurgie, No. 51, 1891, p. 993). A cutting forceps is at-
tached, by a peculiar mechanism, to the lower circumfcr-
* The instrument could he made more useful by inereasing the cali-
ber of the tubes and thus, of course, also, of the cystoscope up to No. :i0
and more. A female urethra will always, and the male urethra in a few
instances or after meatotomv, admit that number.
116
MEYER: THE PROGRESS OF CYSTOSCOPY.
[N. Y. Med. Joob.,
ence of a cylindrical tube. Its two blades carry at their
end a small, sharp scoop. They are opened and closed by
a lever, which moves in a longitudinal slit at the upper end
Via. 1
of the same tube. The whole is slipped on the shaft of the
ordinary cystoscope No. 1, and can be moved on it, down-
ward and upward (see Fig. 1 and Fig. 2).
A few more mechanisms of a similar pattern have been
designed for intravesical topical treatment.
F«i. 2.
To enable one to disinfect these different instruments,
and also to make the armamentarium which is needed for
intravesical surgery as simple and comparatively cheap as
possible, the funnel of the cystoscope has been made mova-
ble. It can be screwed on or off the shaft. Thus we can
use the same cystoscope for all the manipulations, and only
need a number of the cylindrical tubes, which carry the
proper mechanism. The cystoscope for this kind of work
has, besides the movable funnel, a smaller caliber and a
longer shaft than the ordinary No. 1. The instrument
armed with the forceps has the size of an evacuator as used
in litholapaxy ; if armed with the other mechanisms, it
corresponds to about Nos. 21 to 23 of the French gauge.
Before introducing the operating cystoscope the cylin-
drical tube. Fig. 2, a, is shifted down toward the prism and
the forceps, for instance, closed by pressing the lever, h,
upward. The two blades then surround the beak in such a
manner as to form one solid body with it. (The arrange-
ment of the other mechanisms is similar to this.) The in-
strument will now easily pass a urethra which is not too
narrow. As soon as it has entered the bladder the tube is
slipped back toward the funnel of the cystoscope (Fig. 1),
the light is turned on, the forceps, etc., opened, and every-
thing is read!y for work. In looking through the telescope,
the motion of the two blades of the forceps or of the cold
or red-hot wire of the snare-6craseur can be thoroughly
observed and controlled by our eyes.
Thus, an immense progress has again been made. The
cystoscope, which hitherto could only be used for diagnostic
purposes, is now ready for local intravesical treat incut.
With the same, if not with more, precision than, for in-
stance, in laryngoscopy, we can make topical application
with certain drugs in the bladder without bringing them in
contact with other spots of the vesical mucous membrane;
we can cauterize (with the galvano-cautery) ulcers and flat
tumors,* can tear off pedunculated growths with the for-
ceps, can seize and extract
foreign bodies, small stones,
or the fragments of larger
ones, which have been previ-
ously crushed. And all this
under the direct guidance of
our eyes. Indeed, the medi-
cal profession, as well as a
great portion of suffering
mankind, owe thanks to I)r. Xitze for the many brilliant
gifts he has bestowed upon them.
In the last three years a few more varieties of the same
mechanical principle have been advanced. I will mention
these for the sake of completeness :
1. Hurry Fen wick's
Modification of the Leiter
Instrument. \ — Part of it
has been mentioned above.
A further modification is the
perforation of the silver cap
by three small holes on the
side opposite the pane of
rock-crystal which covers
the oval window. This is done "to allow of a free 'cur-
rent of water to surround the lamp, whereby the hood
is kept perfectly cold." In hematuria the non-perfo-
rated hood has to be slipped on. Fenwick adds in a
foot-note : " I break more lamps in the long run, but
incur less risk of burning the mucous membrane." In
buying a Leiter cystoscope it will be certainly advisable to
also order a perforated cap, which is, no doubt, a pretty
and sensible improvement, as the larger mignon lamp, situ-
ated in the middle of the beak and covered by the rock-
crystal pane, heats the entire cap. When in use, the urine
or water in the bladder carries off this heat as fast as it is
formed, its temperature not being perceptibly raised, even
if the lamp is burned for an hour in the bladder. But as
soon as it comes in contact, with the sensitive mucous mem-
brane of the bladder wall, the patient invariably has a burn-
ing sensation. It will be readily understood that a longer-
unintentional contact, for instance, during narcosis, may
really burn the mucous membrane.
The short-beaked Xitze cystoscope carries the incandes-
cent lamp in the tip uncovered in direct contact with the
surrounding medium. It presents the perforated hood in
peculiar original form. Its lamp does not heat by far
much. In a large number of cystoscopies, with or withou
amesthesia, I have so far never had a mishap. The touc
of the bladder-wall with Xitze's cystoscope also creates
slight burning sensation.
* Of course thi- can not he done if the bladder is filled with water.
For such purposes it has to he expanded by air. As Xitze's lamp
situated in the extreme end of the beak, it can burn in the open air for
about two to three minutes without spoiling the prism. I presume
Nitze intends to proceed in this manner. He promises, in his prelimi-
nary article, to give soon full particulars in a more elaborate essay.
f Fenwick, lor. cit., p. 43.
Jan. 80, 189*2.|
MEYER: THE PROGRESS OF CYSTOSCOPY.
2. The Irrigating Cystoscope of Berkeley Hill. — Hill pro-
posed * to add two small tubes to the lower aspect of the
instrument through which irrigation is easily made. The
tubes do not greatly increase the caliber. f Nitze' s irrigat-
ing cystoscope, which carries the tubes inside, seems to
offer better advantages.
3. The " Improved " Incandescent-lamp Cystoscope of
Whitehead, Manchester. \ — The Leiter pattern of 40 French
gauge (instead of the usual 22 French) ; the window of ob-
servation and incandescent lamp present double the size,
thus increasing the field of vision as well as the brilliancy
of light. It is introduced through a median incision in
the membranous urethra.
Such an application of the instrument directly annuls
the special advautage of cystoscopy — namely, " that it af-
fords a visual diagnosis without a cutting operation." It
may, however, be useful and valuable in the female, where
the urethra can be easily dilated to No. 40 French.4*
4. Brunner's Modification of the Leiter Pattern for
sounding the Bladder and Catheterism of the Ureters
under the Guidance of the Eye.\ — Cystoscope No. 2, of No.
28 French, which carries a separate small channel on the
convex side of the shaft. This channel terminates just
below the window and can also be used for changing the
water in the bladder. It is occluded by a mandrel, when
the instrument is introduced. The mandrel later is ex-
tracted and replaced by a minute English catheter or an
elastic metal sound. Brunner thus succeeded in pushing
the catheter into each ureter of a female patient exposed
by the light, but failed to do the same in the male. He has
had no opportunity to continue his trials in this direction.
When the catheter or sound is in the ureter, the instrument
itself may be slipped back over it. Perhaps also topical
treatment of the bladder could be instituted with this help.
5. Messrs. F. A. Reichardt & Co., surgical instrument
makers, New York city, have tried to manufacture a cysto-
scope according to a modified Berlin pattern, which latter
i bears no international patent. They have, however, not yet
succeeded in accomplishing the difficult and expensive task.
i: The instrument which I have inspected at their store was
very unsatisfactory in many respects.
6. The French Cystoscope of Boisseau Du Rocher, of
Paris,A is manufactured by Collin, Maison Charriere, of
* Irrigation of the Bladder in Cystoscopy. Lancet, London, 1889,
i, 109.
1 \ In a valuable essay of Alexander Stein, New York — Some Points
in the Differential Diagnosis of Bladder and Kidney Affections — which
i appeared in the Journal of Cutaneous and Genito-urinary Diseases,
\ 1838, p. 870, 1 find this passage: "In hematuria the injected fluid soon
loses its transparency, so that we can see but indistinctly or not at all.
I think this latter can be remedied by soldering an oval tube to the bot-
tom of the cystoscope, which would reach to the curve, so that the blad-
der could be irrigated and refilled without removing the instrument."
\ British Medical Journal, April 7, 1888, p. 768.
* At Hurry Fenwick's suggestion, Leiter has made a larger cysto-
scope of 40 French, to be used exclusively for the female bladder. Its
shaft is three inches shorter than in the ordinary cystoscope.
| Leiter. Neue llcleuehtunij.vippurate rnit Zuh'tlftnahine tlis tlek-
trixelien Lichtes. Wien, 1889, p. 9.
A Presented by me with the following remarks to the Surgical Sec-
tion of the New York Academy of Medicine, March 9, 1891.
Paris. In July, 1885, the first report was made about it to
the Academie des sciences. But the instrument was not
used by others until last year, when Boisseau du Rocher de-
scribed it at length in an article which appeared in the An-
nates des maladies des organes genito-urinaires, fevrier, 1890.*
He called his instrument " megaloscope" and the method
of examination for which it was to be resorted to, " megalo-
scopie vesicate.'''' The doctor maintains that his " rnegalo-
scope^ is an entirely new design ; that its pattern originated
with him independently from those which are already in
the market.
To settle this question from the start, it must be said
that Boisseau Du Rocher's cystoscope is in its principle
nothing else than an elongated ordinary cystoscope of the
Leiter pattern No. 2, which is used for an easy inspection
of the fundus of the bladder.
In comparison with the latter, the specially striking
new features of the Paris instrument are :
A longer beak ; a longer telescope, which causes the
length of the instrument and in its peculiarities greatly en-
larges the spot coming into view ; an additional combina-
tion of pipes for irrigating the bladder and also for passing
the telescope, or passing instruments for catheterism of the
ureters.
But the principles in accordance with which the megalo-
scope has been constructed are, of course, and had neces-
sarily to be, the same as those brought out in the Nitze-
Leiter original cystoscope — viz., the introduction of the light
itself into the cavity which is to be examined, and an optic
apparatus which magnifies and enlarges the object. The
priority of these two devices, which, combined, effected the
immense recorded progress in cystoscopy, is due to Nitze
beyond a doubt. Any new cystoscopes or endoscopes can
only be variations of this original idea.
Further, the medical profession should not accept a new
name for Boisseau Du Rocher's instrument and for that
which can be done with it. We talk of a laryngoscope and
laryngoscopy, of an ophthalmoscope and ophthalmoscopy.
We should only have different patterns of a " cystoscope,"
and one name for the practice created by it — " cystos-
copy."
The probable advantages of the Paris instrument, in
comparison to the Berlin or Vienna one, as far as I have
been able to see them, are the following:
1. That, on account of the length of its telescope, it is
six to seven inches longer, and the face of the observer is
therefore farther removed from the genitals than is possible
in using the other cystoscopes. (But, on account of the
great length, a slight motion of the handle will result in a
by far greater one of the beak, wliich thus will often touch
the wall of the bladder.)
2. That we can perceive with one glance a larger area
and see everything in the same upright position as our eyes
would see it without the telescope. (The latter is also ex-
perienced in using the Nitze or Leiter pattern No. 2.)
3. That the pipes which run alongside and inside of the
* See also W. v. Vragassy. Das "Megaloskop" des Dr. Hoisseaic
du lloeher in Paris. Wiener mat. I'resse, 1888, pp. 51 and 90.
118
MEYER: THE PROGRESS OB CYSTOSCOPY.
[N. Y. Mbd. Jour.,
lower aspect of the shaft enable us to wash out the bladder
before, and apply permanent irrigation during, the cysto-
scopic examination. There is a wider canal in the center
of the instrument for passing the telescope. It is filled out
by a steel mandrel while the instrument is introduced into
the bladder. If we make use of this canal for irrigation,
the viscus can be very thoroughly flushed.
4. That the larger one of the small pipes can be utilized
for passing instruments of minute caliber for catheterism
of the ureters.*
5. That the telescope is introduced after the; whole in-
strument has passed the urethral canal — i. e., is in the blad-
der. The objective lens can thus never be dimmed by an
adherent mucous or pus shred or a small blood-coagulum.f
6. That the instrument can be sterilized by boiling wa-
ter, the cement which is used for fastening the rock-crystal
pane in the window of the beak, etc., being such as to
stand a great heat. The other cystoscopes can not be
boiled. They are disinfected by wiping them very carefully
and thoroughly with gauze dipped in a three- to five-per-cent.
solution of carbolic acid.
Now, has the French cystoscope also drawbacks as an
offset to these advantages } Yes, and very serious ones.
1. We can not inspect the whole inner surface of the
bladder with this cystoscope, which, besides, is quite
clumsy and not at all as easy to handle as that of Nitze or
Leiter.
Boisseau Du Rocher finds an objection to Nitze's in-
strument on account of the latter's advice \ to make five
exact motions with the cystoscope in the bladder in order
to bring into sight every tpot of its interior with mathe-
matical exactness. With his own, when introduced into
the bladder, the whole fundus, the posterior wall, and a
portion of the upper and the two lateral walls come at once
into view, without turning or moving the instrument. ( In
trying to obtain this result we shall, however, get a kind of
bird's-eye view.) But to examine the anterior portion of
the vertex with the Paris cystoscope. the examining person
would nearly have to sit on the floor, and even then the re-
sult miodit not be satisfactory. Therefore two instruments
become necessary.
2. The caliber of the shaft is No. 27 of the French
scale, that of the beak No. 23. The increase of the size of
the shaft is caused by the pipes for irrigation. It is to be
mentioned, though, that they are situated at the lower as-
pect of the shaft, and thus give the tube a conical shape
(cf. Brunner's modification). The top of this cone corre-
sponds with the lower circumference of the urethra, which
can be stretched. (The size of Nitze's and Letter's cysto-
scope is No. 22, that of Nitze's irrigating- cystoscope, the
shape of which is round, No. 25.)
* Of. the Brunner modification.
f Cf. Nitze's irrigating cystoscope. If we make it a rule always
lo inject some glycerin into the posterior portion of the urethra with
the help of a Nelaton catheter right after a careful irrigation of the
anterior portion of the urethra, of the neck of the bladder, and of the
latter organ itself, and right before introducing the cystoscope, we
certainly shall quite rarely meet with this annoying occurrence when
using the ordinary cystoscope.
% Cf. Nitze's Texi-book on Cyxloscopy, pp. 93-99.
3. The beak is very long — half an inch longer than that
of Leiter's, and twice as long as that of Nitze's cystoscope.
4. The angle at the junction of the beak and shaft ig
130° and abrupt ; in the other two instruments only 145°
and well rounded.
.5. The lumen of the two pipes used for irrigation and
passing catheters for catheterizing the ureters is extremely
small. There is at present no catheter in the market, in this
city at least, small enough for this purpose.
6. There is no key or screw to make and break the elec
trie circuit. We always have to put in or unscrew one of
the conducting wires for this purpose.
7. It is difficult to thoroughly cleanse the inner surface
of the objective lens of the telescope. This lens can not
be detached from the tube, but has to be reached by a long
conductor which holds at its end a piece of maple-marrow.
I have not, so far, succeeded in removing some particles
of dust from the inner surface of this lens. A compliance
with this need by the manufacturer would mean an im-
provement of the telescope.
8. The spherical aberration of the lenses of the tele-
scope.
9. A constant dripping of water out of the upper end
of the instrument during examination. The intravesical
pressure constantly forces the water alongside the telescope,
which does not snugly occlude the lumen of the central
canal.
So far I have got the impression that the French cysto-
scope will not as easily come into general use as that of
Nitze and Leiter. It decidedly has a few important new
features, which will make it desirable for the cystoscopist
to be in possession of it. But uiftil the defects mentioned
above shall have been remedied.* we certainly shall always
need the additional use of one of the two other cystoscopes
in the market if we want to be ready to thoroughly perform
a cystoscopic examination in cases where this method can
be applied.
In closing this section, a tabulated comparison of the
size of the different parts of the three cystoscopes which
attract special interest may perhaps be welcome. (See next
page. )
In regard to the batteries, a great variety is now at
our disposal. Hartwig & Leiter sell a battery with the
cystoscope which fully answers the purpose.! The fluid is
a mixture of pure chromic acid (to be ordered of Messrs.
Churchman & Co., Philadelphia), sulphuric acid, and water
(Formula for Hartwig's battery: Chromic acid, 375; sul-
phuric acid, 300; water. 3,000. For Leiter's: Chromic
acid, 500; sulphuric acid, 375; water, 3,000.) The two
original Leiter batteries, with hard-rubber cells, are not
to be recommended, as they will surely crack and leak after
short while. The repair of such a crack is troublesome an
* According to a remark of Dr. W. K. Otis, of this city, in the dis-
cussion on Dr. L. B. Bangs's paper — Cases illustrating some Difficultiee
in the Use of the Cystoscope (Section in General Surgery of the New
York Academy of Medicine, meeting of November!*, 1891) — this gentle-
man is at present engaged in improving Rocher's instrument.
f For description, see Nitze's Text-book, p. 62 ; Leiter, Catalog
1889, pp. 13-17.
Jim. 30, IN92.
MEYER: THE PROGRESS OF CYSTOSCOPY;
119
Size.
French gauge.
Length of entire in-
strument, measured
from outer brim of
funnel to tip of beak,
in a straight line.
Length of shaft,
measured from
outer brim of funnel
to junction n ii h
beak.
Length of that part of the
Instrument which alone
comes into consideration
with reference to length
of urethra—namely, from
inner brim of funnel to
lower border of prism.
Length of beak.
Size of angle
between shaft
and beak.
Inches.
Centim.
Inches.
Centim.
Inches.
Centim.
Inches.
Centim.
22
25£
H
24
21
3
¥
2
145 "
28$
( Rounded.)
9<)
o£
m
10*
26}
n
23 J
a
4
2
Or
m
28J
!0|
26}
8f
3
4
2
99
25
9
23
H
is i
1
2}
\ Sbaft = 27
161
42}
16
41
8f
221
H
3}
13(T
/ Beal: = 23
(With teleseope.)
(With telescope.)
(Fr om entrance of tubes
(Abrupt.)
for irrigation to ver-
tex of an^le between
shaft and beak, at its
concave side.)
Cystoscohk.
Ni,zl'- 1 No.
Llrrip
Letter, No. 1
Boisseau do Rocher.
1
1 , long.,
ating cy.-
toscope
always unreliable. Since last year the cells have been made
of glass. Thus a very annoying disadvantage is at last elimi-
nated. Fenwick uses a battery supplied by Schall (Lon-
don),* and is pleased with it. He wants a rheostat, For
evstoscopists on this side of the ocean I would recommend
the cheap and easily manageable, portable, small six-celled
battery of the Galvano-Faradic Manufacturing Co., New
York city. Not to destroy with it the incandescent lamp at
once, the elements must be screwed very slowly and care-
fully into the fluid until the light is bright. In all these
batteries there is no rheostat attached. I so far have
never seemed to be in actual need of the latter. In a nearly
four years' practice in cystoscopy the number of lamps de-
stroyed by me is a very small one. Still, its presence in a
battery will be welcome. A very fine storage battery, Gib-
son's (three different sizes), f is sold by the W. F. Ford
Surgical Instrument Co. It contains four large cells and
has a rheostat, Its lighting power is ample.J It can be
arranged to permit of endoscopic and galvano-caustic work
at the same time, which will be found especially convenient
in urethroscopy. Recharging once in two to six months ; *
in spite of its price, I should advise its purchase by a cystos-
copist who lives in a great city.
I still have to call attention to the various attempts
which have been made in regard to fixing the picture as
seen with the cystoscope by clay or wax modeling, colored
drawings, and, photography.
Fenwick, the originator of the first-mentioned method, ||
bag proved, by the very pretty pictures in his work, how
* Loc. cit., pp. 46, 47.
\ Size I weighs about fifty pounds, and has a capacity of fifty amp.
hours ; size II, about forty pounds, capacity thirty amp. hours; size III,
about thirty pounds, capacity fifteen amp. hours.
\ The Nitze mignon-lamp requires more electro-motive force (9 to 10
volts) than that of Leiter's cystoscope and urethroscope (6 volts), be*
cause its filament is finer, and consequently offers more resistance to
the current. The maximum force of the Gibson four-cell storage battery
is eight volts and a fifth. The Ford Co, is now constructing a six-
cell storage battery which lights the Nitze lamp also to brilliancy. Its
price and weight are of course slightly higher. The manufacturer of the
Nitze lamp should build it eight volts or less. This can easily done be.
* This is, of course, a disadvantage, as it makes us dependent upon
the electrician. In houses that are connected with the street electric,
light system, charging can be done at home.
| ('lay and Wax Modeling of the Living Urinary Bladder under
Electric Light, British Medical Journal, January 5, 1889 ; and The
Electric Illumination, etc., loc. cit., p. 88.
nicely and thoroughly the various pathological conditions of
the interior of the living bladder, especially of tumors, it'
modeled in some plastic material, wax or clay, and then
photographed, may be recorded and demonstrated to others
who could not attend the examination.
E. Burckhardt very lately gave us a fine collection of
colored drawings of bladder images in health and disease ; *
every one of them was observed by himself and drawn at
once with the cystoscope in position. The Atlas will espe-
cially be useful to the beginner, and explain to him many a
picture which was seen but could not be at once identified.
Instantaneous photography, " the ne plus ultra of cysto-
scopic delineation (Fenwick)," is still in its infancy. Nitze
has theoretically laid out an interesting method of best
getting a small negative, and then magnifying it. Want of
time has not permitted him to make practical experiments.!
Ceza von Antal, J by his assistant, B. Hermann, published
the photographic picture of the cystoscopic appearance of
a black hair-pin in a female bladder. It is, however, utterly
indistinct.
Fenwick (in connection with Mr. Pearson-Cooper, of
the London Camera Club) has succeeded in obtaining good
negatives of artificial growths both in the dummy and the
dead bladder. But the negatives of the living bladder
were too indistinct. A number of certain mechanical ob-
stacles have so far formed an almost insuperable barrier to
such a method being successful and practical.
In view of the rapid strides of modern technique, it is
to be hoped that these obstacles will soon be overcome
and that we shall then be enabled to " graphically record the
many new and interesting clinical facts which the electric
cystoscope is constantly revealing."
As it seems, this hope has meanwhile already been ful-
filled. (See Ueber Photographic innerer Korperhdhlen,
insbesondere der Harnblase und des Magens, by Dr. Robert
Kutner. Deutsche med. Wochenschrift, Berlin, No. 48, No-
vember 26, 1891, p. 1811. Kutner is a former assistant
of Nitze.)
(To be concluded.)
* Atlas dcr Cystoskopie, mU 24 Tafeln in Farbendruck : Basel, 1891.
See, also, the few excellent colored drawings at the end of Nitze's hand
book.
\ Text-book, p. o26.
j Internationales Ctrlbl. fur I'hi/nwloaie n. Patholoyir der Ham- u.
Sexualorgane, Bd. i, licit i, p. is.
120
ABBE: GASES OF GALL-BLADDER SURGERY.
[N. Y. Meo. Jock.,
CASES OF GALL-BLADDER SURGERY*
By ROBERT ABBE, M.D.,
BURGEON TO 8T. H'KE'9 HOSPITAL ;
PROFESSOR OF SURGERY IS THE NEW YORK POST-GRADUATE MEDICAL SCHOOL.
It is superfluous before this society to-night to review
the methods advocated for the relief of diseases of the gall-
bladder. These have so recently been written upon by
Crede, Tait, Kummell, Sengcr, Oregg Smith, and others,
that it will serve our purpose if such observations are made
in connection with the unusual features of the cases here re-
corded as will be suggestive to operators in this field.
Rules for diagnosis and surgical treatment have still to
be definitely written, the result of yet to be accumulated ex-
perience. Cases of failure and success have further to be
recorded before we are masters of the grave accident of
complete biliary obstruction.
It is for this reason, and because of the interest attend-
ing this line of surgery, that I ask your attention to the un-
usual cases of which I will speak.
I may say that in general the experience of most oper-
ators is favorable to the accomplishment of surprisingly
good results in bad cases of obstructive diseases of the gall-
ducts, and this is amply borne out by my own four success-
ful cases.
As illustrating the simplest form of operative procedure
in cases of obstruction without inflammation, I will first
speak of one, done six months ago, and of the ultimate re-
sults of which I may now speak with some confidence.
Case I. Multiple Attacks of Biliary Uolic during Four
Months; Exhaustion ; Cholecystotomy ; Removal of Three
Large Gall-stones ; Immediate Suture of the Gallbladder; Re-
covery.— In April, 1891, Mrs. W., a lady of sixty-four years, came
under my care with symptoms of chronic biiiary obstruction.
She had been for tliree months under the care of Dr. Partridge,
of this city, who had watched her through many severe and con-
stantly recurring attacks of biliary colic.
Her first attack dated to five or six years before. There was
then a period of freedom until four months before I saw her,
when she was seized with a most severe attack, repeated at in-
tervals of a week or less during the four mouths following. Each
attack was succeeded by moderate jaundice and progressive ex-
haustion. Though in the earlier intervals she resumed her work,
she became too weak during the last month to leave her room.
The usual accompaniment of clay-colored stools and dark
bile-stained urine followed each attack.
At last the pain became nearly continuous and she was be-
coming exhausted. Her skin had a moderate jaundice only, per-
sisting between attacks, though after each severe exacerbation
she was quite yellow. I had her removed to a room at the hos-
pital, where poulticing and massage soon relieved the pain and
cholaunia, the urine becoming free from bile.
On any attempt to walk, however, pain immediately recurred.
There was a moderate tumor the size of an egg at the site of the
gall-bladder. A diagnosis of gall-stone obstruction of the cystic
duct was made, based on the subsidence of cholaemia with con-
tinuance of pain and gall-bladder distention.
I operated April 24th by vertical incision.
The distended and elongated gall-bladder popped out of the
wound as soon as the peritonamm was opened, and afforded an
* Read before the N'e« York Surgical Society, October 14, 1891
excellent opportunity for handling it without soiling the perito-
neal cavity.
Three good-sized stones were found, the largest free, the two
smaller ones wedged tightly in the cystic duct. The contents
of the gall-bladder showed no suppurative change. The stones
were, after considerable trouble, worked back into the gall-blad-
der and removed.
A small gum-elastic bougie was then passed into the com-
mon duct and onward far enough to show all obstruction re-
moved.
I then ventured to do the ideal operation of suturing the in-
cised gall-bladder and returning it into the peritoneal cavity.
The mucous and peritoneal coats of the collapsed bladder being
'Edematous and sliding freely on each other, I thought best to
make a separate suturing of each. With fine catgut I stitched
the muscular layer so as to invert the mucous edges, and then
with finest black silk sewed the peritoneal edges.
The abdominal wound was closed, as usual, in separate layers
by buried sutures.
The patient made an uninterrupted convalescence, and left
the hospital on the twenty-second day in excellent condition,
having gained rapidly in weight, having good digestion, normal
movements, and being free from pain.
At the present date (six umnths after operation) she remains
in perfect health, is free from pain, and has resumed her work.
The abdominal scar is solid.
This case illustrates the feasibility and safety of the so-
called " ideal operation " of immediate suture of the wound
in the gall-bladder and replacement in the abdomen.
I believe the absence of suppurative inflammation with-
in it is a sine qua non of the procedure. The ability to pass
a bougie through the unobstructed ducts may be wanting,
for the tortuous and pocketed condition of the cystic duct
will often entrap the point of a probe so as to make it im-
possible to pass it through even a pervious canal. In such a
case one might fill the gall-bladder with fluid after removing
the impacted calculi, and, by pinching the incised wound,
observe wdiether the fluid can by pressure be emptied into
the intestines. If so, I see no reason why the immediate
suture should not be resorted to.
It has been observed that a comparatively large sound
will pass through a sacculated duct when a small probe
will be entrapped. In one case I was unable to pass either
a large or a small one, yet the duct was pervious. In an-
other such case I would try fluid, and, if pervious, I would
prefer to suture and rtturn to the abdomen.
Case II. Gall stone with Suppurating Gall-bladder and
Enormous Thickening, simulating Cancer; Cholecystotomy ; Re-
covery.— In April, 18Sf>, F. M., a young married woman, cama
under my care for progressive debility and hectic, with a tumor
of the right side below the ribs. There had been a vague his-
tory of colicky pain before the tumor began. She had not been
jaundiced. The tumor had been noticed for five or six mouths.
It was at this time apparently as large as one's fist and quite
movable, lying in the direction of the gall-bladder. The mass
was tender to pressure, and had been diagnosed as a cancer.
Believing it to be an empyema of the gall-bladder, 1 did lapa-
rotomy in the usual site, and, much to my surprise, came upon
a solid tumor occupying the exact site of the gall-bladder, and
running backward so as to include the ducts in the mass.
Adhesions to the adjacent parts were present.
In spite of its very malignant look, I thought best to make a
Jan. 80, 1892.]
ABBE: CASES OF GALL-BLADDER SURGERY.
121
free incision into it, to relieve, if possible, any pent-up source of
sepsis from which I judged her to be suffering. The incision
only seemed to confirm our fears. The missive and hard walls
were from an inch to an inch and a half thick, and in gross ap-
pearance resembled and cut like carcinoma tissue. The rem-
nant of the gall-bladder cavity was a small channel holding only
two drachms of muco-purnlent fluid. No foreign body could
be felt within it.
I therefore established a fistula from it through the abdomi-
nal wall, and gave the patient rather an unfavorable prognosis.
During the next few weeks she made an easy convalescence.
The sinus, however, did not close, but the mass remained quite
as evident to external palpation as before.
Six months afterward she returned to me to see if the sinus
could not be closed.
I was surprised to find her in restored health. The sinus
secreted copious mucous discharge, but, on probing, it no longer
led into an indurated mass. The tumor was no longer to be
found. In the sinus was a gall-stone, incrusted with phosphate,
the size of a pecan nut. This I removed.
The sinus promptly healed, and some months afterward I
had an opportunity of examining her side, and could find no
trace of tumefaction. The patient was in robust health.
This extraordinary hyperplasia of the walls of the vis-
cus presented, a strikingly deceptive appearance of malig-
nancy. It has been occasionally observed by others, but
no explanation bas been offered of why it should occur in
one case more than in another.
Case III. Cholecystotomy and Removal of Fifty-three
Stones, followed in Six Months by Cholecystectomy and Re-
moval of One Stone more. — Mrs. L. B., aged twenty-nine years,
admitted to St. Luke's, October, 1888, with the following
history :
Ten years previously she had her first attack of gall-stone
colic. It was followed six months later by another, three
months later by another, and afterward almost every month for
many years. The intervals ranged from two weeks to three
months. The attacks were agonizing, and she had acquired a mor-
phine habit in consequence. Jaundice had supervened on sev-
eral of the attacks, but she had no chronic jaundice. She had
become emaciated physically and discouraged morally.
The region of the gall-bladder was tender on palpation, but
no tumor could be felt. Even her corset pressure was painful.
I operated on October 8, 1888, by the vertical incision. The
gall-bladder had old, intimate adhesions to the stomach, which
being dissected off, I secured its presenting end by two loops of
silk stitched through its wall before opening, and evacuated
fifty-three small and large calculi. The fluid in the gall-bladder
has thin, whitish mucus.
Although no probe could be passed into the common dm t
nothing could be felt suggestive of stone, either within by probe
or without by palpation of the duct. The gall-bladder was
stitched in the wound. The patient made a quick recovery aDd
went to her home in Maine with a sinus not yet healed.
Six months later she returned ^ith the sinus still discharg-
ing a mucous fluid without bile, and having had moderate re-
currences of pain.
I advised reopening the abdomen to explore the cystic duct
and remove the atrophied gall-bladder.
No calculus could be felt by palpating or sounding the cystic
duct. I therefore dissected the gall-bladder from the liver and
from adherent colon and stomach and ligated it close to its
junction with the hepatic duct.
On cutting it away, I found that a calculus the size of a pea
was locked between two strictures of the duct, and had been
the evident cause of continued pain.
The wound being now clean, the abdominal wound was
closed at once.
The lady made an immediate recovery of her health, and
all pain ceased from that date.
A letter received two days since from her physician states
that up to the present date, three years since operation, she
has remained in perfect health, without the least recurrence of
pain.
I was impressed in this case with the difficulty of dis-
cerning by the touch of a silver probe the soft surface of
a gall-stone. I doubt if one can know in any case whether
all stones have been removed except by the touch of the
finger within the gall-bladder.
I was also pleased to find the dissection from the sur-
face of the liver not a difficult or serious matter. There
had been enough inflammation in past years to cause more
intimate union with the liver than the usual cellular tissue.
Yet the haemorrhage was readily controlled by pressure.
The fourth case is one of great interest.
Case IV. Impaction of Gall-stones in the Hepatic, Cystic,
and Common Ducts for Two Years and a Half ; Profound
Chola>mia ; Removal of Gall-stones and Gall-bladder; Recov-
ery.— A. C, aged thirty-six years, was in excellent health until
two years and a half since, when she was first seized with bili-
ary colic and became gradually jaundiced. The colic was soon
relieved, but her jaundice increased, and during the entire period
has only grown worse and worse. At times she seemed almost
black with it, as she expressed it, yet she continued to work at
her occupation of dress-making. She lost flesh, and now weighs
thirty pounds less than she did. Since the first attack she had
indigestion and vomiting frequently, but never of blood. Her
stools have been clay-colored and her urine like porter. Two
months ago she had a renewal of the biliary colic, which she
characterizes as "terrible," but it diminished iu one week.
She has grown quite unlike her old self, in being subject to
nervous attacks, and occasionally has what resembles petit mal,
losing consciousness for a few moments. She presents the most
intense form of jaundice in her face, body, and mucous mem-
branes. The complexion is rather of a blackish-green than yel-
low, owing to prolonged staining and pigmentation. The liver
is very much enlarged, extending two inches below the free
border of the ribs. A tumefaction can be felt somewhat deeply
at the site of the pylorus, quite hard and suggestive of malig-
nant or inflammatory growth.
During abdominal palpation over this portion, the patient
on every occasion was seized with semi-epileptic, semi- hysteri-
cal attacks, at first groaning, then lapsing into unconscious-
ness, with muscular contractions — evidently from pressure
near the solar plexus, in a woman profoundly cholaemic. The
patient, was altogether in a poor condition, with five per cent, of
albumin in her urine and hyaline casts. After consultation with
my colleagues, I operated, April 13th, under ether. The verti-
cal incision was used. Adhesions of the stomach to the gall-
bladder and liver hid it from view, but after careful dissection
it was released. Several moderate-sized calculi could be felt
through the walls of a rather small gall-bladder, as well as in the
cystic duct, and one, as large as a walnut, farther down in the
common duct. The bladder was opened and some viscid bile
escaped. The stones being removed from the gall-bladder, it
became necessary to incise the cystic duct to release others.
No amount of manipulation availed to move the largest one
in the common duct. An attempt was made to crush it ex-
122
OOULEY: DISEASES OE THE URINARY APPARATUS.
[N. Y. Med. Joob.,
ternally, but without effect. I therefore split the wall of the
common duct in continuation of the cut in the gall-bladder and
duct, and found the large stone locked between two strictures
of the duct. It being removed, a bougie passed readily into the
intestine through the duct.
I then sewed up the cut of the duct with finest black silk,
and cut away the gall-bladder and its duct entirely, leaving only
the greatly dilated hepatic duct, into which the finger readily
passed and from which stones were removed.
The engorged liver poured out large quantities of healthy
bile during my manipulation. To control the discharge I in-
troduced a large rubber drain into the hepatic duct, running it
upward into the liver a short distance. Over this I passed a
larger tube, which terminated at the site of the junction of the
ducts, and around it I packed a small iodoform gauze tampon-
ade— the object being to divert all the bile from the liver out
of the abdominal wound, and after a few days by removing the
inner tube to let the larger one remain to drain the sinus — thus
leaving the bile free to travel along the common duct as soon as
swelling had subsided.
This device worked admirably, and surprising quantities of
bile were poured out during the first two days. Her jaundice
soon began to clear perceptibly. The urine cleared at once.
Seidlitz powders were given the second and third day with
good results.
At the end of a wTeek she suffered an attack of acute dry
pleurisy, from which she slowly recovered.
On the ninth day the first bile tinged her stools. One week
later she had a sloughing abscess of her back, from no apparent
cause. This retarded her convalescence.
In four weeks she sat up, ate well, and was losing the
jaundice, but had a bronzed skin from pigmentation.
At the end of four weeks a fistula only remained in the side,
through which most of her bile escaped. Having seen abundant
evidence of bile in the stools, I ventured to have the fistula
strapped. Immediate and complete closure and healing fol-
lowed.
In five weeks her bile was all pursuing its normal course, and
she was entirely well, except for color, which was slow to leave.
During the summer she has resumed work, and is in perfect
health again at the present time, her color having now become
perfectly natural.
This case shows that intense cholsemia is not necessarily
as fatal an element in operable cases as has been commonly
taught. The operative method I have adopted is by the
vertical incision over the site of the gall-bladder, and I be-
lieve that thus more extensive exploration can be made than
by any other method.
The last case I will mention is that of a man with chronic
obstructive chokemia from a small malignant growth just within
the outlet of the common duct. This man was for many weeks
under medical care in St. Luke's Hospital before being trans-
ferred to my service. He was profoundly jaundiced and suffer-
ing from an exhausting hectic fever. His liver was enlarged to
three inches below the ribs and a considerable tumor of the gall-
bladder was perceptible. The most marked feature in the his-
tory of his illness was the absence of an initial attack of colic.
This in itself was presumptive evidence of malignant obstruc-
tion. The distended gall bladder with grave hectic warranted
the diagnosis of empyema of the gall-bladder. The suppurating
gall-bladder was found and relieved by the usual operation. No
stone or malignant di>ease was found. The gall ducts were im-
passable to small or large probes passed into the gall-bladder.
The probability of a stricture or other obstruction at the duo-
denal end of the common duct led me to search for this through
an incision into the duodenum ; this I made two inches and a
half long and, as I supposed, about four inches and a half from
the stomach. Most careful search and palpation failed to reveal
the site of entrance of the duct into the duodenum, and the in-
cision was closed by a continuous Lembert suture. Drainage of
the suppurating gall-bladder was therefore all that was accom-
plished. The man survived one week. Post-mortem examina-
tion showed the duodenal incision to have been four inches be-
low the site of the duct. A small, soft malignant growth was
attached to the wall of the duct just within its lower end, and
acted as a valvular stricture. It was scarcely large enough to
be perceived by palpation through the intestinal walls at the
post-mortem. From this origin, however, multiple secondary
deposits of cancer were found in the liver and lung, some of thein
as large as a hen's egg.
The ease illustrates the comparative ease and safety with
which the duodenal end of the common duct can be exam-
ined by proper incision into the duodenum. Had there been
any stone or growth of considerable size in the lower end of
the duct, it would certainly have been felt by the finger
within the intestine and could have been removed.
In conclusion, I would emphasize the fact that the four
cases of obstructive disease from gall-stones here narrated
were all progressing to a fatal end and the patients were all
restored to perfect health by operation, the time elapsing
since operation being from six months to three years.
DISEASES OE THE URINARY APPARATUS.
By JOHN W. S. GODLEY, M.D.,
8URQEON TO BELLEVUE HOSPITAL.
( Continued from page 95.)
PART L — PHLEGMASIC AFFECTIONS.
Section II. — SPECIAL CONSIDEPwATIONS.
X.
Accidents, Complications, and Consequences of thk
Acute Types of Urethritis.
When exempt froin accidents, complications, and con-
sequences, urethritis resolves in four or five weeks, or, if
primitive and in a young healthy subject, may be cured in
eight or ten days. It is principally in this second class of
cases that the rapid cures are so frequently reported,
while the accidents, complications, and consequences are
too often ranked by themselves as if they had no connec-'
tion with urethral phlegmasia. It is therefore necessary,
in the management of urethritis, to keep in mind the lia-
bility of the occurrence of the accidents which may arise
from the imprudence, carelessness, or neglect of the patient ;
of the complications which aggravate the urethral phleg-
masia ; and of the consequences of unwise, untimely, or
rash treatment. Not many years ago was still in vogue the
routine treatment of " gonorrhoea," consisting in the ad-
ministration of large doses of copaiba or cubebs, and in
the use of strongly astringent urethral injections, without
regard to the type or stage of the phlegmasia. The fre-
quency of accidents and of more or less grave sequela? was
then great as compared to what it is at present. The
Jan. 30, 1892.]
GOULEY: DISEASES OF THE URINARY APPARATUS.
123
rational treatment, based as it is upon a sounder pathology
and more accurate diagnosis, seems now to be so firmly
established that these accidents and sequelae occur with
markedly less frequency than in former times, and are
much better managed.
The accidents of acute urethritis are urethral haemor-
rhage and conjunctivitis. The complications to which
acute urethritis is liable are balanitis, posthitis, and balano-
posthitis, the last causing or aggravating phimosis, and the
forcible retraction of the narrowed and swollen prepuce
producing paraphimosis. The consequences of acute ure-
thritis are lymphangeiitis, inguinal adenitis, peri-urethritis,
cryptitis, bulbo-urethral adenitis, prostatitis, orchitis, gone-
cystitis, trachelocystitis, pyelitis, nephritis, septicaemia,
pyosapraemia, rheumatism, chronic urethritis, .and urethral
stenosis.
Accidents of Urethritis. — Urethral hcemorrhaye dur-
ing acute urethritis is ordinarily due to frequent and pro-
longed erections of the penis, to masturbation, or to coitus,
and is not an uncommon accident. It is rarely abundant,
and ceases spontaneously in the majority of cases. Pre-
ventive and afterward repressive means should be promptly
employed, for the reason that haemorrhage indicates here a
solution of continuity of the mucous membrane, and there-
fore liability to a rapid stenotic process. Profuse haemor-
rhage is rare and generally due to " breaking the chordee "
in superacute urethritis. It usually ceases spontaneously
in the course of thirty-six hours, but sometimes continues
several days, much to the detriment of the sufferer. Active
measures should therefore be taken to suppress the flow of
blood. If cold fails when applied externally or by way of
intra-urethral irrigations, it is wise, without further delay,
to introduce a urethroscope as far as the seat of haemor-
rhage, to wash away the blood with iced water, and to
touch the bleeding spot with a camel's-hair brush previ-
ously dipped in persulphate of iron solution, and then to
irrigate once more in order to be sure that the haemorrhage
is checked. The patient should be kept quiet in bed, cold
external applications continued several hours, and other
suitable means taken to prevent erections, but the parts
should not be meddled with any further, for the more
handling, the greater the liability to recurrence of the
haemorrhage. Internal pressure by the introduction and
maintenance in position of a large catheter has been recom-
mended in these cases, but this should be avoided except in
the most extreme circumstances. The presence of such a
foreign body becomes almost intolerable, and in the course
of three or four days is liable to cause ulceration of the
mucous membrane, and even perforation of the urethra and
urinary fistula.
Virulent conjunctivitis arises from the accidental con-
tact of pus from virulent urethritis with the conjunctiva.
The pus may be conveyed to the eye by a soiled hand or
Ihrough sonic other medium, such as a towel or cloth pol-
luted with urethral pus. The right eye is oftener affected
than the left, and both eyes are very rarely involved. This
phlegmasia, commonly called "gonorrhoea! ophthalmia," is,
fortunately, an extremely rare accident of urethritis, for it
is ordinarily superacute. Though it may resolve in a few
days under suitable treatment, leaving but slight traces of
its occurrence, its sequelae are frequently refractory to
treatment, and sometimes fatal to vision. Its progress is
occasionally so rapid that the eye perishes in a few hours
after the first symptoms. It is characterized at its outset by
some itching of the edges of the lids, by a sensation as if a
small foreign body had lodged beneath the eyelid, and by
great increase of lacrymation. Then follow much tumes-
cence of the conjunctival capillaries, chemosis, intense pain
in and around the eye, annoying photophobia, and a pro-
fuse flow of pus. The chemosis sometimes increases so
rapidly as to strangulate and destroy the cornea before
medical aid can be obtained.
The main features of the treatment employed by expe-
rienced ophthalmic surgeons is here given to guide the gen-
eral physician in whose practice cases of virulent conjuncti-
vitis occur, for the salvation of these inflamed eyes depends
upon the promptness and efficiency of the treatment which
should be forthwith begun, to be vigorously continued unti\
the arrival of an expert ophthalmologist, with whom the re-
sponsibility of the further management of the case is shared.
But, inasmuch as an ophthalmologist may not be accessi-
ble for several hours, or even for a day, as in small towns,
the general physician should render himself competent to
manage cases of virulent conjunctivitis to the end. For his
own protection he should, at his first visit, make a note of
the exact condition of the eye, and have some person to
witness this examination of the eye and of the writing of
the memorandum, which he should sign and the witness
should countersign.
The treatment of this violent phlegmasia should be
most prompt and energetic, the prime indication being to
check the rapid phlegmasic process and thwart its destruct-
ive tendency. In the early stage, and then only, free local
depletion should be effected through leeches applied to the
temple close to the outer canthus of the eye. The instilla-
tion of atropine solution should at once be begun, to be
continued to the end of the phlegmasic process. Copious
catharsis should be induced. The patient should be placed
in a dark room and his sound eye properly protected, but
the infiamed eye should not be covered. A nitrate-of-sil-
ver solution, sixty grains to the ounce, should be applied
once each day to the whole conjunctival surface with a
camel's-hair brush, and immediately washed away. When
chemosis appears, free cuts should be made through the
conjunctiva radiating from the cornea's edge. But what is
most efficient and most to be depended upon to relieve the
chemotic pressure upon the eye is free section of the ex-
ternal canthus, including the dense aponeurotic layer, and
this simple operation can not too soon be employed in cases
of extreme chemosis. Almost incessant ablutions of the
eye during the first forty-eiyht hours should be made with
cold, mildly astringent antiseptic solutions, and this eye
kept under the watchful care of a trustworthy and faithful
nurse, who shall obey strictly the physician's directions.
After forty eight hours, or after the danger of strangula-
tion of the cornea is passed, the ablutions need not be so
frequent and the !Utrate-of-silver solution may be weaker.
124
but still used once daily until the conjunctival membrane
appears normal. If the whole cornea have already sloughed,
the eyeball should be extirpated as soon as expedient after
the termination of the phlegmasic process.
Complications of Urethritis. — Balanitis — phlegmasia
of the glans penis, involving the mucous membrane, the
spongy substance, or both — is characterized, in the first case,
by an itchy and burning sensation, more or less intense red-
ness, swelling, and at length a purulent discharge. It may
be of the same nature as, or may have appeared before, the
urethritis, by which it is intensified, particularly when caused
by the accumulation of smegma. In superacute urethritis
there sometimes occurs an abundant plastic exudation in
the substance of the glans penis, which swells and becomes
very tense. Resolution is slow or is not accomplished, and
the imperfectly organized exudate undergoes sclerous de-
generation, causing irregular shriveling of the glans. Sub-
acute balanitis, with plastic exudation and induration of the
glans, is often the outcome of violent, careless, and unduly
frequent catheterism. The induration thus caused is most
apparent around the urinary meatus, and is in some cases
so strongly marked as to be mistaken, at first sight, for ma-
lignant disease.
Posthitis — phlegmasia of the foreskin of tbe penis, affect-
ing its mucous layer, its cutaneous layer, or both of these
]ayers — sometimes exists independently of balanitis, but, as
a general rule, is associated with balanitis and is designated
as balano-posthitis. Posthitis occurs frequently in young
subjects affected with vesical stone, causing frequent and
painful urination and subacute urethritis ; this frequent
escape of urine, and the traction upon the prepuce made
by the sufferers in endeavoring to obtain relief, being the
excitino- cause of the posthitis. The foreskin is elongated,
sodden, swollen, red, and painful, and its mucous membrane
emits pus and sometimes blood. This sodden condition of
a long prepuce in the adult occurs in cases of urethral steno-
sis and obstruction to urination from other causes, leading
to unduly frequent urination, or to constant dribbling of
urine.
Infibulation of the prepuce — a device of very ancient
date, to insure continency among the young until the age
of twenty-five, described by Celsus, practiced extensively in
the middle ages, condemned by Dionis and others during
the seventeenth century, seriously recommended within the
last fifteen years as a cure for " epilepsy and seminal loss " —
is still occasionally, but secretly, employed. It is hurtful
not only on account of its favoring the accumulation of
filth, but of the irritation excited by the buckle, which is
liable to induce posthitis with so much induration of the
foreskin as to lead to the suspicion of malignant disease.
Dupuytren relates such a case which at first he believed to
be cancer of the prepuce. The jealous mistress of the pa-
tient had succeeded in inserting an ingeniously contrived
gold ring through the end of the foreskin and had locked
it. In the course of time the extremity of the penis was so
much enlarged, indurated, and painful, that the ring
was removed ; this afforded relief from the pain, but the
swelling and induration were slow in yielding to treat-
[N. Y. Mm,. Joub.,
ment. The parts finally regained in a measure their normal
state.
Balano-posthitis is generally due to the accumulation of
smegma beneath a long prepuce, but at times it begins with
the attack of urethritis, and is even superacute and asso-
ciated with lymphangeiitis. The mucous membranes of the
glans and prepuce are tumid, of a vivid red, very sensitive,
and emit a considerable quantity of pus. In extreme cases,
complicated with phimosis, these mucous membranes ulcer-
ate in patches, so that when cicatrization is accomplished
the two surfaces adhere permanently unless precautions are
taken against the occurrence of such adhesion.
The treatment of balanitis and balano-posthitis, in cases
where only the mucous membranes are involved, and the
prepuce is short or easily retracted, consists in thoroughly
cleansing the glans and prepuce with antiseptic solutions
three or four times daily, and after each washing to cover
the affected parts with a thin layer of a powder composed
of equal parts of oxide of zinc and boric acid, or else
aristol, or europhen, which is said to be an iodide of iso-
butvlorthocresol, and which does not possess the objection-
able odor of iodoform. Ointments are not tolerated in the
majority of cases.
Phimosis. — Balano-posthitis complicated with phimosis
not being amenable to treatment by powders, the preputial
cavity should be irrigated with antiseptic fluids two or
three times daily until the subsidence of the phlegmasic
process. If the prepuce be only long enough to cover .the
glans penis, divulsion of the preputial orifice may be em-
ployed to relieve the constriction ; but if this orifice be ex-
tremely narrow or its edges much indurated, posthotomy
will be the more efficient procedure. This operation con-
sists in making a longitudinal incision through the skin and
mucous membrane of the prepuce on its dorsal aspect, so that
the glans can be easily exposed. The edges of the skin and
mucous membrane should then be stitched together, so as to
obtain a transverse scar from the longitudinal incision, and
thus increase the size of the preputial opening.
When the prepuce is long and so narrow as to render
its retraction difficult or impracticable, posthectomy should
be performed, but not until the subsidence of the phleg-
masic process, unless the integrity of the glans be imperiled
by the existence of chancroids. This minor operation, per-
formed for many thousand years largely as a religious rite,
consists in cutting away the superabundant foreskin and
enough of its mucous membrane to permit the glans penis
to be easily uncovered. As a religious rite the greater part,
if not the whole prepuce, is removed. For the purposes of
the surgeon it is rarely necessary to make a complete
posthectomy. The operation is the same in principle as it
has ever been, but its details have undergone many hun-
dreds of modifications. The essential steps of posthectomy
arc — 1, to pull gently forward the prepuce; 2, to apply I
suitable clamp to retain it in position and to protect from
injury the extremity of the glans penis; 3, to quickly cut
away all that part of the prepuce isolated by the clamp ; 4,
to remove the clam]) and slit the mucous membrane longi-
tudinally not more than half an inch ; 5, to trim with scis-
sors the angles of the mucous membrane ; 6, to take proper
GOULEY: DISEASES OF THE URINARY APPARATUS.
Jan. 30, 1892.]
GOULEY: DISEASES OF TEE URINARY APPARATUS.
125
means to arrest any oozing of blood or, if necessary, to tie
bleeding vessels ; 7, to stitch the mucous membrane to the
skin with very fine silk or with horse-hair ; and 8, to apply
a light dressing to the parts. In very young subjects no
stitching is necessary. Ordinarily the wound heals pri-
marily.
Paraphi?nosis, an accident of phimosis, occurs from the
forcible retraction of a narrow prepuce for the purpose of
cleansing the glans, or during coition or masturbation. It
is then very difficult or impossible for the patient to bring
toward the retracted prepuce, owing to swelling of the glans
penis. When paraphimosis has existed several days it is
not possible sometimes, even after section of the constrict-
ing ring, to replace the foreskin. Ordinarily it is rather an
inconvenient and unsightly deformity than a dangerous con-
dition, for the glans penis is very rarely damaged by an irre-
ducible paraphimosis. A portion of the dense ring into
which the retracted prepuce is converted finally sloughs and
the strangulation ceases, but the adhesions which take place
forbid the ultimate reduction of the prepuce.
The reduction of the retracted prepuce in paraphimosis
can generally be effected by compressing the glans penis and
pushing it backward while the prepuce is, as it were, un-
rolled upon the glans, using for this purpose the thumb and
index and middle fingers of each hand. This process is ap-
plicable only before the glans penis has become very tumid.
When the tumefaction of the glans is such as to forbid re-
duction by this method, a simple and quick process is to
apply elastic compression by means of a bandage, one inch
wide, of thin India-rubber, such as dental surgeons use un-
der the name of rubber dam. Compression so made expels
the blood from the glans and sufficiently decreases its size to
permit of reduction of the retracted prepuce. The last turns
of the bandage should he applied to the oedematous prepuce
to expel the serum from the meshes of its connective tissue.
The bandage is not removed from the glans penis until the
reduction is nearly complete. It has been proposed to re-
lieve paraphimosis by placing the patient on his back, grasp-
ing the penis with one hand, and striving thus to lift him.
This is said to have been practiced on children as well as on
adults. The violence of this remedy is such as to make it
worse than the discomfort which it is designed to relieve,
for the traction incident to the effort of raising the whole
body by the penis is so great as to seriously injure the ure-
thra, and possibly also the cavernous bodies.
Consequences of Urethritis. — Lymphangeiitis of the
larger subcutaneous lymphatic vessels of the penis occurs in
consequence of slight injuries, of friction by the clothing
during exercise, or of the untimely use of urethral injec-
tions. The phlegmasia may be subacute, acute, or super,
acute.
Subacute lymphangeiitis is characterized by its indolence,
by the slight engorgement of the subcutaneous lymphatics,
and by a little oedema of the neighboring connective tissue.
It is a frequent consequence of acute urethritis and may ap-
pear during the first ten days or not until the decline of the
phlegmasia. It rarely suppurates and resolves under rest
and simple lotions in the course of four weeks.
Acute lymphangeiitis is characterized by longitudinal
reddish tracts in the course of the lymphatics, which are
tense, nodulated, and tender to the touch, from the preputial
framurn to the inferior inguinal glands where they terminate.
The prepuce is much swollen from serous exudation, and
sometimes the whole phallic integument is in the same tumid
condition. This type of lymphangeiitis very rarely suppu-
rates, and resolves in the course of three or four weeks un-
der absolute rest in recumbency and soothing lotions.
Superacute lymphangeiitis is characterized by a diffuse
erysipelatous redness and swelling of the integument of the
whole penis. Although it most frequently resolves under
the same management as the acute type, it is sometimes fol-
lowed by abscesses in the course of the lymphatics, and in
very rare instances by diffuse suppuration, requiring free
and early incision. In still more rare instances the phleg-
masia is propagated to the cavernous bodies of the penis
(phallitis), and leaves a certain amount of induration which
deforms the penis during erection. This plastic exudation
in the cavernous bodies sometimes undergoes calcareous in-
filtration, a condition often miscalled bony transformation
of the penis.
Inguinal adenitis often follows lymphangeiitis of the
penis consequent upon urethritis, but it also occurs without
there being any lymphangeiitis, and may appear as a conse-
quence of any of the forms of virulent urethritis or of simple
non-contagious urethritis. One or more than one gland may
be inflamed. The phlegmasia may resolve after a few days
of rest, may be indolent, or suppuration may ensue. This
form of adenitis is one of the varieties of non-syphilitic bu-
boes ; there being two varieties, one of which resulting from
chancroids of the penis or urethra, the other from non-in-
fecting urethritis. These buboes are ordinarily on a level
with or a little below Poupart's ligament, and may be uni-
lateral or bilateral. In the event of suppuration, the dis-
eased glands should be freely incised, and in some eases
excised.
Peri-urethritis arises as a consequence of acute, but
more frequently of superacute, urethritis, the phlegmasic
process extending itself to the submucous connective tissue
or even to the spongy substance, and occupying a part or
the whole circumference of the urethral canal. It occurs in
the perineal, in the scrotal, or in the phallic region of the
urethra, most frequently in the last-named region. It is
often provoked by untimely urethral injections, by the so-
called abortive treatment of benign urethritis with strong
solutions of nitrate of silver, by violence to the inflamed
urethra such as may occur from coition or from masturba-
tion, or by any ingested substance which may render the
urine acrid. It is characterized by a more or less abundant
plastic exudation in the submucous connective tissue, or
both this and the spongy substance. The exudation may
occupy the whole extent of the inflamed part of the urethra
or may be confined to one or several isolated points, caus-
ing much pain during erection and, to a greater or less ex-
tent, curvation of the penis (chordee). When the exudate
retains its semi-fluidity it may soon be absorbed, or may
end in suppuration and peri-urethral abscess. The abscess
opens oftener in the urethra than externally. In the latter
126
GOULEY: DISEASES OF THE URINARY APPARATUS.
|N. Y. Med. Jock.,
case the urethra may be perforated and a urinary fistula
thus established. When the exudate is partly organized,
sclerous degeneration begins and urethral stenosis is the
sequel. This sclerous degeneration may be so rapid that
in a few months the lumen of the urethra is reduced to the
point of admitting only a capillary bougie, or it may be so
slow that rive, ten, twenty, or even thirty years may elapse
before the caliber of the urethra is sufficiently reduced to
attract the attention of the sufferer.
In the treatment of peri-urethritis the first indication is
the discontinuance of the injections which may have pro-
voked the phlegmasia. If balsamics had already been ad-
ministered, they too should be discontinued. The patient
should be confined to bed for five or six days, and means
taken to abate the frequent and painful erections of the
penis which so much aggravate the phlegmasic process. An
evaporating lotion, or, better, dry cold, by mediate irriga-
tion, as suggested by Petitgand, applied through India-
rubber tubing of small size and thin walls, coiled around
the penis so that a continuous flow of water at any desir-
able temperature may be used without wetting the bed or
otherwise inconveniencing the patient, has the double effect
of preventing erections and of acting as a local antiphlo-
gistic. The urine should be rendered bland by the admin-
istration of diluent drinks, and five grains of gum camphor,
one grain of hyoscyamus extract, and five grains of taraxa-
cum extract, made into a bolus, should be taken at bed-time
and, if necessary, once again during the night.
When these means fail to induce resolution, and sup-
puration ensues, the peri -urethral abscess opening in the
urethral canal, it is necessary to take measures to prevent
the entrance of urine, rare as this occurrence may be, into
the abscess cavity for two or three days, or until the forma-
tion of granulation tissue. This is effected by the passage
of a small, soft catheter whenever urination becomes neces-
sary. If the abscess points externally, it may be incised, or,
if small, the few drops of pus it contains may be removed by
aspiration, as advised by Christian Smith. For this purpose
the ordinary syringe employed for hypodermic injections
may be used. This simple process, perhaps repeated two or
three times, tends to prevent urinary fistula. Should it, how-
ever, fail, a sufficiently free external incision is indicated.
When resolution is slow or when the exudate, instead
of leading to suppuration, becomes more consistent, with a
tendency to undergo organization, the oleate of mercury,
applied dailv along the under surface of the penis or the
perinaeum, according to the site of the peri-urethritis, is of
much advantage. In obstinate cases the oleate of mercury
may be replaced by vesicating collodium once every week
until this vesication has been used three or four times. In-
ternally the bromides of sodium, ammonium, and potas-
sium, two grains each, should be given in a wineglass of
water four times a day for a week or ten days.
Resolution failing, the peri-urethritis becoming chronic,
or sclerotic degeneration beginning, which is the same as
saying that a stenotic process is established, the most effi-
cient method of treatment, designed to prevent the forma-
tion of a narrow stricture, is free dilatation of the urethra
once a week continued several months.
Urethral cryptitis — phlegmasia of the mucous follicles
of the urethra — a common consequence of acute urethritis,
is often very persistent and sometimes constitutes the main
cause of chronic urethral discharges. It occurs most fre-
quently in the balanic region, but may affect one or many
follicles in any part of the urethral canal. It happens occa-
sionally in acute urethral phlegmasia that the mouth of a
follicle becomes occluded by swelling of the mucous mem-
brane. Purulent accumulation ensues, distends the follicle,
and forms a small, hard, globular, or ovoid abscess, contain-
ing only four or five drops of pus, which is finally dis-
charged into the urethra, or externally through a very narrow
orifice. This orifice does not always close, and there re-
mains a fistulous tract through which some urine escapes.
To prevent the formation of a fistula, an attempt should be
made to open the mouth of the inflamed follicle with a slen-
der probe, such as the smallest used in stenosis of the
lacrymal ducts, so that the pus may escape in the urethra.
This failing, aspiration is made as in periurethral abscess,
or even external incision. The treatment of chronic eryp-
titis will be considered under the head of chronic ure-
thritis.
Bulbo-urethral adenitis is a rare consequence of acute
urethritis. This phlegmasia having already been described,
it is now only necessary to thus briefly notice it as a conse-
quence of acute urethritis.
Prostatitis, having also been described, requires no fur-
ther examination.
Orchitis is used as a generic term to signify a phleg-
masia affecting any or all of the divisions of the testicle.
Epididymitis is the term commonly used for phlegmasia of
the summit of the testicle, and didymitis for phlegmasia of
the body of the testicle, the latter occurring rarely. Of
222 cases of epididymitis consequent upon urethritis ob-
served by Founder, 164 were from acute urethritis and 58
from chronic urethritis. Of the 164 cases from acute ure-
thritis, 6 occurred during the first ten days of the urethri-
tis, 15 on the eleventh day, 34 during the third week, 30
during the fourth week, 29 during the fifth week, 19 dur-
ing the sixth week, 9 during the seventh week, and 21 dur-
ing the eighth week. Of the 58 cases from chronic ure-
thritis, 22 occurred during the third month, 1 during the
seventh year, and the remainder scattered between the fifth
month and the fourth year.
Epididymitis is a frequent consequence of urethritis.
It occurs in about thirty per cent, of all cases of acute ure-
thritis, and generally appears on or about the third week
from the beginning of the urethritis — i. e., during its period
of decline, or after it has reached the prostatic region.
However, this extension of the phlegmasia to the prostatic
region sometimes occurs in a few days after the beginning
of the urethritis, particularly if the urethritis begins in the
prostatic region. In either case, epididymitis may begin
verv soon after the development of urethritis. It arises
from extension of the phlegmasic action, by continuity of
mucous membrane and lymph-vessels, through the ejacula-
tory duct and spermatic canal, and thus reaches the epi-
didymis. In some cases the phlegmasic action is most
intense in the spermatic canal, and is even propagated by
Jan. 30, 1892.]
GOULEY: DISEASES OF THE URINARY APPARATUS.
127
the iymph-vessels to the spermatic cord. In these cases
there is sometimes little swelling or pain in the epididymis,
while at other times the epididymis is much swollen, very
painful, and accompanied by perididymitis, the pain ex-
tending to the inguinal region and even to the abdomen.
These last are cases of superacute epididymitis.
A young man affected with superacute epididymitis
complained, on or about the third day, of severe pain, ex-
tending from the testicle and spermatic cord to his abdo-
men, which soon became distended. This was the begin-
ning of a sharp seizure of peritonitis, from which he, how-
ever, recovered. A little reflection as to the explanation
of the attack of peritonitis led to the conclusion that the
canal between the peritoneal cavity and the tunica vagina-
lis, formed in foetal life by the descent of the testicle, had
remained patent, and that the phlegmasia of the tunica vagi-
nalis, consequent upon the epididymitis, had through this
channel extended itself to the peritonaeum. It is worth
wdiile to take into account the possible existence of such an
anomaly in case of peritonitis arising in connection with
epididymitis, though it is also possible for peritonitis to
occur by transmission through the medium of lymph-ves-
sels.
Phlegmasia of the epididymis may he developed slowly
and gradually in six or eight days, or may be superacute
and reach its height in twenty-four hours. It is often at-
tended with febrile reaction and gastic disturbance — furred
tongue, nausea, vomiting, etc. Ordinarily, however, it at-
tains its maximum of intensity in the course of three or
four days. Both testicles rarely suffer at the same time.
The phlegmasic action may affect only that part known as
the tail of the epididymis, may be extended to the body, or
may be most intense in the head of the epididymis. This
same phlegmasic process frequently involves one or both
seminal vesicles. Suppuration is a very uncommon result
of epididymitis. Resolution occurs on or about the third
week ; but there often remains some induration at one or
two points at the head or toward the tail, or the whole of
the epididymis becomes sclerosed, and finally shrivels.
Epididymitis occasionally recurs several times in the course
of three or four months on the same side, and sometimes
on the opposite side — orchite a bascule (Ricord). These
recurrences are apt to be owing to the existence of small
abscesses in the substance of the epididymis.
One of the occasional consequences of bilateral epididy-
mitis is sterility. This is owing to chronic phlegmasia of
both spermatic canals, the acid pus destroying the sperma-
tozoa. In some cases these canals become completely oc-
cluded by a gradual stenotic process, with destruction of
the epithelium, or by pressure from without at the tail of
the epididymis during the shriveling of a phlegmasic
nodule.
Several patients who had suffered bilateral epididy-
mitis married healthy women, whom they have never suc-
ceeded in impregnating. One of them married a second
time, and his wife, a well-formed woman in excellent physi-
cal condition, had not become pregnant ten years after.
Didymitis and epididymitis are specialized because, in
the first ease, the phlegmasia sometimes scarcely affects the
epididymis, but expends itself on the body of the testicle,
and, in the second case, because often the spermatic canal
is very little affected, and the body of the testicle is intact,
while the epididymis is the center of the phlegmasic pro-
cess. To warrant this specialization there are other reasons,
among which may be mentioned that didymitis sometimes
arises from direct violence to the body of the testicle, and
that this didymitis is said to occur secondarily to parotitis
and tu variola without epididymitis.
I Mdymitis, consecutive to epidymitis, may be subacute,
acute, or superacute. It may resolve in three or four
weeks, may suppurate, may end in gangrene of the testicle
in two or three days, or become chronic. Superacute epi-
didymitis is almost always attended with perididymitis, and
sometimes with parenchymatous didymitis. In either case
there is true orchitis, all the divisions of the testicle being
affected.
Subacute parenchymatous didymitis is attended with
little pain, but is slow in resolving, and liable to recur every
few weeks. These recurrences forebode the development
of purulent foci in the testicle. After three or four recur-
rences of dull pain and a sense of tension in the testicle, the
two layers of the tunica vaginalis become adherent ante-
riorly or laterally. This is evidence that an abscess is ap-
proaching the surface. It happens that in some cases a
single abscess is formed, becomes encysted, and is not
recognized until the diseased testicle is removed and cut
open, when a central mass of cheesy pus is enucleated.
Acute parenchymatous didymitis, though very painful,
the pain extending from the testicle along the spermatic
cord to the inguinal and even to the lumbar region, gener-
allv resolves with the accompanying epididymitis, and very
rarely suppurates. Sometimes resolution fails and the
phlegmasia becomes chronic. The seminiferous tubules are
then plugged with plasma, and the intertubular substance
is soon involved, sclerosis and shriveling of the testicle en-
suing. This is not an uncommon occurrence in cases of
didymitis consecutive to parotitis. There is a type of didy-
mitis in which the testicle remains indurated for many
months, and finally breaks, by ulceration, through the
bounds of its tunics and integument, and is extended as a
fungoid mass, named benign fungus, sometimes mistaken
for syphilitic or for tubercular disease. Benign fungus oc-
curs among persons whose health is much deteriorated by
debauchery and its consequences. This so-called benign
fungus consists of no other elements than those composing
the testicle in a state of chronic phlegmasia, together with a
covering of granulation tissue.
Superacute didymitis is of rare occurrence. It is at-
tended with very great pain and much febrile reaction,
reaching its maximum of intensity within forty-eight hours,
when the fate of the testicle is decided, for after this the
phlegmasic process is on the decline or t he testicle is in
a gangrenous state. The whole body of the testicle is af-
fected, the intertubular as well as the tubular substance.
Its form and size are unchanged, the fibrous tunic yield-
ing no space for swelling, hence the occurrence of gan-
grene, the hardness, and the almost intolerable sense of
tension experienced by the sufferer. Even when the tes-
128
ABLER: A CASE OF SO-GALLED LARYNGEAL VERTIGO.
[N. Y. Med. Jouh.,
ticlc escapes gangrene it is likely to be otherwise injured,
for it either suppurates or ends in chronic induration,
sclerous degeneration, and shriveling.
The treatment of epididymitis should be adapted to
the degree of the phlegmasia and to the peculiarities of in-
dividuals. Fretful, hyperaesthetic, algophobic patients
affected with the mildest epididymitis are sickened by what
others regard as a minor degree of pain, and require to be
tranquillized by free doses of the bromides or even of
opium. Otherwise the mild cases need nothing more than
rest and suspension of the testicle. Other patients affected
with superacute phlegmasia, endangering the testicle, make
little or no complaint, though they experience much pain.
Jn these cases prompt antiphlogistic treatment and the
closest attention are necessary to save the testicle.
Acute epididymitis demands free catharsis, rest in the
horizontal posture, and the ice-bag for forty-eight hours,
or perhaps longer. There are cases in which cold applica-
tions fail to relieve pain ; in these, hot fomentations often
have the desired effect in the course of a few hours. The
testicle should then be swathed in a thick layer of carded
cotton sprinkled with half an ounce of tincture of opium,
and the whole well suspended. In case of phlegmasia of
the spermatic cord with much pain, a small plaster com-
posed of powdered opium (one drachm) and a sufficient
quantity of water to make a thin paste should be applied
over the inguinal canal, as recommended by Velpeau, after
ten or twelve leeches have extracted as many ounces of
blood from that region. As a general rule, poultices should
not be used ; they are particularly hurtful in cases compli-
cated with scrotal dermatitis. When there occurs effusion
of serum in the tunica vaginalis (acute hydrocele), attended
with much pain, relief is very soon afforded by making fif-
teen or twenty punctures with an exploring needle, the
serum escaping in the scrotal connective tissue. " Strap-
ping " is worse than useless and is sometimes destructive
to the testicle. The patient should be kept in the hori-
zontal posture for at least a week, and the testicle properly
supported during that time and for two or three weeks
thereafter. When suppuration has taken place in any part
of the epididymis free incision should be made without
delay.
The treatment oV didymitis is essentially the same as
that of epididymitis, except in the case of the superacute
type, which demands more heroic antiphlogistic measures,
beginning with the application of at least sixteen leeches in
the inguinal region on the affected side. Then the ice-bags
— one anteriorly, the other posteriorly, as suggested by Curl-
ing— should be used continuously night and day for four or
five days. Sufficiently free doses of opium, or of morphine
hypodermically, to blunt the senses and induce sleep, are
absolutely necessary. The prime indication is to prevent
the occurrence of suppuration or of gangrene of the semi-
niferous tubules. When the violence of the phlegmasia is
expended, when the pain is relieved, the affection is to be
dealt with as in the case of epididymitis. But when, in the
course of thirty-six or forty-eight hours, the faithful use of
ice and of the other antiphlogistic agents fails to subdue
the phlegmasic process, and the sense of tension is rapidly
increasing, a free incision should be made through the
scrotum and tunica albuginea. This is imperative as the
only means of increasing the space for swelling or of re-
establishing the local capillary circulation and thus prevent-
ing necrosis of the seminiferous tubules. The patient has
a right to the benefit of the doubt, if any doubt exist in the
mind of the physician as to the expediency of the proced-
ure at the particular time, by a prompt resort to this incis-
ion, for even a brief delay may be fatal to the integrity of
the testicle. This seemingly violent mode of treatment was
advocated about fifty years ago by Vidal (de Cassis), who
afterward wished to generalize it in all forms of orchitis,
and made incision of the tunica albuginea, and even of the
parenchyma of the testicle, in four hundred cases. He was
criticised with undue severity by Gosselin, who asserted that
the incision scarcely ever extended beyond the tunica vagi-
nalis, and that the relief experienced by some of the pa-
tients so treated was owing to the exit of serous fluid which
had distended the tunica vaginalis and had been the chief
cause of the pain. Vidal did, however, accomplish incision
of the tunica albuginea and often found the testicle already
necrosed. In such cases incision is surely indicated. Hernia
of the seminiferous tubules is liable to occur after incision
of the tunica albuginea, but better this than gangrene, for
under favorable circumstances cicatrization follows, though
the testicle is more or less damaged.
( To be continued.)
A CASE OF
SO-CALLED LARYNGEAL VERTIGO.
By I. ADLER, M. D.,
VISITING PHYSICIAN TO THE GERMAN HOSPITAL, NEW YORK.
That peculiar, though somewhat varying, group of
symptoms which, following the lead of Charcot, is com-
monly designated as laryngeal vertigo, is still a subject of
discussion as regards both its pathology and its aetiology.
The well-authenticated cases thus far reported are compara-
tively few in number. Scarcely more than two dozen cases
have been reported since Charcot first called attention to
the affection in 1879, and the authors differ widely in their
interpretation of the clinical facts. Under these circum-
stances every new case of so rare an affection becomes valu-
able as possibly shedding some light on a point hitherto
doubtful or obscure. From this point of view I venture to
present the following case :
Mr. J. E. H., aged about fifty-three, merchant. No heredi-
tary taint of any kind. With the exception of several attacks
of gonorrhoea, claims never to have had venereal disease. Mi-
nute examination detects no evidence of syphilitic lesion. Does
not use tobacco in any form. Is accustomed to take several
glasses of wine or beer with his meals. He is a man of florid
complexion and robust and healthy appearance. He professes
never to have had any serious illness, but is subject to " colds
and coughs." From time to time during the last few years he
has shown slight but sufficiently well marked symptoms of a
gouty tendency and has had occasional attacks of muscular
Jan. 30, 1892. J
ABLER: A CASE OF SO-GALLED LARYNGEAL VERTIGO.
129
rheumatism. About three years ago he had an attack of acute
bronchial catarrh with little or no febrile symptoms, accom-
panied for several days by thin, foamy, and not very copious
bloody expectoration. No pulmonary lesion could be detected,
and the sputum then and since remained free from tubercle
bacilli. The slight haemorrhage was referred to congestion of
the bronchial mucosa. In November of 1890, in the course of
a slight bronchial catarrli attended by rather violent paroxysms
of cough, he claims during one of these coughing spells to have
suddenly " fainted." Eeing hurriedly called in and arriving a
few minutes after the attack, I found the patient apparently
perfectly well and bright. Questions addressed to him and to
the members of his family who had witnessed the attack
elicited the following facts: The paroxysm of cough had been
no worse than usual. He was in a sitting position when the
cough seized him, and during the coughing he arose as if to
expectorate, then suddenly fell to the floor, totally unconscious.
He claims to have noticed no premonition of any kind. There
was no giddiness; he was not conscious of any tickling or burn-
ing or other sensation about the larynx. The bystanders were
unable to state whether the face was pale or turgid or livid.
There was no cry, no involuntary micturition, nor were any
convulsive twitchings noticed. The unconsciousness lasted but
a very few seconds. The patient raised himself without assist-
ance from the floor, laughed at the alarm expressed by his
family, felt no lassitude, sleepiness, or any discomfort whatso-
ever. Careful examination showed some dry rales in the larger
bronchial tubes, slight hyperaemia of the pharynx and larynx, and
an elongated uvula, otherwise no lesion of any kind. The bron-
chial catarrh, accompanied by still rather violent paroxysms of
cough, passed away in about a week, but no further seizure like
the one described occurred. The treatment consisted in the
administration of opiates and expectorants.
I desire to note here a peculiarity in Mr. H.'s manner of
ooughing which struck me whenever I had occasion to see him
for one of his periodical attacks of coughing. It seems as if he
had acquired a habit of "choking" over his cough whenever
the paroxysm is even moderately severe. The chin is depressed
so as almost to touch the sternum, head and shoulders stoop
forward, the face becomes turgid and red, the superficial veins
swell out, and the cough consists of a deep inspiration, succeeded
by a number of short, spasmodic expiratory movements follow-
ing each other in rapid succession, and differing only from per-
tussis in lacking the long sibilant inspiration which commonly
ends the paroxysm in the latter.
During April of this year Mr. H. had an attack of influenza,
and following this, after the febrile stage had passed, a very vio-
lent cough. At first there were all the symptoms of diffuse
bronchial catarrh, sonorous rales over the entire chest, muco-
purulent expectoration, etc. Later on the rales gradually van-
ished, the expectoration diminished, and finally at the end of
about ten days ceased altogether, but the cough remained more
violent than ever, and assumed a more spasmodic character.
The peculiar habit referred to above was still more marked.
The cough came in paroxysms, during both day and night, seri-
ously interfering with his sleep. It commenced with tickling in
' the region of the throat and larynx, became at once very vio-
i lent, accompanied by turgidity of head and neck, lasting from
some seconds to several minutes, and ended usually with the
j expectoration of a small lump of glassy mucus, sometimes, how-
ever, without any expectoration. This state of thinps continued
for about a week, sinapisms, opiates, expectorants, and inhala-
tions being administered without any apparent effect on the par-
oxysms of coughing. One evening during a violent coughing
spell, which occurred while Mr. H. was standing upright, he
suddenly dropped to the floor utterly unconscious. I was called
in at once and arrived a few minutes after the seizure. There
had been no premonitory signs. The cough commenced with
the usual tickling in tho upper air-passages, but did not appar-
ently differ from any of the preceding paroxysms. There had
been no giddiness. The patient did not feel that anything un-
usual was going to happen. He simply dropped to the floor,
almost immediately to arise again, feeling perfectly well, but
not aware of any unusual occurrence.
The physical condition now was the following: Very mod-
erate granular pharyngitis, elongated uvula, slight hyperaemia
of the larynx, heart and lungs in normal condition, pulse full
and regular — between 60 and 80 beats per minute. The pupils
of equal size and reacting normally. Ophthalmoscopic exami-
nation negative. No appreciable symptoms on the part of the
nervous centers. The knee-jerk somewhat subnormal, but still
sufficiently well marked. The urine, which was examined fre-
quently and carefully, at no time showed albumin, casts, or
sugar. The quantity of phosphates and urates was slightly in
excess of the normal. No other abnormity could ever be de-
tected. Opiates had been given before ; they were now admin-
istered in larger doses. No attack during the next two days ;
then another one of exactly the same character as before, with
merely this difference: that, happening to recline on the sofa, he
did not fall to the ground, but simply lost consciousness. As
opiates had been of no service, they were now replaced by large
doses of the bromides of sodium and ammonium, and a com-
petent laryngologist made daily applications of a spray to the
pharynx and larynx. The attacks of sudden loss of conscious-
ness following cough now appeared daily, soon several times
during twenty-four hours, by night as well as by day. During
one of these attacks about this time Mr. H. slightly bit his
tongue. The seizures evidently becoming more frequent and
more severe, the local treatment, after about ten days of spray-
ing, was discontinued. By the desire of the patient and his
friends, the advice of a very well known neurologist was ob-
tained. On recommendation of the latter, iodide of sodium was
added to the bromides, and both gradually increased up to ten
grammes pro die, also gradually increasing doses of the red
iodide of mercury, blisters to the back of the neck and laryn-
geal region, and large doses of cerium oxalate. This treatment
was continued for about three weeks. Under the influence of
the bromides the pharynx and larynx became quite anaesthetic,
and the patient stupid and somnolent. There were marked
symptoms of iodism. The seizures, however, steadily increased
both in violence and frequency. He had now as many as four
or five in twenty-four hours. In one of these attacks, which came
upon him while descending from one floor to another, he fell
down stairs and was badly bruised. In another he dropped while
standing with a friend in the street and severely hurt his face.
It is to be noted that, while no seizure ever took place with-
out preceding cough, by no means every violent paroxysm of
cough was followed by loss of consciousness. The daily cough-
ing spells were quite numerous — sometimes several dozen in
twenty-four hours — but, as far as I have been able to ascertain,
he never had more than five seizures attended by loss of con-
sciousness in one day. Nor were always the most violent fits of
coughing followed by these peculiar attacks. Not infrequently
a very violent paroxysm would pass without further conse-
quences, while a comparatively rather mild cough would sond
the patient into unconsciousness. It is stated, too, that in several
instances, when the state of unconsciousness had been of some-
what longer duration than usual, slight convulsive twitchings of
the eyes and arms were noticed just before consciousness re-
turned.
As the patient was evidently getting worse, all this treat-
ment was now stopped : no medicine whatever was adminis
13d
AVZERs A CASK OF SO-CALLED LABY&GEAL VE&TIQO.
|N. Y. Med. Jote.,
tered, and when, after about six days, the local etfcct of the
iodide and bromide had completely disappeared, another very
careful general and local examination was made. The result of
the general examination proved entirely negative. Locally the
same appearances were found as above stated. The larynx was
carefully examined with a probe, in order to determine the
presence of any hypertestbetie spot as the oiigin of the convul-
sive coughs. No such spot was found. As no tangible point
of attack could be made out in the larynx, as medicinal treat-
ment had plainly and completely failed, and bearing in mind
the experiences of Gleitsmann, who had cured a similar case by
removing adenoid vegetations at the base of the tongue, and of
Charcot, who effected a cure by cauterizing a granular pharyn-
gitis, I determined to clip the uvula. This was done at once.
The patient went home and had no attack for twenty hours ;
then two very slight ones in rapid succession, and none since
then. The cough continued tor some five or six days, having
completely lost its spasmodic character, and then disappeared
altogether.
The preceding history has been given at great length
because it seems to offer several points of interest. We.
have here a man without organic lesion and of fairlv good
health, who, after a moderate attack of bronchitis, becomes
subject to spasmodic cough, attended by frequent seizures
of complete loss of consciousness. There is no aura pre-
ceding the seizure, no cry, no involuntary micturition, no
hebetude or confusion of mind on regaining consciousness.
Unfortunately, it so chanced that I was never able to ob-
serve an attack in person. It is therefore impossible, to say
what was the behavior of pulse and heart during a seizure.
The members of Mr. H.'s family, who witnessed quite a
number of these sudden losses of consciousness, were in-
variably startled and alarmed to such a degree as to render
them unfit for the purposes of closer observation. It was
impossible even to make out with any degree of certainty
whether the patient was red or pale in the face. Altogether
the witnesses tend more toward the belief that the face was
red and turgid. The patient himself describes his sensa-
tions during a violent paroxysm of cough as " choking," as
" wishing to cough, and not being able to cough out " — a
sensation evidently very similar to that described bv the
patient of Russell.* It seems reasonable to assume from
all this that the spasmodic cough was frequently followed
by spasm of the glottis. That for this latter the elongated
uvula was principally responsible would seem to follow from
the failure of all other treatment and the prompt relief from
all symptoms after the clipping. In what manner the uvula
produced the spasm can not be positively ascertained. I
am inclined to assume that it was by direct irritation of the
rirna ylottidis. The patient's peculiar attitude while cough-
ing would tend to raise the larynx sufficiently to permit
this, •while the fact of these spasms occurring frequently at a
time when the pharynx and superior portions of the larynx
were well under the influence of bromide anaesthesia would
seem to preclude any other mode of mechanical irritation.
It is not impossible that the attack of influenza which pre-
ceded these spasmodic seizures may have induced a more
than ordinary irritability of the nervous system, and that
this may explain why former attacks of cough were never,
* Birmingham Medical Rerieir. vol. xvi, August, 1884.
with but a single exception, followed by similar complica-
tions.
Leaving out of consideration those cases in which simi-
lar attacks have occurred in the course of locomotor ataxia,
as so-called laryngeal crises, and where well-marked ana-
tomical lesions have been found in the track of the pneumo-
gastric and recurrent,* we find widely differing opinions as
to tin' nature of this singular neurosis. Charcot \ is inclined
to accept this group of symptoms as a disease sui e/encris and
analogous to Meniere's disease, the afferent nerve in this in-
stance being the superior laryngeal. Gray J and Massei*
consider these attacks to be essentially epileptic. Others
again, such as McBride, || Russell,A Knight,A and Gleits-
mann, | explain the loss of consciousness and attendant
symptoms by disturbances of circulation in the brain, basing
their views on the well-known experiments of E. F. Weber, t
It is not my intention to enter into a detailed discussion
and criticism of these conflicting opinions, nor to give an
exhaustive review of the cases thus far recorded. All this
has been done most fully and ably by Thermes, % Knight,
and others. In the case of Mr. II., the complete loss of
consciousness and the absence of all vertigo and even giddi-
ness, as well as of nausea and vomiting, seem to preclude
all analogy to Meniere's disease. There seems no necessity
of ranging our case under the head of reflex epilepsy. No
spot or nerve could be found by the irritation of which it
was possible to produce an attack. Nearly all cases of
well-authenticated reflex epilepsy present well-marked con-
vulsive seizures with all the classical symptoms preceding
ami following the convulsions. Interesting in this respect
are the cases of Schneider.**
The oft-quoted case of Sommerbrodt, ft in which a large
fibroid of the left vocal cord apparently caused true convul-
sive attacks of epilepsy, can not be considered here, as the
patient had had epileptic attacks fifteen years before which
were at that time referred to a cicatrix on the right hand
and disappeared after the excision of the scar. Evidently
this was a case of well-marked " epileptic disposition."
It seems as if all the symptoms in our case could be
satisfactorily accounted for by the experiments and theory
of Weber. Forced expiratory movements with a spasmod-
ically closed glottis caused increased intrathoracic pressure.
* Jean, Gazette hebdom., 1876, Xo. 27. Feieol, Gaz. hebdom.,
1869, No. 7.
f Lf Progrts mid., 1879, 17. Reime des sciences med., x, p. 135.
$ Amer. Jour, of Neurol, and Psych., November, 1882.
* Giomalc internaz. delle scienze med., Anno vi. Abstracted in In-
termit. Ctrlbl.f. Larungologie u. Rhinologie, 1885, p. 21.
| Edinb. Med. Jour., March, 1884.
A Loc. cit.
§ Transactions of the Amer. Lariing. Assoc., 1886, p. 34.
| Med. Monalssrhr., i, p. 510.
I Ueber ein Verfahren, den Kreislauf des Blutes un<l die Function
des Herzens willkiirlich zu unterbrechen. Muller's Archiv, 1851,
p. 88.
J Deux observations de vertige larynge dans la eoqueluelie cliez les
vieillaids. Jour, de med. de Paris, 1887, p. 936.
** Einige F&Ue von geheiller Rellexepilepsie der Nase. Bert. klin.
Woch., 1889, No. 43.
+ + Ueber ein grosses Fibroid des Kehlkopfes als Ursaclie del Epi-
lepsia Berl Min, Woch., 1876. p. 563.
Jan. 30, 1892.]
LEADING
ARTICLES.
131
Ultimately not only the heart itself to a certain extent, but
principally the vence cavce are compressed, the flow of blood
to the heart is diminished and then ceases, a condition of
arterial ischasmia and venous hyperaemia ensues in the
brain. The pulse becomes weaker and finally disappears
altogether, and the heart's action comes to a standstill un-
less, before this climax is reached, the glottis is reopened
and normal respiration is resumed. That this mechanism
can and does produce complete loss of consciousness with
total amnesia, and even convulsive twitchings, within a frac-
tion of a minute is established by Weber's experiments on
himself. All the conditions given by Weber were present
in the case of our patient — the spasm of the glottis with vio-
lent, rapid expiratory movements, the turgid face and neck,
etc. Had it been possible to obtain a satisfactory record
of the pulse and heart, or even of the pulse alone, during
one of the seizures, the question could have been settled
beyond perad venture. As it is, the case appears in all
essential respects analogous to Thermes's second case, where
the pulse and heart during the spell of unconsciousness were
found so characteristically in accord with Weber's results.
Being still completely ignorant of the true anatomical
lesion underlying epilepsy, and the experiments of Kuss-
maul and Tenner and others making it at least probable
that disturbances of cerebral circulation play an important
role in the pathology of epilepsy, there can be no objection,
if one was so inclined, to call the peculiar seizure of laryn-
geal vertigo epileptoid — epileptoid attacks, however, result-
ing not from a hypothetic irritation of a peripheral nerve,
but from great and sudden disturbance of cerebral circu-
lation.
Finally, it is perhaps worthy of note that in the present
case again, as in so many before recorded, there is a his-
tory of gout and rheumatism. That in all hitherto recorded
cases, with but one exception (the second case of Knight),
the patients are males, of whom the large majority had
passed their fortieth year when they became subject to
these attacks, are facts that must be taken into account in
the future study of this affection.
The Medical Society of the State of New York.— Dr. J. H. Glass,
of Dtica, the chairman of the committee on credentials, announces
that the committee will be in session, together with the treasurer, at
the Delavan House, Albany, on Monday evening, February 1st, to fa-
cilitate the registration of members and delegates.
The Alvarenga Prize of the Paris Academy of Medicine, — Accord-
ing to the Lancet, Dr. Frederick Bateman, of Norwich, England, whose
views regarding the localization of the speech center have been men.
Boned in the Journal, received the award on December 15th, for his
treatise on Aphasia and the Localization of Speech. The prize was
divided equally between him and Dr. Leguen, of Paris. There were
twenty-five competitors, the prize being open to all comers.
The Death of Dr. Stanislas Zalewski, of Bordeaux, France, is re-
1 ported in the Proyrea medical, lie hud reached the patriarchal age of
one hundred and eleven yeais. He was born at Warsaw in 1780, but
h:nl lived in France since boyhood. lie retired from practice thirty
years ago, subsisting on a slender pension allowed him by the French
Government. Until quite recently his health had been excellent, and
all his faculties unimpaired.
Answers to Correspondents :
No. 370. — Probably you could obtain it of Messrs. Kimer & Amend
No. '205 Third Avenue.
THE
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by Edited by
D Appleton & Co. Prank P. Foster, M. D.
NEW YORK, SATURDAY, JANUARY 30, 1892.
MOLIERE AND THE MEDICAL PROFESSION.
The presidential address presented at the last meeting of
the Ohio State Medical Society deals with that greatest satirist
of the medical profession, Moliere. Its author is Dr. Conklin,
of Dayton, and the address may be found in the Transactions
of the society, just issued.
Moliere's true name was Poquelin, Moliere being that
adopted by him during the ten years of his life when he was a
strolling player. It was some time in the year 1658, when he
was thirty-six years old, that Moliere emerged into the sun-
shine of court recognition. Then it was that the long-coveted
opportunity, an invitation to play before the king, came, and
grandly did Moliere's genius plume its wings for dramatic flight.
During the fifteen years that embraced the true career of the
dramatist, the favor of Louis was unshaken, and it was re-
warded by that brilliant series of comedies which mark an era
in French literature. In that time Moiiere composed thirty
pieces, half of which are classical. The later ones are the best,
for in them he found the true field of his genius — the por-
traiture of the Tartuffes, Sganarelles, Dandins, Argans, and
other perennially true types of human character.
Dr. Conklin's contention is in Moliere's favor as against the
views commonly pronounced by the critics. Nearly all com-
mentators assume that Moliere was actuated by an implacable
rancor against physicians and their calling. A careful study of
his writings, of the friendly tenor of his life, and of the state of
the times will prove that this harsh indictment has been over-
drawn. The two great objects of the dramatist were the self-
ish one of maintaining court favor and the intellectual one of
exercising his creative faculty as poet and comedian. It he
failed to keep the king amused and to make the people laugh at
his characters, he would be relegated to the strolling profession.
His genius impelled him to chastise the shams and hypocrisies
of his time. He hated cant and pedantry, and attacked every
station of life, from the highest to the lowest, that exposed
these frailties to his view. Without rancor, with very little of
avoidable personality, and without partiality, he made the
nobles, the Church, the doctors feel the sting of Ins satire where
they were most vulnerable. "The shafts of his humor, like
the arrows of Tell, pierced the foibles at their center, without
wounding head or heart."
Moliere had not a few intimate friends among the physi-
cians of the court, some of whom were under discipline by the
Faculty of Medicine for the use of antimony and other chemical
innovations. Moliere had very little of sarcasm to expend
upon the faction addicted to the nntimonial " irregular ty," but
the phlebotomists of the academy are never -pared. They are
ordinarily represented as ignorant pretenders, speaking in
132
MINOR PARAGRAPHS.
[N. Y. Meu. Jouk.,
mongrel Latin like that which, in Le malade imaginaire, is put
into the mouth of the candidate who has a stereotyped answer
for all questions about the treatment of diseases:
" Clysterum donare,
Postea seignare,
Ensuita purgare,"
and in the event that this treatment fails, he next replies:
" Reseignare. repurgare et reelysterisare."
Medical sects and dissensions abounded, and physicians
carried on their controversies with all the acrimony of theo-
logians. The sick-room was the scene of many an unseemly
quarrel, from the death-bed of Cardinal Mazurin down to the
cot of the coachman. These scenes were the legitimate prey of
the satirist, and they became immortal in the text of L1 Amour
medecin and Le malade imaginaire. The latter was composed
by Moliere when his health was rapidly failing and the shadows
were gathering about him. It is a dying comedian's sarcasm
on the impotence of the medical art against life's last ebb. His
health had been nrecarions for six years ; he was annoyed by
cough and haemorrhages, due either to aneurysm or to pul-
monary phthisis. " How much a man suffers ere he dies!" was
his weary exclamation when on his way to the theatre on the
evening of his death. Under these circumstances, and others of
an embittering nature, it is not surprising that he gave vent to
satire and bitter invective against the art that tailed him at the
pinnacle of his genius and renown. " You have a doctor," said
the king to him when they were walking together in the royal
garden, " what does he do for you ? " " Sire," he replied, " we
walk together, he prescribes remedies which I do not take, and
I get well." But medicine may be said to have obtained a
poetic revenge against Moliere, since his death-blow fell upon
him in immediate connection with his fourth rendering of the
Malade imaginaire. He was taken violently ill while on the
stage, and was carried to his deserted home, where he tiled in
less than an hour, suffocated by a pulmonary haemorrhage. He
thus literally materialized the dismal prediction which he had
put into the mouth of Argan, in the play last mentioned, when
saying that Moliere would get only his deserts if the physicians
"would let him die without medical assistance." He died with-
out assistance, but not for the reason stated by Argan, "and
that will teach him another time not to make fun of the
Faculty."
To sum up the case as stated by Dr. Conklin, Moliere was a
man of genius, with many traits of true nobility ; he hated a
lie, a sham, a miser, and a bigot. He could not fail to see the
foibles of his time, and he had the courage and ability to chas-
tise them. " Nothing was too humble or too sacred for his
purpose. The doctors were fair game and easy to ridicule.
Everybody, when well, laughs at doctors, and no one — not even
the doctors — is seriously the worse for it."
MINOR PARAGRAPHS.
SEPTIC PNEUMONIA IN THE NEW-BORN.
In the Archiv fur pathologische Anatomic und Physiologie
undfiir klinische Medicin, l>r. U. Lubrasch and Dr. H. Tsutsui
report interesting post-mortem findings in the case of an infant
two days after birth. The autopsy was performed thirteen
hours after death, and revealed pleuritis and pneumonia of the
left upper lobe, bronchitis of both sides, and atelectasis of the
right lung; parenchymatous infiltration and uric-acid infarction
of the kidney ; fat infiltration and congestion of the liver; an
enlarged spleen ; and icterus. The microscopical examination
of the organs revealed the presence of Gartner's bacilli in great
numbers. These micro-organisms were found in the vessels of
both lungs, between the cells and the fibrinous masses of the
pneumonic exudation, and in the fibrinous effusion in the pleura.
The spleen contained numerous patches of micro-organisms
similar to the typhus bacilli. These were also found in the kid-
ney, in the glomeruli and intertubalar capillaries. None were
found in the mucous membrane of the intestines. Cultures were
m-ide from material taken from the lungs and spleen, and then
inoculated into rabbits and guinea-pigs, and the condition brought
about in these animals proved the nature of these germs. Gart-
ner declared these bacilli to be identical with those that he had
previously described. It was thought at first that the case was
one of Winckel's disease, as the important clinical symptom of
hoamogh 'binuria was present, followed by genuine septicaemia,
until the finding of the Gartner bacillus. It was a matter of
considerable wonder how these organisms had entered the child's
system, as every possible avenue of entrance, such as the um-
bilicus and the intestines of the infant and the external genitals
of the mother, were examined with negative results.
THE TREATMENT OF DEBILITY, AN. EM I A, AND RICKETS.
A very common error in the treatment of diseases of de-
fective nutrition is pointed out by Dr. Cheadle in the July
number of the Practitioner. It consists in relying wholly or
chiefly upon drugs. Children are dosed with iron, phosphates, or
cod-liver oil without regard to the condition of the digestive
functions or their fitness for the reception of such materials. A
delicate child is condemned to cod-liver oil because it is flabby
and anaemic, without regard to other conditions. Perhaps the
appetite is poor, the tongue is coated, and the bowels are con-
stipated. The chief cause of the symptoms in this case is to be
found in the disordered state of the functions of digestion, ab-
sorption, and excretion. Cod liver oil and iron are invaluable
in their proper place, but here, by intensifying the digestive
difficulty and diminishing the appetite, they are likely to do
more harm than good. A few doses of gray powder, followed
by a tonic with some saline laxative, will be far more effectual.
At the same time the diet must be carefully regulated. When
the digestive disorder has been removed the oil, iron, and phos-
phates may be found of the greatest value in completing the
cure in rickets. Plenty of fresh milk and cream, raw meat
juice, fresh air, and sunlight are better medicines than any to
be found in the pharmacopoeia.
BORO-BORAX.
According to Lyon medical for January 3d, this is a coin-
pound, discovered by Jaenicke, formed by mixing equal parts
of borax and boric acid in boiling water. It is a crystalline,
neutral body, of great solubility in comparison with boric acid,
sixteen per cent, dissolving in cold water, about thirty per cent,
in water of the temperature of the blood, and seventy per cent,
in boiling water.
LAVAGE IN THE TREATMENT OF ILEUS.
Dr. Aufreciit, in the 7 herapeutinr.he Monatslieft, says that
the method of treatment from which he has had the best re-
MINOR PARAGRAPHS— ITEMS.— PROCEEDINGS OF SOCIETIES.
133
suits is to give a dose of morphine subcutaneously at once, and
thee to introduce an oesophageal tube into the stomach and irri-
gate with large quantities of water. By this means the gas is
allowed to escape, the distention got rid of, and the stomach
cleared of its abnormal contents. In some instances but one irri-
gation has been sufficient to relieve the distress and quiet the
patient. He advises the giving of the morphine hypodermic-
ally in every iustance, as in this way its action is much more
prompt in arresting spasm. The patient should be kept under
its influence and the irrigation repeated if distention reappears.
RESECTION OF THE LIVER.
According to the British Medical Journal for January 10th,
Professor Tansini, of Modena, in extirpating a hydatid cyst of
the liver found it neco-sary to excise a portion of hepatic tissue.
There was free haemorrhage from the cut surface of the liver
that was controlled by catgut ligatures; the hepatic wound was
closed by silk and catgut ligatures, and the patient was well
within a fortnight.
ITEMS, ETC.
Infectious Diseases in New York. — We are indebted to the Sanitary
Bureau of the Health Department for the following statement of cases
and deaths reported duiing the two weeks ending January 26, 1892 :
IWeek ending Jan. 19. Week ending Jan. 2(5.
DISEASES.
Cases.
Deaths.
Cases.
Deaths.
9
6
8
2
242
33
211
26
4
2
2
O
152
9
128
9
Diphtheria
115
46
122
38
Small-pox
0
0
11
0
2
2
5
0
9
18
0
0
2
0
0
0
1
0
Army Intelligence. — Official List of Changes, in the Stations and
Duties of Officer* serving in the Medical Department, United States
Army, from January 17 to January 23, 1892 :
BitEcnEMiN, Louis, Captain and Assistant Surgeon, will proceed without
delay from the Presidio of San Francisco, Cal., to Vancouver Bar-
racks, Washington, and report in person to the commanding officer
of that post for temporary duty.
v Appel, Aaron II., Captain and Assistant Surgeon, is relieved from duty
at Fort D. A. Russell, Wyoming, and will report in person to the
commanding officer, Fort Bufoid, North Dakota, relieving Cabell,
Julian M., First Lieutenant and Assistant Surgeon, who will then
report in person for duty at Fort D. A. Russell, Wyotniug.
Society Meetings for the Coining Week :
. Monday, February 1st : New York Academy of Sciences (Section in Bi-
ology); German Medical Society of the City of New York; Mor-
risania Medical Society (private); Brooklyn Anatomical and Sur-
gical Society (private); Utica, N. Y., Medical Library Association;
Corning, N. Y., Academy of Medicine ; St. Albans, Vt., Medical
Association; Providence, R. I., Medical Association ; Hartford,
Conn., Medical Society; Chicago Medical Society,
i Tuesday, February 2d: Medical Society of the State of New York
(first day — Albany); New York Obstetrical Society (private) ; New
York Neurological Society: Elmira, N. Y., Academy of Medicine;
Buffalo Medical and Surgical Association; Ogdensburgh, N. Y.,
Medical Association ; Hampden, Mass., District Medical Society
(Springfield); Hudson, N. J., County Medical {Society (Jersey City);
Androscoggin, Me., County Medical Association (Lewiston) ; Balti.
more Academy of Medicine.
Wednesday, Ftbruary 3d : Medical Society of the State of New York
(second day); Society of the Alumni of Bellevue Hospital ; Harlem
Medical Association of the City of New York ; Medical Micro-
scopical Society of Brooklyn ; Medical Society of the County of
Richmond (Stapleton), N. Y. ; Penobscot, Me., County Medical So.
ciety (Bangor) ; Bridgeport, Conn., Medical Association.
Thursday, February Jflh : Medical Society of the State of New York
(third day) ; Neyv York Academy of Medicine ; Brooklyn Surgical
Society ; Society of Physicians of the Village of Canandaigua, N. Y. ;
Boston Medico-psychological Association ; Obstetrical Society of
Philadelphia ; United States Naval Medical Society (Washington).
Friday, February 5th : Practitioners' Society of New York (private) ;
Baltimore Clinical Society.
Saturday, February 6th : Clinical Society of the New York Post-
graduate Medical School and Hospital ; Manhattan Medical and Sur-
gical Society (private) ; Miller's River, Mass., Medical Society.
jprocccbings of Societies.
NEW YORK SURGICAL SOCIETY.
Meeting of October 1%, 1891.
The President, Dr. Charles K. Briddon, in the Chair.
Obstructing Cancer of the Rectum. — Dr. Willy Meyer
presented a man sixty-one years old, upon whom he had oper-
ated for this trouble a year before. Bimanual palpation had re-
vealed a large movable tumor obstructing the gut entirely. In-
guinal colotomy was performed, and the gut was opened at
once. Six weeks later the speaker did an exploratory lapa-
rotomy with the view of ascertaining whether the growth
could be removed by this route, but he found the parietal peri-
tonaeum studded with the malignant growth, which bad also
spread over the mesocolon.' He said that he now presented the
patient, because he had been treating him for a prolonged period
with the aniline dyes (pyoctanin), irrigating with a l-to-1,000
solution, and methyl blue internally. He was aware that after
the establishment of an artificial anus, as had been done in this
case, these patients would often do well for a considerable
period ; still, he was inclined to attribute a good deal of the
comparative well-being of this patient at present to the aniline
treatment. The growth itself was unchanged in size, but the
metastatic, nodules were still slowly increasing. The man had
remained in fair condition and had not lost weight during the
past nine months.
Excision of the Right Tonsil, the Pharynx, and the
Tongue for Sarcoma.— Dr. Meyer showed another patient,
thirty-four years of age, upon whom he had recently operated,
according to Miculicz's method, for a malignant invasion of the
right tonsil, the tongue, and the pharynx. The patient had suf-
fered excruciating pains, and though the speaker had feared that
the operation would very much endanger the man's life, the
patient had begged that it might be undertaken. Tracheotomy
was first performed and the Trendelenburg tampon-cannnla was
introduced. Then an incision was made curving downward
from the mastoid process to the chin, the flap was raised, and
the glands, few and soft, were removed. Then the right ex-
ternal carotid artery was tied, also the ascending branch of the
inferior maxillary. It was found necessary to remove the ton-
sil, with the pharynx of the right side, the epiglottis, and the
whole tongue. The patient was narcotized through the tampon-
cannula, and this instrument, with the blown-up bulb, was kept
in place forty-eight hours. It was then exchanged for an or-
dinary tracheal cannula. A soft-rubber catheter was passed
through the wound into the oesophagus, and the patient fed
134
PROCEEDINGS OF SOCIETIES.
[N. Y. Med. Jouh.,
through it, The cannula was removed from the wound on tlie
tenth day, and the man soon learned to swallow the stomach-
tuhe. The patient, as would he seen, was now in good shape
complaining only of some shortness of breath. He could eat
and swallow well, and was able to articulate distinctly enough
to make himself understood.
The Use of Wire ar.d Pins in Ununited Fractures.— Dr. L.
A. Stimson presented a man upon whom he bud recently operated
for ununited fracture of the thigh bone with considerable over-
lapping of the fragments. The speaker had cut down upon the
parts and had taken off enough of the hone to permit of the
fragments being brought into apposition by transverse section
placing the parts in a splint so that the lower segment was sup-
ported by the upper. Satisfactory union had followed. He
presented this patient in order t;> emphasize his opinion that the
use of wire and pins in such esses was needless and probably
detrimental, being likelv to prevent ratlier than promote union.
Fracture of the Head of the Radius.— Dr. Stimson also
presented a patient who bad come under his care with a fract-
ure of the head of the radius. This was, the speaker said, quite
a rare accident, some eighteen cases only having been reported,
of which three bad come under hi- own care. The injury had
been produced in this case, as in most of the others, in the
course of a backward dislocation of the bones of the forearm at
the elbow. The patient, in trying to save a child from falling,
had sustained an injury which had been diagnosticated as a dis-
location. He had remained under treatment for about two
weeks, and had then come under the speaker's notice. Upon
examination, there was found a prominence at the upper aspect
of the elbow, and this seemed to be a portion of the head of the
radius. An operation had verified this opinion. The specimen
he presented as an example of a rare injury and to draw atten-
tion to the good results which had followed its removal. At the
time of the operation the patient had lost the power of flexion
and extension of the forearm, and almost entirely that of rota-
tion. Motion was now very fair. The speaker would also draw
attention to the beautiful appearance of the cicatrix, due to the
use of Dr. Halsted's method of subcuticular suture.
A Bullet in the Brain.— Dr. J. A. Wyeth presented a boy
the full history of whose case had already been published. The
youngster was shot at short range with a pistol in the hands of
a playmate. The bullet entered the cranium and was never
located. The boy was seen shortly after the injury and an in-
cision was made admitting of the removal of pieces of bone
which had been driven in upon the dura. The wound was then
cleansed and an aseptic dressing applied. The boy had some
slight symptoms ot delirium for two or three days. He had
been, however, kept exceedingly quiet and in the recumbent
posture for a considerable time, and all the untoward symptoms
had passed away. He had now been ten months out of bed, and
seemed to be entirely well. The speaker had brought the pa-
tient to show the good results that might follow such an injury
when no attempt was made to trace a foreign missile in the
brain.
Cancer of the Tongue. — Dr. Fkank Hartley presented a
patient who had been admitted into the Roosevelt Hospital on
August 11th. The man was twenty-eight years old, married,
and a farmer. His previous history gave nothing of interest.
His present trouble, the patient thought, had begun three
months before his admission. He had suffered mostly from a
sore throat. He was examined by Dr. Beatty, and a diagnosis
was then made of carcinoma involving the posterior third of
the tongue and the adjoining portion of the anterior pillar of
the fauces. The growth was distinctly circumscribed, hard, and
only superficially ulcerated. The epiglottis was uniuvolved and
no glandular enlargement existed within the neck. The pos-
terior third of the right half of the tongue and a small part of
the posterior third of the left half of the tongue were directly
infiltrated. The man's general health was good. The heart
and lungs were normal. There was no alcoholic habit. He
smoked only moderately.
An operation was performed on August 18th, preceded by
the usual antisepsis for the mouth, teeth, face, and neck.
Tracheotomy was done and etherization carried on through
the tube. A curved incision was made, five inches from the
right angle of the mouth, downward and backward until the
posterior part of the submaxillary triangle was entered. Hem-
orrhage having been controlled, the inferior maxilla was divided
at the site of the second molar tooth, after its extraction. The
tongue was then divided parallel to, but midway between, the
rhaphe and the left border. Both lingual arteries were tied as
they entered the tongue from the hyoglossus muscle. The floor
of the mouth on the right side and three fourths of the tongue
were removed as far as the hyoid bone. The anterior pillar of
the fauces and the tonsil on the right side were also removed,
as the induration seemed to extend to them. An enlarged glaDd
to the right of the pharyngeal wall and to the inner side of the
ramus of the jaw was also taken away. The small portion of
tongue remaining was sutured to the floor of the mouth. A
drainage-tube was used in the lower angle of the wound, just
below the division in the inferior maxilla. The inferior maxilla
was held in position by catgut sutures through the bone. The
skin was sutured with silk, and the mouth and pharynx were
packed with iodoform gauze. The progress of the case had
been as follows :
August 19th. — Rectal feeding every twenty-four hours.
Temperature, 101°; pulse, 80.
21st. — Drainage-tube removed.
22d. — Tracheotomy-tube removed. Packing in the mouth
and pharynx removed. Rectal feeding stopped. Stomach-tube
used in feeding.
26th. — Primary union in the wounds. Peroxide of hydro-
gen used as a mouth wash ; packing discontinued.
29th. — Use of the stomach-tube discontinued; fluid diet
used.
September 9th. — Patient discharged; wounds healed; the
teeth in good apposition.
An examination of the growth, made at the laboratory of
the College of Physicians and Surgeons, bad shown it to be a
carcinoma.
Cases of Gall-bladder Surgery.— This was the title of a
paper by Dr. Robert Abbe (See page 120.)
Dr. Charles McBukney recalled the case reported by him
this year in which the gall-stoue was found lodged in the lower
part of the common duct, in the hollow of the pancreas. The
gall-bladder itself had entirely disappeared, doubtless owing to
repeated attacks of inflammation. TK< stone, however, could
be felt distinctly. It was impossible to reach the stone through
incision in the side of the duct, and he had preferred to open
the duodenum by vertical incision, lie had hen found the
intestinal opening of the duct, split it upw ard for about an inch
to the stone, and removed the latter through the intestine.
The intestinal wound was then closed. The patient made an
excellent recovery, and is now perfectly well. He would sug-
gest as a useful method, where the duct was open above,
that a sound should be passed from the gall-bladder down the
duct in order to come as near the intestinal opening as possible,
and so mark the position of the latter after the intestine was
opened. In his case the opening was marked by the presence
of a prominent ridge, two inches before it entered the intestine,
becoming more and more marked as it passed down to the
opening.
Jan. 30. 1892.1
PROCEEDINGS OF SOCIETIES.
135
Dr. F. Lange had had occasion ?everal times to operate for
obstruction of the common duct, both by stone ;ind malignant
growth? at the head of the pancreas, and several of his cases
had been brought before the society in former years and pub-
lished. Tn a case in which he had performed colocystotomy
, for cancer of the pancreas the method of sewing the gall-blad-
der to the gut, which in this instance was the transverse colon,
was by invaginating the gall-bladder into the gut. He had
done this because the gall bladder was extremely thin and be-
cause he had hoped that a valvular closure could be obtained.
The patient had made a satisfactory recovery, but died six
i months later trom progress of the cancerous growth. The
general result of the operation, however, was not encouraging.
The communication had diminished to an opening which would
barely admit the passing of a probe. During life the appear-
• ance of gall in the stools had varied. At times it would disap-
pear for a week or two and then come on again. He would
| therefore advise that this mode of operating should not be
chosen. Perhaps it was better to invaginate the gall-bladder
1 partly into itself, so that the edges of the incision could not
come in contact again. It was an open question as to how
much diminution would take place after this operation. In
another case the malignant disease was complicated by the
presence of stone. The patient was, however, in such a cho-
laamic condition that death had taken place from uncontrollable
capillary haemorrhage from within the gall-bladder, and prob-
ably from the liver, in the course of a few days. In both of
these cases there were advanced liver changes.
Dr. Lange also showed a number of gall-stones, removed
from a lady on whom he had operated and who had malignant
disease of the gall-bladder itself. The stones were of unusually
large size. He had removed the stones, but had not thought
that malignant disease existed. The wound, however, had not
healed, but had kept secreting more and more, and luxuriant
masses grew from the bottom of the gall-bladder. Microscopical
examination had then determined the existence of large spindle-
celled sarcoma, from which the patient eventually died, since
radical operation did not seem advisable.
Dr. L. S. Pilcher cited a case in which he had operated last
winter, when, at the time of the removal of some hundred cal-
culi from the gall-bladder, the presence of a stone impacted in
the common duct was appreciated, but the condition of the pa-
tient had then contra-indicated further interference. She had
recovered from the operation, and before an opportunity could
be made for again attacking the obstruction the calculus had
passed spontaneously. He thought that sometimes, where it was
necessary to leave the duct thus impacted, Nature might be looked
to as likely to effect a cure. His patient had since completely
recovered her health.
Dr. F. Kammerer, referring to the last case cited by Dr.
1 Abbe, thought that it was not often that so small a malignant
tumor made such large deposits in the lung and liver. He had
seen an interesting case of malignant disease lately. A woman
had come to the hospital giving the history of biliary colic in
former years. She was in a very low condition. Examination
showed the existence of an enlarged liver, and below it was a
i large fluctuating tumor, the size of a child's head, reaching to the
brim of the pelvis, giving the impression of a tumor of the kid-
. ney on bimanual palpation. As the patient had no jaundice, this
• case had presented some difficulties. He had punctured the liver
several times and had got nothing. The patient had considera-
ble rise of temperature and something had to be done. Puncture
of the tumor itself drew away sero-purulcnt fluid. Operation
had demonstrated that the tumor was an enormously distended
gall-bladder. There was some ascites on incision. A large quan-
tity of the sero-purulent fluid and some inspissated pus came
away when the gall-bladder was incised. When the fingers were
introduced into its cavity large masses of debris and about forty
gall-stones were found and extracted. There was a large per-
foration connecting with the liver, the distended bladder having
become adherent to almost the entire lower surface of the liver,
and the liver-tissue itself was much broken down. The patient
had never rallied. Post-mortem examination had shown that
the trouble was a malignant tumor of the gall-bladder. There
were no metastatic deposits in the liver. The cancer was most
likely a consecutive disease to the development of stone in the
gall-bladder.
Artificial Appliance after Removal of One Side of the
Lower Jaw. — Dr. MoBurney, after calling attention to the
great discomfort which resulted to patients subsequent to the
removal of part of the lower jaw, from imperfect articulation of
the teeth, cited a case in which he had done this operation for
sarcoma and had called in other aid with a view to mechanically
overcoming the subsequent difficulties. At the time of the op-
eration he had had an interdental splint made, which was worn
during the healing process. Afterward Dr. Albert Westlakehad
devised the apparatus, a model of which he exhibited. This de-
vice was still worn to-day by the patient with absolute comfort,
keeping the teeth of the half jaw remaining in perfect articula-
tion with those of the upper jaw and enabling the patient to
masticate easily and perfectly. Absolutely no lateral displace-
ment of the jaw existed to-day.
NEW YOPvK ACADEMY OF MEDICINE.
section in general surgery.
Meeting of January 11, 1892.
Dr. William T. Bull in the Chair.
Resection of the Rectum.— Dr. Willy Meyer presented a
patient from whom he had removed a section of the rectum
about four inches long on the 9th of October, 1891. The speci-
men was shown. The operation was performed in the knee-
elbow posture by Kraske's incision, the coccyx being resected.
The rectum was then peeled away from its anterior attachments,
the section made through healthy mucous membrane, and a
piece of iodoform gauze passed upward into the gut. The gut
was then brought down and secured. The bowels were opened
on the tenth day. The patient now had control of fa3ces and
usually of gas, and had gained more than fifty pounds since the
operation.
Dr. B. F. Curtis showed a specimen representing an opera-
tion that he had recently performed for resection of the rectum
and sigmoid flexure for carcinoma.
Dr. Parker Syms showed a specimen representing resection
of the rectum for carcinoma. Allingham's operation had been
performed, and it was believed that it had not been sufficiently
thorough, as within two years a tumor was again felt in the
rectum. In March, 1891, Kraske's operation was performed,
and there had been no recurrence as yet. A preliminary
colotomy was performed a few days prior to the Kraske opera-
tion, on account of the weakness of the patient. She now had
partial control of the bowel.
Dr. A. Shunk presented a specimen showing carcinoma of
the rectum which he had recently removed. A left inguinal
colotomy was first performed. Six weeks later the diseased
rectum was removed through the opening in the left groin.
The Chairman showed a specimen of cancer of the rectum.
The patient from whom it had been removed had apparently
been cured by the operation,
Intestinal Anastomosis.— Dr. R. F. Weir exhibited a pa-
tient who had been operated upon for an intestinal fistula which
136
PROCEEDINGS
OF SOCIETIES.
[N. Y. Mko. Jour.,
had developed in connection with ventral hernia. The rela-
tions of the fistula to the intestine were ascertained by a care-
ful dissection and separation of adherent intestines, the diseased
portion was removed, and a lateral intestinal anastomosis was
performed. A second patient was shown upon whom gastro-
enterostomy had heen performed for pyloric stenosis. A third
was also shown who had heen subjected to four abdominal
operations for intestinal obstruction, the fourth, through a
median incision, resulting in relief.
Dr. Robert Abbe presented a patient who had undergone
four abdominal operations within a year. Three of them had
been performed by Dr. A. F. Currier, the last one resulting in
a persistent intestinal fistula. Dr. Abbe had operated for the
relief of this, removing the segment of small intestine in which
the fistula was located, and making a lateral anastomosis. The
result had heen entirely satisfactory, the patient heing now in
perfect health.
The Chairman showed a specimen illustrating gastro intesti-
nal anastomosis. The operation had been performed for cancer
of the pylorus. He also showed a specimen illustrating intesti-
nal anastomosis. In this case an inguinal colotomy had been
performed for cancer of the intestine. After the artificial anus
had persisted three years Dupnytren's operation had been per-
formed, hut without satisfactory result. An intestinal anasto-
mosis was then performed, and the patient lived two years in
comfortable health. At the end of that period symptoms of in-
testinal obstruction appeared, and it was supposed to be due to
contraction in the openings which had been made in the intes-
tines. An abdominal section was performed, which showed
that the obstruction was due to adhesive bands of the intestines.
The operation had resulted fatally, and the autopsy had shown
that contraction in the intestinal openings had not occurred to
an extent sufficient to cause any interference with the intestinal
function. The case was also instructive from the fact that five
years and a half had elapsed since the cancerous growth had
been removed, and there had been no recurrence.
Dr. Abbe read a paper narrating his recent experience with
intestinal anastomosis.
Case I was that of the patient who had been exhibited.
Case II. In this case the symptoms of intestinal obstruc-
tion were pronounced. A left inguinal colotomy was per-
formed without giving relief. This was followed by right
inguinal colotomy, this by a median section at the outer border
of the right rectus muscle, and this by a fourth section, which
revealed a stricture twelve inches above the anus. A resection
was made, and six months later carcinoma of the right ovary
was diagnosticated.
Caselll illustrated lateral anastomosis performed on account
of hernia of the abdominal wall with intestinal obstruction.
The lateral anastomosis in this case was preferable to end-to-
end suture of the segments of intestine, the latter procedure
heing impracticable on account of the difference in their diame-
ters.
Case IV was one of K'raske's operation, in which the rectum
had been resected six inches from the anus. Seven months
later an inguinal colotomy had been necessary on account of re-
currence of the disease.
Case V was one of strangulated right inguinal hernia with
gangrene of the intestine. The gangrenous portion was excised,
the opening in the gut extended an inch in each direction, and
the opening closed by rows of sutures passed parallel to the
transverse axis of ihe intestinal tube.
Case VI was one of cancer of the stomach. There was a
decided tumor in the epigastrium with troublesome nausea,
vomiting, and pain. The patient was very weak, but insisted
upon an operation. After three days of stimulant treatment
the operation was performed. The stomach was found greatly
dilated, and the tumor involved the pylorus and omentum,
(iastro-enterostomy was performed, but the patient succumbed
two hours after the completion of the operation.
Commenting upon these cases, which were all of recent date,
the speaker remarked that almost all cases which called for the
operation of intestinal anastomosis were cases in which the
symptoms were severe and entailed much surgical shock It
had been urged that time was of the utmost importance in such
operations, and, as a means of saving time and abbreviating the
operations, various forms of plates had been devised. All such
plates, whatever their construction or substance, were objec-
tionable for one reason or another, and, afier a considerable ex-
perience, the speaker was of the opinion that better results
could be obtained without them, the intestinal openings heing
carefully apposed and secured to each other by sutures, and a
double row of sutures being passed entirely around the portions
which were brought in contact with eaidi other. The intestinal
openings should be four inches long; they might contract to
half this length within six months, but they would be less likely
to contract unduly if sutures alone were used than if dependence
were placed upon intestinal plates. The speaker was not en-
tirely satisfied that the experiments in anastomosis of the in-
testines of dogs could be depended upon as analogous to the
work which was required upon the human intestine. The tol-
erance of dogs was greater than that of human beings; their
tissues also presented different conditions. In many of the cases
in which intestinal anastomosis was decided upon the patient
should be prepared by a preliminary colotomy.
Dr. J. A. Wyeth believed that intestinal anastomosis could
not be regarded in any sense as a simple operation, and thought
that the prognosis in the majority of cases in which it was per-
formed would be bad. He was not in favor of lateral anasto-
mosis in uiiy case in which terminal anastomosis was admis-
sible.
Dr. B. F. Curtis thought that if lateral anastomosis was to
be performed the method by suture alone was preferable to that
by plates. If the circular suture (end-to-end operation) could
be performed there would be less contraction of the lumen of
the gut than by the lateral method, but the former operation
was the more difficult. Concerning the criticism made upon in-
testinal surgery in dogs, it was true that dogs resisted purulent
infection better than human beings, but he had not found that
they resisted fascal infection any more successfully.
Dr. J. D. Bryant emphasized the necessity of promptness in
operating in cases of intestinal disease in which anastomosis was
necessary. Delay weakened the condition of the tissues and so
rendered them less suitable for resistance when the operation
was performed.
Dr. Weir remarked that the statistics|of the lateral intestinal
operation were thus far much better than those of the circular
operation. Therefore we were not yet in a position to discard
the former method.
Dr. F. Kammeuer expressed a preference for the method by
sutures alone over that in which rings or plates were used.
Dr. Meyer quoted the statements of Kraske, Bramann, and
Schede as preferring the circular suture to any other method
after resection of the rectum. He also spoke of the necessity of
protecting the peritoneal cavity from soiling when removing the
rectum.
Dr. Sy.ms had found the rings ineffectual to prevent extrava-
sation of fa?ces after lateral anastomosis. He had lost a patient
after such an accident.
Dr. R. II. M. Dawbarn adhered to his opinion that plates
were more useful in intestinal anastomosis than sutures alone.
With plates one was far less likely to pierce the mucous mem-
Jan. 30, 1892.] '
REPORTS ON THE PROGRESS OF MEDICINE.
137
brane of the intestine than with sutures alone; hence there was
less danger of fsecal infection. lie also believed in the ad van
tage of the few minutes of time which could be saved when
plates were used. Abbe's catgut rings were believed to be an
improvement upon Senn's bone plates, but the potato plates
which had been devised by the speaker would retain their post
tion longer than the catgut rings.
Hcports on the jprogress of Jttcbtrinc.
NEUROLOGY.
Nervous Complications of Gonorrhoea. — In the Gazette des hopitaux
for Septembers, 1891, Dr. Paul Raymond states at length the complica-
tions of gonorrhoea. They are not unlike those induced by other forms
of infectious disease. Charvot, in his article on sciatica, says that two
predisposing pathological factors of this disease are found in pelvic in
flammations among women and gonorrhoea in men. When due to gon
orrhoea, sciatic inflammation rarely appears during the first week, but
is delayed till the second or third week. The onset is sudden, almost
instantaneous. The early symptoms often come on in a night, and thei
extreme limit of severity may be reached in twenty-four hours, relative
calm being established in four or five days. Then the neuralgia disap
pears, or remains stationary for a time, worse at night, and always
most intense about the exit of the sciatic nerve. The pain travels down
the thigh, but rarely beyond the popliteal space. There is also a crural
neuralgia of similar onset and origin. These conditions coincide with
the degree of articular manifestation in gonorrhoea, both being com-
plications or extensions of an infectious process. A double sciatica
suggests the involvement of the spinal cord — a meningo-myelitis. Me-
ningeal inflammation of the cord in no wise differs clinically from other
infectious forms of myelitis, from the erysipelatous, from that due to
variola or typhoid fever. When due to gonorrhoea, it usually lasts
from a fortnight to six months, and quite exceptionally over two years.
Death sometimes occurs. Reflex paralysis due to joint trouble gives
about the same symptoms as a true myelitis, without organic lesion.
There are also muscular atrophies following gonorrhoea that do not ap-
pear to be consecutive to the joint lesions. Abnormities of special
sense appear as complications of gonorrhoea. Amblyopia may accom-
pany multiple arthropathies and last several days. Optic neuritis of
similar origin has been noted, and also severe headache and deafness.
The skin does not escape. A gonorrhoeal erythema sometimes appears
that is a true angeioneurosis. This is a morbid process quite distinct
from eruptions due to local applications, such as balsam of Peru, which
are frequently seen during the treatment of gonorrhoea. The cuta-
neous complications of nervous origin are symmetrical and have more
the appearance of congestion than of true inflammation.
The Diagnosis of Anaesthetic Leprosy and Syringomyelia. — In the
paper contained in the Revue de medecine for September 10, 1891,
Dr. Marestang arrives at the following conclusions to the effect that
syringomyelia and anaesthetic leprosy are distinct entities, thus proved
by pathological anatomy. Syringomyelia is based upon a medullary
process, of gliomatous nature most frequently, while anaesthetic leprosy
is the outcome of a specific neuritis. There are certain clinical differ-
ences :
Syringomyelia. Ancesthetic Lejtro.ii/.
Disassociation of sensory dis- Abolition of the sense of touch.
tnrbances. Atrophy and paresis of superfi-
Integrity of superficial muscles cial muscles of the face.
of the face. Thickening and nodular swell-
Absence of discolorations on ings of nerves.
the skin. Discolorations (painless) upon
Hair unaffected. the body.
Deviations of the spine.
In leprosy there is spontaneous resorption of the phalanges, pro-
found alteration in the nails, partial or complete loss of hair, and the
presence of Hensen's bacillus in the portions of tissue that are ulcer-
ated.
Neurasthenia and its Mental Symptoms. — In the Medical Communi-
cations of the Massachusetts Medical Society, vol. xv, No. 2, 1891, appears
in full Dr. Edward Cowle's exhaustive paper with the foregoing title.
Neurasthenia is one of the most frequent and important of nervous
diseases. Its mental symptoms afford significant indications for diag-
nosis, prophylaxis, and treatment. Depression, weakened mental con-
trol, and irritability are signs of the characteristic mental weakness.
Insanity, in its functional and curable forms, is always weakness, and
its study is useful in relation to neurasthenia, because they have a com-
mon origin. In normal fatigue, toxic products of exercise are formed
in nerve and muscular tissues. From this and other sources toxic ele-
ments may accumulate in the blood and tissues. In pathological fa-
tigue these contiibute to local or general inanition or auto-infection.
Visible changes in nerve cells that attend normal fatigue go to support
the inference of a molecular and chemical variation, in pathological
fatigue, that manifests itself as a condition of exhausted or changed
nutritional power. To the aetiology and pathology of neurasthenia they
bear a direct relation. Habit, diathesis, idiosyncrasy, have an impor-
tant influence in causing " dispositions to repeat organic processes,"
whether normal or abnormal. The analysis of normal and pathological
fatigue shows that mental symptoms in the latter may be easily recog-
nized. They correspond with the physical events in neurasthenia. The
phenomena, so far as they go, are in unison with the like conditions of
melancholia. The symptoms are objective and subjective, mainly the
latter, which include the mental symptoms. There is mental de-
pression and a sense of ill-being; diminished power of voluntary atten-
tion and mental control ; introspection and worry, with attention act-
ing in its attracted form ; and changes in the " sense of body " —
irritability and hyperasthesia, languor and anaesthesia. In conse-
quence, two conditions of clinical importance become prominent.
These are morning weariness and anassthesia of the sense of fatigue.
Neurasthenia, then, is a morbid condition of the nervous system, and
ts underlying characteristics are excessive weakness and irritability or
languor, with mental depression and weakened attention. It may be
regarded as the initial term of many nervous disorders having a varied
(Etiology. The treatment logically includes elimination, rest, exercise,
massage, and the promotion of sleep. The mental indications and other
subjective symptoms, being the earliest and most significant always, are
the best guides to treatment. This must be suited to the different
stages of neurasthenia, to the conditions of first effects and after-effects,
and to the special type that the patient represents.
Facial Neuralgia and Ear Troubles. — A most interesting series of
observations, recorded by Dr. Gelle, upon the condition of the ear in
various forms of nervous disease has appeared in recent issues of the
Progres medical. The coexistence of pain in the ear and neuralgia
upon the same side of the face was found in twenty-two cases of facial
neuralgia. Often facial neuralgia starting from different points is
symptomatic of acute inflammation of the ear, or of new inflammatory
attacks set up on some former diathetic otorrhoea. The facial pain in
this case precedes by several days the otic or periotic complication. At
times, in spite of frequent attacks and intense otalgia, the ear itself
remains sound. In certain instances the attacks bear a close relation
to a simple or diathetic inflammatory condition at the level of the orifice
of the Eustachian tube. In three cases examined, syphilis proved to
he the cause of the unilateral ear difficulty, one of the patients present-
ing severe otalgia without lesion for some time before the appearance
of a subacute otitis resulting in suppuration, secondary symptoms ap-
pearing only after the ear trouble. There is a history of facial neural-
gia in nearly all cases of chronic deafness. It is also a frequent pre-
monitory symptom of facial paralysis, and accompanies vertigo ab aure
sa and hyperacusia. The cases cited demonstrate a close relation-
ship between facial neuralgia, acute otitis, and facial hemiplegia.
Guarana in Migraine. — The Journal dc medecine for October 18,
1891, quoting from Pcmberton Peake, recommends the following method
of warding off or ameliorating an attack of migraine : When prodromes
appear — restriction of the visual field, ringing in the ears, etc. — work
must cease. The patient is to take twenty or thirty grains of guarana
in a little broth, go to bed, and try to sleep. When the characteristic
138
REPORTS ON THE PROGRESS OF MEDICINE.
[N. Y. Med. Jouh.,
headache begins, a good-sized cup of tea is in order. A little reading
or conversation will help banish the depression that the pain causes.
This plan of treatment shortens the attack.
Facial Paralysis due to Rupture of the Ear-drum.— In the Journal
de medicine dc Paris Dr. Delobel records a case of this kind. The
patient was thrown from a carriage, falling upon the left side of the
head. There was a cut about the loot of the nose, and bleeding from
the nose and ear. There wns no loss of consciousness, will, or of
movement; no vertigo, no evidence of fracture. The patient com-
plained of great pain, noises, and deafness in the left ear. This pre-
vented his hearing a watch applied to the ear, though the sounds were
heard distinctly when it rested upon the forehead or was put into the
mouth. Eleven days after the accident complete left-sided facial
hemiplegia was present. There were disturbances of taste and diminu-
tion of sight. Electricity and strychnine were the remedies used. In
about two weeks a slight improvement was noticed. All paralysis
disappeared by slow degrees, and in time the sense of taste returned.
Symptoms pointing to some deap-seated lesion of the seventh pair of
nerves, as loss of taste and of faradaic response in muscles supplied
by them, caused the author to regret that he did not use subcutaneous
injections of pilocarpine, as suggested by Strauss, to settle at once
the question of profound lesion by the absence or delay of sweat on the
affected side or its simultaneous presence on both sides.
Paraplegia of Syphilitic Origin. — The Annales ,1, dermatologie et de
syphiligraphic for October, 1891, contain a report of this condition,
based upon seventy-one eases, by Dr. Pierre Boullocke. The facts ap-
pear in the form of brief r&sumfo, the chief points being the earlier exist-
ence of syphilis, the age at which paraplegia appeared, and its course,
nature, and duration. Syphilitic myelopathy alone is rare — found only-
seventy seven times in a given number of cases in which cerebro-spinal
syphilis existed four hundred and sixteen times. At what age of the
disease docs paraplegia make its appearance ? Among the cases under
consideration evidences of paraplegia existed during the first year of in-
fection in eight cases, in the second year in eighteen, in the third
year in ten, in the^fourth also in ten, from the fifth to the tenth year
in seventeen, and between the tenth and the twenty-second year
in eight. Therefore, in sixty-two cases of paraplegia out of every
hundred the onset has been during the first four years following the
initial lesion. Late sy philitic myelitis is comparatively rare. Myelitis
of syphilitic origin that develops rapidly within a few weeks or two or
three months is most unfavorable as regards prognosis. Chronic dif-
fuse myelitis is seldom fatal, and it is not often completely cured.
Vesical troubles remain after nearly all the signs of paraplegia have dis-
appeared. Weakness of the legs, difficulty in walking and standing
upright for any length of time, a certain degree of contracture in
severe cases, are some of the after-effects more or less permanent.
The Neuroses of Development. — Dr. T. S. Clouston's admirable
lectures on this subject that have appeared in various issues of the
Edinburgh Medical Journal during the year end in the August number
with a few'considerations in regard to prevention of the neuroses of
development. Heredity is a question of degree and intensity in each
case. Fortunately, in most instances it needs an exciting cause to de-
velop the diseases which are its outcome. There are one or two
general principles sale to follow as making for prevention. Build up
bone and fat and muscle, especially fat, by every known means during
periods of growth and development. Make fresh air the breath of life
to the young. Develop lower centers rather than higher ones when
there is poor heredity. Avoid, if possible, alcohol and nervine stimu-
lants. Do not cultivate, rather restrain, the imaginative and artistic
faculties and ready sensitiveness and idealisms generally in cases
where such tend to appear too early and too keenly. They will be
rooted on a better brain and body basis if they come later. Cultivate
and insist on method and order in all things. The weakly neurotics
are always disorderly, unbusinesslike, and unsystematic. Fat, self-
control, mihI order nre the three most important conditions for them to
aim at and develop.
Attacks of Tremor among Epileptics. — Dr. Fere notes in the Revue
<h mlidrr.hu- for .lime Id, 1891, the different aspects of tremor among
epileptics. It may be merely an episode in the classic epileptic seizure,
or the only symptom of a paroxysm, with loss of consciousness. Some-
times tremor lasts for hours or days, either general or local. It is
usually rapid, especially in the hand, the oscillations ranging from
seven to ten a second.
The Pathology of Ophthalmoplegia. — This is the subject of an in-
teresting paper by Dr. J. W. Collins, of London, and Dr. L. Wilde, of
Durham, England, in the Ameriran Journal of ihr Medical Science* lor
November, 1891. Owing to the complexity of the structures concerned,
post-mortem examinations have been of comparatively slight value.
The site and nature of the lesion to which the group of oculo-motor
palsies is due have been mooted questions. In no other situation are
there opportunities for a small lesion to affect so many cranial nerves
as in the cavernous sinus. Putting aside the rather obscure ocular
palsies of cortical origin, the floor of the aqueduct of Sib ins and fourth
ventricle and the walls of the cavernous sinus would be the man
favorable site for small lesions to bring about extensive results. In the
former, such lesions would be mostly nuclear, in the latter necessarily
neural. The authors introduce the following scheme:
Ophthalmoplegia.
I. Cerebral. —
/ ( !onjugat< deviation.
(a) Cortical. - llemiptosis ('!).
' Hysterical ophthalmoplegia.
(I>) Cortico-peduncular.
(<■) Nuclear. t 1. Cvcloplegia. , . . » ,,
w I . ( Ophthalmoplegia interna.
Third nerve. - 2. Iridoplegia. <
' :(. Palsy of the extra-ocular muscles ; ptosis.
Fourth nerve. 4. Palsy of the superior oblique.
Sixth nerve. 5. Palsy of the external rectus.
(d) Radicular (and ? commissural).
II. Basal. — (a) Region of pons;
(/>) " " peduncles.
('•) " " cavernous sinus.
(d) " " sphenoidal fissure.
III. Orbital (including peripheral).
Ophthalmoplegia of cortical or cortico-peduncular origin is usually
conjugate, not unilateral. The only exception to this rule, apparently,
is that of ptosis occurring exclusively upon the side opposite to that
of the cerebral lesion (Landouzy). Observations by the authors of
120 cases show that some evidences of syphilis were found in 33
percent.; of the whole number, 65 per cent, were men; from twenty
to forty years of age were the periods of its most active manifesta-
tions; and the condition was unilateral in 61 cases. In 65 of the
patients in which external ocular muscles were affected, there was
also some disordei of intra-ocular muscles. In 29 of the 65 both
iris and ciliary muscle were involved. Special attention must be di-
rected to the mode of linking of extra-ocular palsy with cvcloplegia
and iridoplegia, respectively, as bearing upon the work of Henser
and Volker, and of Kohler and Pick. In the 34 cases in which only
one of the two — viz., iris or ciliary — was affected, plus extra-ocular
palsy, in no less than 31 the iris and not the ciliary presented abnor-
mity. In only three, therefore, was the ciliary alone affected. If it
be true that the centers for ciliary, iris, and extra-ocular muscles are
arranged in the foregoing order, tandem fashion, on the floor of the
aqueduct, the connection of these ocular palsies is at once apparent.
In 116 cases, analysis in regard to distribution of the palsy according to
nerves involved showed an implication of the third nerve alone in 47
instances. In 42, the third, fourth, and sixth were affected in com-
pany; in 11, the sixth only; in 8, the third and fourth together; in 4,
the third and sixth ; in 2, the fourth and sixth ; and in 2, the fourth
alone. Of the 92 cases out of the 120 in which the result is noted, 53
improved under treatment, 26 completely recovering. In 15 there was
no improvement, in 2 the disease was progressive, and in 22 fatal.
Under ten years of age 50 per cent, died ; over ten, 23 per cent.
A Case of Acromegaly. — This is reported in detail in the Rt vw
de rnedecine for September 10, 1891, by Dr. Spillmann and Dr. Haus-
halter. The tables of measurements are particularly interesting. The
patient, a rcligicuxe, fifty-two years old, noticed the onset, of her present
condition at the age of forty, up to which time she always enjoyed
robust health. Menstruation then ceased suddenly, to be immediately
followed by a gradual enlargement of face, hands, and feet. The skill
"Jan. 30, 1892.] .
MISCELLANY.
139
thickened by degrees and the back became arched. The characteristic
ugliness of acromegaly is reproduced in the cuts illustrating the report.
The patient is cheerful, without headache or any sensory trouble, and
with mind unaffected, Cloves are not manufactured sufficiently large
for the hand, and men's shoes of enormous width and length are the
only ones this religieuse can wear. The ocular troubles consist of
marked amblyopia on one side and almost complete amaurosis on the
other. There ts no sensitiveness to cold, but constant complaint of
heat. The skin is oily and frequently covered with profuse perspiration.
The Brain in Microcephaly. — Dr. Giacomo has recently made public
his observations upon this subject, of which the following is a resume :
The morbid process causing microcephaly is essentially one of the cen-
tral nervous system, and the deformity of the skull results from want
of development of the brain. There is no microcephaly that is primarily
psteal. It is always neural. The condition is not confined to the brain
alone. There is also micromyelia. The nervous system in microcephaly
presents no pathological alterations that could be produced by arrest of
Development. The brains all belong to the human type, varying ac-
cording to the period of embryonic life wherein arrest of development
took place, and ranging in degree from one below the normal adult brain
to the verge of anencephaly. The formation of the cortex in extreme
cases, aside from the evident arrest of development, bears much resem-
blance to that of certain animals and may be considered an example of
atavism to the evolutionists, for this formation has never existed dur-
ing the historical period of the human race.
Synopsis of Opium Inebriety. — In the Journal of Mental and Nerv-
ous Disease, June, 1891, there is a paper with the foregoing title. Mor-
phinomauiacs include literary men, mathematicians, and scientists.
Medical men are more exposed to the formation of the l.abit than any
other class. They have a seemingly reasonable excuse, knowing the
speedy effect of morphine that permits a return to work. In time the
will is paralyzed and personality destroyed. Molecular changes are
brought about and a neurosis is produced. Mental faculties are the
ones that suffer first from the use of opium. There are marked depres-
sion of spirits, hallucinations, especially of sight, and morbid fears.
Sensation is usually impaired or perverted. There is a wan complex-
ion, greasy skin, a vacant look, listlessness, loss of appetite, and obsti-
nate constipation. Upon the withdrawal of the dr ig there is diarrhoea.
If this does not occur, it is safe to suspect that the patient still con-
tinues the use of opium in some secret fashion. There are several plans
of treatment. The noted German, Dr. Livenstein, stops all morphine
at once without regard to length of habit or dose. This entails much
mental and physical suffering and the risk of suicide. Collapse is
threatened. Against this plan Dr. J. B. Mattison, of Brooklyn, ex-
presses himself with much emphasis and holds that no man is war-
ranted in subjecting his patient to such horrible torture. The dread of
such an ordeal as described by others keeps many in the continued toils
of the morphine habit. The rapid but not abrupt withdrawal of opium
is what Dr. Mattison advocates. A certain amount of control of reflex
irritation may be obtained by bromide of sodium in large doses for four
or six days. The maximum sedative effect of the bromide should be
secured by the time the maximum nervous disturbance is expected or
brought about by withdrawal of the opium. But even this plan causes
much suffering. The gradual method seems more rational. The only
reasonable hope for cure at all is in the wise care of a specialist familiar
with all the exigencies that may arise. A collapsed condition is best
met by stimulants, ammonia or alcohol. Delirium can be warded off
by coca, chloral, and bromides. For vomiting, stop all solid food, give
hot, beef extract, hot milk, and beef peptonoids in liquid form ; and as
remedies ammonii ar. spir., bismuth subnit. To overcome diarrhoea,
first use an emulsion of castor oil with brandy ; then give bismuth
subnitrate and zinc sulphocarbolate. Treat pains in the legs by
hot foot baths, massage, and friction. In the event of apparent
sleeplessness, be sure, first, that the patient is not shamming, and
then administer full doses of bromide, sul phonal, and sometimes va-
lerianate of zinc in the form of elixir. Codeine can be given to
allay pain as safely as any opiate and without great danger of its use
growing into a habit. In anaemic conditions, iron and strychnine are
indicated. In notable depression or long-lastiug prostration, alcoholic
stimulants are required. Restlessness and insomnia may be warded off
by a hot bath before retiring. Electricity, especially the electric bath,
«ill in most cases tranquillize tlie system. Mental quiet is a positive
essential. Cheerful surroundings, amusement, and pleasant society are
necessary. If the patient uses the hyp' dermic syringe, this should be
instantly discarded and all opium given b) the mouth. The physician
should take complete possession of his charge, and be to him a constant,
kind adviser and moral support.
Bl i s c e 1 1 ;t n u
Mortality in Cities in the United States. — The following table
represents the mortality in the cities named, as reported to Dr. Walter
Wyman, Surgeon-General of the Marine-Hospital Service, and pub-
lished in the Abstract of Sanitary Reports for January 22d :
New York, N. Y...
Chicago, 111
Brooklyn, N. Y
Brooklyn, N. Y. . . .
St. Louis, Mo
Boston, Mass
Baltimore, Md
San Francisco, Cal .
Cincinnati, Ohio. . .
Cleveland, Obio . . .
Cleveland. Ohio . . .
Pittsburgh, Pa
Washington, D. C
Detroit, Mich
Detroit. Mich
Milwaukee, Wis
Rochester, N. Y
Kansas City, Mo. . .
Kansas City, Mo. . .
Proyidence, R. I. . .
Denver, Col
Toledo. Ohio
Richmond, Va
Nashville, Tenn . . .
Fall River. Mass. . .
Portland. Me
Binghamton, N Y.
Yonkers, N. Y
Mobile, Ala
Auburn, N. Y
San Diego, Cal
Pensacola, Fla
! Jan. 16.
Jan. IB.
Jan. 9.
i Jan.
Jan. 9.
Jan. lti.
I Jan. 16.
Jan. 9.
Jan. 15.
I Jan. 9
j Jan. lti.
: Jan. 9.
Jan. 9.
Jan. 9.
Jan. 16.
Jan. 9.
Jan. 16.
Dec. 36.
Jan. 2.
Jan. 16.
Jan. 9.
I Jan. 15.
Jan. 9.
Jan. 16.
Jan. 16.
: Jan. 16.
Jan. 16.
i Jan. 16.
Jan. 16.
Jan. 9.
Jan. 9.
Jan. 9.
DEATHS FROM
1,515
1,099,
806,
806,
451.
448.
434.
298.
296,
261.
261.
248,
230.
205.
205,
204.
133,
132,
132,
133,
1(!6,
81
81
76.
36
35
32
31
25
16,
11
1| ts J ?
r |§ i!
•■101
85I :
343
343
770
477
489
:i!ir
908
353
358
617
876
876
t68
896
716
716
146
713
434
3K8
168
398 !
425!
005
033
076
858
159
.750
907
600
m
465
825
225
195
146
95
122
88
132
116
110
109.
67 1
51 j
41
73
40
84 1
341
88
50
27
25
17
25
9
7
•g.'S
41.39
17 27
1324
12 25
6
9
11
4
3 1(1
1
. 11
12
21 ... .
1 1
The Treatment of Influenza. — The following, except for a few ver-
bal changes, appeared as an editorial in the Boston Medical and Surgical
Journal for January 21st :
In the prophylaxis of influenza it must be remembered that the
disease is a something (germ or other morbific factor) phis, not infre-
quently, a severe cold. A catarrh or cold is a mechanical congestion of
the naso-pharvngeal mucous membrane due to exposure to alternating
temperatures, not necessarily accompanied by fever or any constitu-
tional disturbance. This congested mucous surface furnishes a favor-
able nidus for the influenza germ as well as for the germs of ordinary
suppuration. The germs or their ptomaines find entrance into the blood
and produce the rigors and other constitutional symptoms. The main
prophylactic indication, then, would be to avoid, as far as possible, the
causes of ordinary colds. When once the congestion is established,
means should be taken to prevent this extending, and to destroy any
germs that have effected lodgment on the congested membrane. Here
the use of diaphoretics (a warm bath, a vapor bath, heaters, liquor am-
monii acetatis, jaborandi, Dover's powder — the patient being in bed)
may be salutary ; the Symptoms of prostration are to be treated by
abundant stimulants. The menthol spray, or eucalyptus inhalations,
stimulate the local circulation, and are perhaps germicides. The euca-
lyptus may be inhaled from a handkerchief, and a two- to live-per-cent.
[solution?] of menthol in some form of liquid vaseline be injected into
the nostrils in chronic catarrh.
140
MISCELLANY.
[N. Y. Meu. Jouu.
There is no special treatment for the bronchitis of influenza. The
aeuteness of the attack, the oppress-on, the teasing, dry c ugh, the
scanty expectoration of the first stage, indicate the need of expecto-
rants and salines, whilst the prostration indicates the disadvantage of
their administration. Ten drops of wine of ipecac, one drop of tinct-
ure of aconite, five grains of nitrate of potassium in a dessertspoonful
of liquor ammonii acetatis, constitute a convenient mixture for this
stage of the disease ; the dose may be given every two hours during
both day and night, or the tincture ol lobelia inflata in five-minim doses
may be substituted for the ipecacuanha wine. Citrate of potassium in
thirty-grain doses with lemon juice and syrup is a favorite combination,
making a mixture which is very pleasant to take. No one will question
the beneficial effects of hot fomentations and cataplasms to the chest,
especially when there is pain and dyspnoea. The old custom of giving
an emetic at the onset of a severe bronchial attack has gone out of fash-
ion, still there are times when nothing will so speedily relax the tight-
ened bronchi, allay the element of spasm, and promote expectoration, as
a full dose of ipecac or turpeth mineral. The latter emetic is espe-
cially applicable to children with abundance of subcrepitant rales all
over the chest, dyspnoea, and other symptoms of capillary bronchitis.
When expectoration has begun (and in influenza it sometimes does
not begin at all) there is probably no better expectorant than carbonate
or chloride of ammonium. The latter, if rubbed up with extract of
licorice and taken in emulsion, in water or in syrup, is not especially
disagreeable to the taste. The aromatic spirits ot ammonia may be
given in syrup of Tolu or syrup of senega, and often no other expecto-
rant will be needed. Marotte has recently published a paper in which
he recommends, in order to oppose the pulmonary manifestations of
la grippe, the employment of chloride of ammonium in doses amount-
ing to two or three grammes daily. He would give the salt in capsules
or cachets, the dose being fifty centigrammes.*
As the adynamic symptoms are always marked, a supporting treat-
ment should be instituted from the first, and alcoholic stimulants are
frequently indicated. A tablespoonful of whisky in a glass of milk is
a favorite combination with many. Or the milk is given in teacup fuls
every two hours, and is alternated with a glass of grog or champagne.
The alcohol often seems materially to aid expectoration, besides com-
bating restlessness and insomnia. It is especially in broncho-pulmo-
nary cases, complicated with weak heart and pulse, that alcohol is a
necessity. Physicians doubtless do not sufficiently utilize the stimulat-
ing and supporting effects of strong coffee, which may of ten be allowed
to advantage in influenza ad libitum.
Where the cardiac enfeeblement is very marked there can be no
question as to the benefits of digitalis, strophanthus, caffeine, and
sometimes of nitroglycerin. In the pneumonia and broncho-pneu-
monia of influenza the leading indication is often to support the strug-
gling heart, and digitalis may be given here with often happy effects.
An eligible form is the infusion, of which a teaspoonful may be given
every two hours for a day or two; then strophanthus or caffeine may be
substituted for the digitalis.
Many practitioners have great faith in sulphate of quinine, both as
an abortive means in the early stages (abridging duration of the at-
tack), and as a supporting agent all through the sickness. By general
consent, however, quinine has of late been relegated to a secondary
and subordinate place in the therapeutics of this and other affections,
being given in rather small doses and for its tonic effect.
For the nervous symptoms of influenza — the headache, the back-
ache, the pains in the limbs, the restlessness and insomnia, etc. — there
seems to be nothing so good as acetanilide or phenacetin, and no medi-
cines are more generally prescribed. Just bow these medicines act is
not yet known, but they certainly have a marked action in allaying the
rheumatoid and neuralgic pains of influenza, and they also combat the
fever element and relieve the insomnia. A recent writer in the Lancet
even affirms that acetanilide is curative of the bronchitis, destroying
the micro-organisms that pervade the mucous membrane and the spu-
tum; and that he has found it to cause the cough to disappear. Other
practitioners may not have seen the same results, but there is abundant
* Bull, ft mem. tie V Academic tie medecine, June lti, 1891.
testimony that phenacetin and acetanilide are invaluable and safe medi-
caments in influenza. The former may be given in ten- and the latter
in five-grain doses every two hours until the muscular or neuralgic
pains cease ; two or three doses generally prove sufficient. 8ome pre-
fer to give stimulant with these drugs, as it hastens their action and
counteracts any depressing effects. When the muscular pains are
obstinate, salol (five grains) or salicylate of sodium (fifteen grains)
have been recommended.
A capital point in the treatment is to watch the patient, that he be
not allowed to go out too soon, for cases are not rare where, after a
light attack, exposure to cold has been followed by fatal pneumonia.
We can but just allude to Maclagan's treatment of influenza by
salicin in large doses. This writer reports a series of cases which, he
maintains, go to show that salicin in doses of twenty grains every hour
for five or six hours, then every two hours for a day, " arrests the
course of the disease as effectually as it does that of acute rheumatism
when given in the same manner." In all his reported cases the cure
was rapid, "the temperature falling to the normal, and convalescence
commencing in all within twenty-four and in most within twelve hours
of the commencement of the treatment."
To Contributors and Correspondents. — The attention of all who purpose
favoring us with communications is respectfully called to the follow-
ing:
Authors of articles intended for publication under the head of " original
contributions " are respectfully informed that, in accepting such arti-
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tions are to be observed: (1) when a manuscript is sent to this jour-
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stated in a communication accompanying the manuscript, and n<>
new conditions can be considered after the manuscript has been piu
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articles which, although they may be creditable to their authors, are
not miitable for publication in this journal, either because they art
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All communicationx relating to the business of the journal should be ad-
dressed to the publishers.
THE NEW YORK MEDICAL
Original (Jlommimtaiticms.
A CONTRIBUTION TO
THE SURGERY OE THE (ESOPHAGUS.*
By ARPAD G. GERSTER, M. D.
In tlie summer of the year 1878 a Polish Hebrew peddler,
hastily swallowing a piece of beef stew, was suddenly choked
by a hard body, which he felt entering and become arrested in
his gullet. The initial dyspnoea disappeared, but constant pain
was felt in the oesophagus, which was acutely augmented by ef-
forts at deglutition. Only liquids could be swallowed.
The medical man whose aid was sought for the relief of the
sufferer first attempted to ram the foreign body down into the
stomach. The pain felt by the patient was so intense that these
attempts had to be given up. Emetics were then administered,
and when these had failed to bring up the foreign body, large
uoses of castor oil were given by mouth and per rectum. Thus
five days passed by. On the sixth day after the accident the
patient was examined by the writer of this paper. Considerable
fever and an anxious expression were observed, and dysphagia
and a constant pain low down in the neck were complained of.
Liquids could be swallowed with difficulty, solids not at all.
The oesophageal sound was arrested at a distance of nine inches
from the lower incisors by a hard, immovable body, which did
not permit its passage lower down. A long curved oesophageal
forceps was passed, and it was very easy to grasp the body, but
whenever an effort was made to dislodge it, the instrument
slipped off. Evidently the body was so firmly impacted that
any endo-cesopnageal methods at extraction were hopeless;
hence immediate cesophagotomy was earnestly recommended.
The patient was admitted to one of our city hospitals, where he
lay unattended for five days more. On the sixth, external
cesophagotomy was performed, the patient then being very
feeble from high fever and the lack of nourishment. The gullet
was opened without much difficulty, but the extraction of the
foreign body was accomplished even then with very much
trouble, on account of its size and shape. It was a triangular
and equilateral piece of bone, each side being about an inch and
three quarters long, and its thickness about half an inch. The
bone emitted a foetid odor, and some blood escaped from the
gullet after its extraction. The external wound was left partially
open.
The fever from which the patient had suffered before the
operation did not abate; the entire wound became septic, ill-
smelling, and coated with a yellowish deposit, and five days
after the extraction, in the night, he bled to death from the
internal jugular vein, the wall of which had sloughed extensive-
ly. The slough was detached in the night and, before aid could
be summoned, the patient had died.
The lesson drawn from this case was too drastic to be
forgotten. It taught the perniciousness of delay in extract-
ing impacted foreign bodies from the oesophagus, and tlie
uselessness of a late operation.
Here the foreign body was very large, very unfavorable
for a safe passage, and its sharply projecting angles were
\ extremely dangerous during attempts at dislodgment and
extraction. But is the presence of a less angular body —
such as, for instance, a coin impacted in the oesophagus —
free from danger ?
I
* Read before tlie New York Surgical Society, November 11, 1891.
JOURNAL, February 6, 1892.
Let the following history answer this question :
Frederick P., a year old, exhibited symptoms of an intense
tracheal stenosis, principally obstructing expiration. The pa-
tient came under the care of the writer on March 6, 1886, by the
kindness of Dr. Boldt. Tracheotomy was done at once at the
German Hospital without relief. On March 10th the child died
of pneumonia. On autopsy, a brass trousers-button was found
imbedded in old cicatricial tissue between the trachea and
oesophagus, midway between the cricoid cartilage and the bifur-
cation. An open communication existed between the two tubes.
The button was held in place by a rim of cicatricial tissue in the
oesophagus, its free lower margin projecting downward into the
lumen of the trachea like a valve. Thus, inspiration found no
impediment, but on expiration the valve was raised and extreme
expiration stenosis was the result. The parents remembered
that weeks before the child had swallowed a button, but, no
trouble being noticed then, the matter had been forgotten.
The study of an excellent paper by George Fischer,* in
which the'histories of eighty cases of cesophagotomy for im-
pacted foreign bodies are collated, will show that, though
the shape or size of the impacted body is of great impor-
tance as to the ultimate issue, the length of time during
which the impaction remains unrelieved is of much greater
moment. Ulceration by pressure will destroy the integrity
of the mucous lining, and thus a portal for the entrance of
infectious matter is opened. Phlegmonous processes ac-
companied by sloughing will lead to perforation into adjoin-
ing organs or closed cavities — such as the trachea, the pleura
and lungs, the mediastinum, the large vessels — almost each
of these complications having a fatal significance.
Twice the writer has been obliged to practice laryngo-
fissure on account of extensive perichondritis caused by the
penetration of a foreign body from the (Esophagus. One of
the histories is as follows :
Julius M., a peddler, aged thirty-nine. The previous history
pointed at the lodgment of a foreign body in the oesophagus, with
dysphagia, which disappeared spontaneously. Gradually dyspnoea
supervened. The laryngoscope demonstrated the presence of a
small irregular tumor in the larynx, the size of which did not
seem to explain the intense dyspnoea. Tracheotomy was done
December 18, 1886, at Mt. Sinai Hospital. On incising the
trachea above the thyreoid body, a granulating but dense mass,
occupying the posterior and lateral aspects of the larynx just
below the vocal cords, was exposed. Surrounded by this mass
was found the point of a wooden skewer, an inch in length, its
ends being imbedded diagonally in the tissues between the larynx
and oesophagus. No open communication with the latter organ
could be found by probiug. The cricoid cartilage was divided,
the body was extracted, and the granuloma was excised. On De-
cember 27th the tracheal tube was removed. The outer wound
healed promptly, but the old dyspnoea again reappeared, so that
on January 27, 1887, laryngo-ii>surc was performed. Moderate
return of the new growth was found about the defect of the
mucous membrane in which the wooden splinter had been im-
bedded. The probe was introduced into the aperture and pene-
trated downward and backward to the distance of three fourths
of an inch, thin pus exuding from the sinus. Intense swelling
and hyperemia of the entire mucous membrane and submucous
tissue of the larynx and adjoining trachea were noted. In view
* Deutsche Zeitxefn-ift fur Chirurt/ie, vol. xxv, p. 6(!5.
U2
GERSTER: SURGERY OF THE (ESOPHAGUS.
[N. Y. Med. Joue.,
of the perichondritis a tracheal tube was left inserted in the
wound. Subsequently during the writer's absence from town
various attempts were made at wearing an O'Dwyer tube with
a view to curing the stenosis, but these efforts remained futile.
In .June some cartilage was expelled and the patient recovered.
The second case referred to was almost identical with the one
just related. The patient was operated on at Mt. Sinai Hospital
in the winter of 1890. A wooden splinter had penetrated the
posterior wall of the trachea at its junction with the larynx,
and had caused necrosis of a considerable portion of the thyreoid
cartilage. After the expulsion of this the dyspnoea was abated
and the tracheal tube could be dispensed with. But a rebel-
lious tracheal fistula persisted at the site of the tracheotomy
wound and was successfully closed by a plastic operation iden-
tical with that devised by Szymanowsky for the closure of
urethral fistulaj.
In reviewing the vast material presented by George
Fischer, we unhesitatingly come to the conclusion that, if a
foreign body becomes lodged in the oesophagus and can
not be displaced downward into the stomach or extracted
without the employment of much force, it is imperative to
perform external cesophagotomy at once. With the excep-
tion of cases in which a goitre or cervical tumor impedes
the otherwise simple steps of the operation, the procedure
as now practiced is comparatively safe, its rate of mortality
for all cases, recent and old, good and bad, being computed
by Fischer as twenty per cent. The conditions are parallel
to those existing in strangulated hernia. An early operation
is safe ; a late one dangerous and very often useless. Delay
extending over twenty-four hours is never justified, and if
at the end of this period extraction by bloodless processes
is not easy, the gullet ought to be cut at once.
Tedious and often-repeated attempts at dislodgment, in
a case where impaction has been present for more than
twenty-four hours, are apt to be more dangerous than
cesophagotomy. The patient's general condition is usually
bad from fever and starvation, and the depressing effects of
the manipulations in the fauces and oesophagus, productive
of nausea and vomiting, are not to be slighted. Finally,
the further injuring of the mucous membrane in the pres-
ence of septic ulcerative processes or sloughing, and the
probability of causing traumatic perforation, are to be well
weighed.
As regards the technique of (tsophagotomy, the follow-
ing points have to be observed : The incision should be
ample, to permit comfortable operating without the em-
ployment of much traction and bruising of the organs ex-
posed. Blunt methods of division are to be shunned, as
torn tissues are not so viable as cut ones and are apt to suc-
cumb very easily to septic influences that may proceed from
an ulcerating or sloughing (esophagus. The incision should
be just in front of and parallel with the anterior border of
the left sterno-mastoid muscle, beginning a little below the
level of the cricoid cartilage and extending to the sternal
insertion of the muscle. The omo-hyoid is drawn aside,
and the lateral margin of the thyreoid gland is exposed to
serve as a guide. The large vessels should remain undis-
turbed within their common sheath, and are to be drawn
backward and aside, together with the sterno-mastoid. 1 >is-
section should proceed between two mouse-tooth forceps.
Thus vessels crossing the tract of the incision can be recog-
nized and secured before being cut. Should the sternal
porti on of the sterno-mastoid be in the way, it may be cut
also. The recurrent nerve must not be injured. The
(esophagus can be recognized by the longitudinal direction of
its fibers, or, if this is difficult, by protrusion practiced with
a metallic catheter or urethral sound from within. It is
incised between two small, sharp retractors, and fillets of
silk are passed through the edges of the cut, by which
manipulations within the viscus are made much easier. In
the absence of septic complications — and this may be fairly
expected in cases receiving early attention — the edges of the
oesophageal wound should be stitched at once with fine silk.
The outer wound is to be packed loosely with iodoform gauze.
A few silkworm-gut stitches may be inserted into the cuta-
neous edges of the wound, which, however, is to be closed
only after the removal of the packing. In these cases ali-
mentation by the mouth can be commenced at once with
liquid substances, and the patient should swallow very small
quantities and while lying on the right side. Minute leak-
age will often occur, but will not interfere with the rapid
healing of the wound. In those cases where ulceration or
sloughing has occurred, suture is often impracticable and
rarely safe. The open method by packing is in order, and
large defects may necessitate the use of the stomach-tube,
which can be inserted through the wound or by the mouth
or nares.
The following cases may serve as illustration of these
remarks :
Case I. — Margaret Kurtz, aged nine years, swallowed a bi-
convex tin whistle on March 22, 1889. The family attendant,
Dr. Katzenmayer, had made a large number of unsuccessful at-
tempts to dislodge and remove the body, which could be easily
reached by the mouth. On March 29th the writer took charge
of the patient at the German Hospital. The foreign body could
be easily grasped by suitable forceps, but would yield neither to
traction nor pressure. It was firmly held in the region of the
thoracic aperture CEsophagotomy was done at once under chlo-
roform. When the body was grasped through the wound with
a short, stout forceps, considerable manipulation was needed to
change its position and to extract it The oesophagus was
sutured; the outer wound packed. Alimentation with milk
began the next morning. No leakage. Thirteen days after the
operation the patient was discharged cured, without having had
any febrile disturbance.
Case II. — Samuel Brisander, two years old, swallowed a
penny on March 28, 1889. Since then only liquids could be
swallowed. The child complained of pain in the abdomen.
Eleven days after the accident the patient was admitted into
Mount Sinai Hospital. On April 9th — that is, on the twelfth day
— the writer examined the child in amesthesia. There was no
fever. A metallic body could be identified by click seven inches
and a half from the lower incisors, but all efforts at its dislodg-
ment or extraction were futile on account of the smallness of
the space. Fearing that an ulceration was present, no attempt
was made to push the body into the stomach. CEsophagotomy
was at once performed in the usual manner. The penny, which
was very firmly ^rnsped by the walls of the oesophagus, was dis-
lodged and extracted, not without difficulty. The oesophagus
was sutured, the outer wound packed, and nutrition commenced
at once. Slight leakage was noted on the third day after the re-
moval of the first packing, but in three days more it ceased.
Feb. 6, 1892.]
MEYER: THE PROGRESS OF CYSTOSCOPY.
113
No febrile or local reaction was observed. On April 14th the
child became sick with the measles, and, though the wound had
healed kindly within a fortnight, the patient's discharge was
delayed till May lltli by this complication.
It can be fairly assumed that most cesophagotomies per-
formed early and with the proper observance of technique
would yield as favorable results as the ones here recorded.
The dangers caused by the impacted body, especially if it
is jagged and prone to putrescence, are infinitely greater.
Though no cesophagotomy was performed in the last
case, to be reported presently, yet so many points of interest
and importance are illustrated by it that it deserves to be
put on record.
Case III. — Fanny Stiner, forty-three years old, apoorlvTiour-
ished, anxious-looking woman, had swallowed a fish-bone on
April 1, 1889. Since then she had felt considerable pain in the
left side of her throat and been unable to swallow anything but
liquids. On April 9th a painful swelling was observed correspond-
ing to the left lobe of the thyreoid gland, which extended well
backward under the sterno-mastoid muscle. Though the body
temperature was normal, the woman showed a state of marked
depression, with a rapid and small pulse, and her respiration was
markedly stridulous and embarrassed. Search was made in the
oesophagus for the foreign body ineffectually. As subsequent
events showed, it could not be found there because it was not
there. Chloroform being administered, the posterior edge of
the thyreoid gland was exposed as in cesophagotomy. It was
found that the left lobe of the thyreoid gland was ntnmescent
: and very hard. With an aspirator extremely foetid pus was
withdrawn from the gland, whereupon this was freely incised
and about two ounces of ichorous pus were evacuated from a
cavity, the inner wall of which was formed in part by the left
lateral aspect of the trachea and oesophagus. From the bottom
of this cavity was extracted a fish bone which apparently had
found its way there from the oesophagus. The cavity was
packed and the wound treated by the open method. Recovery
was slow, though the reaction was mild, and the swallowing
rapidly improving. On May 10th the patient was discharged
cured.
The great importance of an early incision of phleg-
monous foci caused by perforating foreign bodies originally
impacted in the oesophagus need not be insisted on at this
date. Waiting for the appearance of fluctuation is too
risky on account of the destructive character of the inflam-
mation, and a methodical dissection guided by anatomical
knowledge is the only proper thing.
THE PROGRESS OF CYSTOSCOPY
IN THE LAST THREE YEARS.
By WILLY MEYER, M. I).,
ATTENDING SURGEON TO
THE GERMAN AND NEW YORK SKIN AND CANCER HOSPITALS.
( Continued from paye 119.)
II. Cystoscopy with Reference to Diseases ok the
Bladder.
To give an accurate account of everything of interest
that has so far been seen in the bladder and published is a
difficult task and one of no intrinsic value. The literature
on cystoscopy, which has appeared mostly within the last
three years, is already very large. Nitze's so often men-
tioned fundamental and instructive Text-book on Cystoscopy,
Hurry Fenwick's valuable, lucid, and extremely interesting
work, The Electric Illumination of the Bladder and Urethra,
as well as als:> many other articles bearing on the same
subject, written by different men, fully cover the ground.
The appearance of these writings within the very last
years renders an attempt in this direction at my hands a
work of supererogation. The manifold brilliant results as
enumerated in this part of medical literature demonstrate
how often and sometimes easily an exact diagnosis of a pre-
viously obscure urinary disease can be and has been estab-
lished with electric illumination of the bladder. These re-
sults fully sustain Nitze's original statements and predic-
tions in every particular — namely, that the present electric
illumination of the bladder gives us the means of establish-
ing a strict differential diagnosis between the various forms
of catarrh of the bladder — acute,* chronic, hemorrhagic,
diphtheritic ; that it is easy to see with it ulcerations, to
demonstrate diverticula, to find and localize foreign bodies ;
that it seems almost unnecessary to mention how plainly
we can now see stones, make out their number, size, shape,
and mobility, and percuss them with the beak of the instru-
ment ; how encysted stones, too, will not escape the exam-
ining eye ; that especially the diagnosis of tumors of the
bladder is now easy and can be made early.
It is obvious how strongly this exact diagnosis at once
reflects upon prognosis,! indication, and treatment. Not
infrequently an unnecessary operation can thus be avoided.
Certainly it has been sufficiently established that if any
doubt exists of the diagnosis in a case of vesical disease
and the three cardinal conditions which enable a cystoscopic
examination to be made \ are fulfilled, it is the duty of the
attending physician to submit his patient as early as possible
to this ocular inspection. This on the same ground as he
would look with the help of a mirror at the interior of the
larvnx, eye, nose, or ear in their respective disorders.
A few cases of my own, each representing a different
chapter of vesical disease, selected from a large number of
interesting cystoscopies, perhaps deserve to be briefly re-
ported in this place. In every one of them (the one sub a
alone excepted) the cystoscopic diagnosis was verified in
the subsequent operative interference. I shall omit cases
illustrating the various forms of catarrh (localized and
general) and the hypertrophy of the lateral lobes of the
prostate, although they were frequently met with.
* In cases of acute catarrh the use of the cystoseope is, of course
just as much to he prohibited as that of a catheter or sound
\ Fenwick believes he has seen and found a peculiar condition of
the vesical raucous membrane which he calls "precancerous." The
Elect. Ilium., etc., p. 153 ; also Brit. Med. Journal, September 22, and
October 13, 1888.
\ 1. The caliber and shape of the urethra must permit of passing
the cystoseope into the bladder. 2. There must be sufficient capacity
of the bladder (average = 5 ounces). 3. The fluid in the bladder must
lie transparent, at least during the time of examination (cf. irrigating
cystoseope). See author ou Cystoscopy and the New Cystoseope of
1 Nit/.e and Letter, with a Demonstration of the Same, .V. )'. .1/"/. Jour-
! nal, April 21, 1888, p. 429.
144
MEYER: THE PROGRESS OF CYSTOSCOPY.
[N. Y. Med. Jodh.,
a. Tuberculous Ulceration. — Mr. II. 0. E., aged forty-five
years, married, came to me for examination through the court-
esy of Dr. L. G. N. Denslow, of St. Paul, in April, 1890.*
Twelve years ago first pain in glans penis, which in the follow-
ing ten years often gave rise to trouble. Two years and a half
ago first appearance of blood and mncus in urine, with increased
pains in glans. November, 18K9, a large, painful swelling in the
right lumbar region, which had formed under considerable rise
of temperature, nearly disappeared after the passage of a large
quantity of pus with the urine. One month later last haematu-
ria at the end of micturition. Present condition: Greatly re-
duced man ; pains in glans penis if bladder is full. Urinates
every two hours day and night. No tenesmus, no stoppage.
Right kidney palpable, slightly painful on pressure. Urine
only slightly turbid ; contains a large amount of tubercle bacilli
in every microscopical specimen. Cystoscopy (Nitze's cysto-
scope, No. 1): Immediately above the swollen mouth of the
right ureter and its elevation of mucous membrane an ulcerated
spot of about the size of two silver dollars appears. Purplish-
red, broad elevations (evidently the inflamed fibers of the detru-
sor muscle) cross each other in different directions. Small
particles of snowy, shining mucus, adherent to their surface,
float in the fluid. The depressions between these elevations are
of a lighter hue, also covered with mucous flakes. In between
them numerous very small and larger sessile growths of grayish
coloring are plainly visible, a few about as large as a pin's head,
undoubtedly miliary tubercles. On one spot a small rhomboid-
shaped, dark-red (hemorrhagic) spot can be seen. The entire
other inner surface of the bladder is perfectly normal, of gray-
ish-white color, rather anaemic, corresponding with the condi-
tion of the patient. t As I was informed by Dr. D. some
time ago, the right kidney was lately retnoved, with great
benefit in regard to the patient's general condition. It had
been converted into a large pus-sac.
b. Diverticulum.— Mr. J. P., aged sixty-four, had come under
my care in the summer of 1888 on account of an intense catarrh
of the bladder, due to hypertrophy of the prostate of long stand-
ing. Urine of foetid smell, voided every few minutes. Cystos-
copy (Letter, No. 1). Mucous membrane of dark-grayish ap-
pearance, nearly black, Shreds of mucus and necrotic tissue
adherent to the wall, floating in the injected water. No diag-
nosis made. Subsequent examination of urine showed a far ad-
vanced diabetes which so far had not been diagnosticated. Strict
antidiabetic regimen brought comparatively quick relief. Cys-
toscopic (probable) diagnosis then advanced: diabetic superficial
gangrene of the mucous membrane of the bladder. J About one
year later cystoscopy (Nitze, No. 1) was again performed : All
symptoms of chronic, catarrh, vessie d colonnes ; a little ont-
* Cf. the author's review of Nitze's Text-book on Cystoscopy, Annals
of Surgery, June, 1890.
f It has to be sta'ed that tl>e cystoscopic picture of a tuberculous
infiltration has not yet been established. A failure in making the
diagnosis of tuberculous non-ulcerative cystitis with the cystoscope
before the suprapubic incision is resorted to for clearing up the ob-
scure trouble is no reproach to this mode of examination. If tubercle
bacilli have been found in the urine before cystoscopy is tried — and
they will be by far easier found, even in a relatively clear urine and if
present in a very minute quantity, by t lie centrifugal method of
Stenbeek, modified by v. Fi'isch (Zur Diagnose der tuberkulbsen Er-
krankun'.'en der Uiogenitnlsystems, Interna/, klin. Rundschau, 1891,
Nos. 28-30) — a localized hvpenemic spot of the vesical mucous mem-
brane seen through the cystoscope lias to be diagnosticated as being
mo-t probably one of tuberculous character (tuberculous infiltration);
It is to be hoped that such cases, if made out in this manner, will
henceforth be published in detail.
X Author, A'. Y. Med. Journal, February 'J3, 1889, p. 20'.
ward of the mouth of the left ureter a large, dark spot of about
a five-cent piece is seen. Its lining mucous membrane is wrink-
led. The light of the cystoscope is then turned off and the tip,
posted right in front of this spot, gently pushed forward. It
evidently enters a cavity but touches no concrement. Diagno-
sis: diverticulum. Operative interference for the hypertrophy
of the prostate is not proposed, as patient is satisfied with the
use of the catheter. Strict antidiabetic regimen. Two years
later patient has to catheterize himself every fifteen to twenty
minutes; constant pain, fever, seven per cent, sugar. Epieys-
totomy becomes imperative and shows a large diverticulum at
the diagnosticated spot filled with phosphatic debris.
c. Foreign Bodies.— B. v. P., aged forty-one, was admitted
to the German Hospital on May 22, 1888.* He had always
been a healthy man up to three years ago, when left renal colic
with hematuria had first appeared. The latter had been inter-
mittent since then. Frequently the first drops were mixed with
blood during micturition ; then the urine was clear. Now and
then he passed pure blood. According to the advice of one of
the gentlemen whom he had consulted abroad, he had for a long
time had his bladder flushed daily with a mild solution of per-
manganate of potassium. Two months before entering the hos-
pital a severe catarrh of the bladder had set in. With great
strain small particles of a semi-solid substance had now and then
been voided through the urethra. Frequent stoppage of flow of
urine ; great pains ; morphine habit. On examination, the
searcher did not strike stone. Urine, muddy and of alkaline re-
action, contains three per cent, albumin. Under the micro-
scope: red blood-corpuscles, pus and mucus, no casts. A tumor
of about two fists' size with a smooth surface, evidently belong-
ing to the left kidney (tumor or pyonephrotic stone-kidney?),
can be palpated in the left hypochondriutn of the anaesthetized
patient. Cystoscopy under chloroform (Nitze, No. 1): As soon
as the instrument had entered the bladder and the light had been
turned on, I saw a few (six to eight) curiously shaped more or
less flat curved bodies of black color, covered with whitish de-
posits of phosphates. Stirred up by the outflowing streams of
urine from the ureters, they constantly tumbled over each other
and were thrown against the beak. No click, however, was no-
ticed ; their consistence was soft. Besides these bodies there
was no stone, no tumor, only evidence of catarrh.
To establish a diagno-is with reference to the nature of these
bodies from this cystoscopic picture was entirely impossible.
None of those present had ever seen anything like them. The
most probable supposition seemed to be that of coagulated blood,
which had descended from the left kidney. Still the semi-solid
condition and peculiar shape of the bodies remained unexplained.
Nevertheless the result of cystoscopy was highly satisfactory.
The cause of all the vesical trouble had been found. No searcher,
no bimanual palpation could ever have accomplished anything
like it. When the bladder was incised — above the pubes — about
eight bodies of various size could be easily extracted. They
were of a semi-solid, black substance, flexible, and covered with
phosphatic deposits, just they were made out through the
cystoscope. Chemical analysis showed that they consisted of
sixty per cent, fibrin and forty per cent, permanganate of po-
tassium.
d. Stones. — Case I.— Mr. I)., fifty three years old, t merchant,
for several years troubled with chronic gastritis, was seized with
pain in the glans penis and in his left lumbar region in the fall of
188fi. After three days the pain left him and did not return
until a year later, September, 1887, when he developed symp-
toms of stone in the bladder. Neither hematuria nor stoppage
* Ar. }'. Med. Journal, 1889, p. 198.
+ Ibid., p. 199.
Feb. 6, 1892.]
MEYER: THE PROGRESS OF CYSTOSCOPY.
145
of the flow of urine had ever been present. A thorough exami-
nation with the searcher repeatedly performed at that time by
a very able surgeon failed to detect stone, and the patient was
therefore put on suitable internal medication. Bur, as his con-
dition got steadily worse, his family physician courteously sent
him to me for cystoscopy June 11, 1888. The patient's bladder
being extremely irritable, and examination with the searcher
having been accompanied and followed before by great agony, I
yielded to the patient's urgent request and immediately intro-
duced the cystoscope (Leiter, No. 1). Having turned the instru-
ment 180°, thus directing the prism toward the fundus of the
bladder, I saw at the first glance in brightest illumination an
. oval-shaped, brownish body covered with white spots (evidently
phosphatic deposits) of the size of an almond, lying in the pouch
behind the enlarged prostate. It threw a distinct shadow upon
the opposite wall of the bladder. I then turned off the light and
touched the body with the tip of the instrument. I got an un-
mistakable click. The bladder otherwise presented symptoms
of catarrh. The ureteral openings emitted a clear and trans-
parent fluid. No further special attention was paid to the char-
acter of the jets of urine coming from the ureters at that time,
as no symptoms indicated a diseased kidney.
Suprapubic lithotomy was performed and the stone easily
removed. It presented the characteristics as seen with the cys-
toscope.
Case II. — Mr. X., always healthy, is suddenly unable to uri-
nate. A doctor tries to introduce a soft-rubber catheter, but
: does not succeed. When I saw the patient in consultation my
perforated sound struck a hard substance just at the neck of the
bladder, which slipped back into the viscus. Nearly two quarts
of urine were voided. The patient then was all right. Three
; days later retention for a second time set in, and was again re-
lieved by catheterization. I was convinced that there was a
small stone in the bladder, but was unsuccessful in striking it
i with the searcher. The cystoscope (Nitze, No. 1), of course,
gave at once evidence of a small, uneven concrement, about half
an inch long, not unlike a small dried bean. I proposed to try
i and aspirate it with Otis's evacuator. Meanwhile the stone
again blocked the urethral canal, but, with the help of a sudden
forcible strain, was expelled, to the greatest delight of the pa-
tient. Its characteristics were found as stated in my letter to
i the colleague.
e. Hypertrophy of the Median Lobe of the Prostate. — X.,
aged seventy, relies entirely upon catheter, which has frequent-
ly to be passed. Passage attended by difficulty and pain. Two
strictures— one in the anterior, the other in the posterior portion
of the urethra — had been divulsed about a year before, and then
the bladder carefully washed for some time. Urine was clear —
no blood, no pus, no albumin, no casts; great local distress.
\ Cystoscopy (Nitze, No. 1, long) : In introducing the instrument
its handle had to be pressed far down before the beak enters the
I bladder. A slightly hypertrophied third lobe, of about half to
II three quarters the size of the third phalanx of the middle
■ finger, is easily diagnosticated ; the bladder presents a vessie
d colonnes in a most beautiful manner. Soon afterward su-
prapubic cystotomy was performed by another surgeon. The
third lobe was found as diagnosticated, and pinched off with
] the rongeur.
/. Tumors. — Out of a greater number of these cases I
i cite the following two, which may serve as paradigms :
Cask I. — Mr. X., aged fifty-three years,* was seen by me in
• consultation on March 20, 1890. For six months he had nearly
continuously passed bloody urine without submitting to a close
Cf. Annah of Surgery, I. c.
examination. He had suffered from frequent forcible micturition
and intermittent pain in the glans ; otherwise he had felt comfort-
ably. Repeated careful chemical and microscopical examination
only showed red blood corpuscles and mucous cells, never a par-
ticle of a new growth. Bimanual palpation was very difficult,
and also promised no result on account of the patient's great
corpulence and marked hypertrophy of the prostate. I there-
fore immediately resorted to cystoscopy. As a hypodermic of
morphine, with local cocaine anaesthesia, did not quiet the irri-
table bladder, the patient was narcotized. Now I saw in
brightest illumination a round sessile growth with an uneven
surface, not unlike a large round strawberry, on the left wall of
the bladder, about an inch above the mouth of the left ureter.
I very plainly observed that blood was oozing out of its surface.
The other portion of the interior of the bladder appeared to be
healthy ; there were symptoms of a slight catarrh.
Diagnosis. — Cancerous sessile tumor of the bladder.
Suprapubic cystotomy, March 25, 1890 (performed as usual
in Trendelenburg's posture). Growth, on the spot localized be-
fore, presented all the characteristics as formerly diagnosticated
with the cystoscope. It was, with the adjacent parts of the
wall of the bladder, cut out with the knife by an ellipsoid in-
cision. The base was then carefully burned with Paquelin's
thermo-cautery. Uninterrupted recovery. No recurrence till
date.
Case II. — Mr. J. B., aged forty-eight years, had been in per-
fect health up to May, 1889. At that time he had a sudden and
causeless attack of hematuria, which ceased as suddenly after
forty- eight hours, but only to return after a few weeks. The
bleeding then became intermittent, appearing first about every-
one, two, or four months, later in as many weeks. Pain in
glans and frequency of micturition also were experienced.
January, 1890, retention caused by clots. The catheter brought
relief, but started catarrh. The patient had consulted different
doctors, but only irrigation had been advised. One colleague
proposed suprapubic incision without having strictly diagnosti-
cated the case. Cystoscopy on May 12, 1890 (Nitze, No. 1) ;
five ounces thrown in. On turning the beak to the left side and
slightly directing the prism toward the floor, a large, cock's-
comb-like, pinkish- red tumor is at once detected. Deep, ir-
regular furrows divide the surface into larger and smaller, un-
even, and lobulated areas, which bleed when touched with the
beak of the instrument. The growth is planted on a thick and
succulent base, a little outside of the left ureteral orifice, and
embraces an area of at least a silver dollar. Illuminated by the
electric light— the peaks and plateaus in brightest sunshine, the
many irregular wounded valleys, out of which a few trickling
streams of blood slowly find their way, in dark shade — the ap-
pearance of the whole succulent, erect, and pulsating growth
was picturesque in the extreme. Nearer to the fundus and the
median line a second smaller tumor is seen about as large as a
cherry. The interposed portion, as well as the whole of the in-
terior of the bladder, appears healthy.
Diagnosis. — Cancer of the bladder, still extirpable.
When the bladder had been opened above the pubes, the
condition corresponded exactly to my cystoscopic diagnosis,
which I had before explained to the gentlemen who kindly as-
sisted me during the operation. The large tumor was, shelled
out in healthy tissue with Paquelin's thermo-cautery knife. Two
large spurting arteries which entered the base of the growth
and fed it were ligated with medium-sized silk, as catgut seemed
unreliable and the bladder was to be drained. They could bo
easily tied, as they had been torn about an inch above the in-
ner bladder surface. The smaller cancer was cut out with the
knife and its insertion carefully burned. Tamponade with iodo-
form gauze ; drainage for twelve days. Quick recovery. Seven
146
MEYER: THE PROGRESS OF CYSTOSCOPY.
[N. Y. Med. Jouh.,
months later 1 had to extract a longitudinal small stone from
the patient's urethra. Nucleus: a silk ligature! Seven weeks
later the patient again called on me on account of great distress
and hematuria. On introducing the cystoscope I saw in the
fundus a stone, of at least almond-size, covered with mucus and
phosphates, and in the upper inner angle of the flat, whitish,
shining scar (the result of the former operation) a small, stalked
recurrent growth, of cauliflower shape, overhanging the mouth
of the ureter and swaying at every eddying rush of the ureteral
streams.
In view of this complication, I proposed and performed su-
prapubic cystotomy for a second time. The stone was easily
removed (its nucleus was the other silk ligature), and the bleed-
ing spot, where the recurring tumor had been inserted, thor-
oughly burned. To-day patient is doing well. (This case will
soon be published in extenxo.)
Before closing this section I ought to say that the cys-
toscopic diagnosis in bladder diseases is not at all always so
easily made. First of all, it must be borne in mind that this
ocular inspection can not be applied in every case, and that,
if it can be resorted to, it requires in praxi a great deal of
patience and, to avoid mistakes, also experience. The three
cardinal conditions which alone guarantee a successful ex-
amination should be carefully investigated before the instru-
ment is introduced. If one of them can not be fulfilled, a fail-
ure may be expected. Although I am well aware that we may
be able to make a correct diagnosis, after some experience
at least, with only from three to four ounces of water in the
bladder, still I have made it a point — and I would especially
give this advice to the beginner — always to try and have five
ounces thrown in. We know, from Nitze's investigations,
that this amount just expands all the folds and grooves of
the intravesical surface. The only exception from this rule
I make is in cases of supposed tumor of the bladder with
obstinate hematuria, but without a marked vesical catarrh.
Here the cystoscope is introduced as soon as the bleeding
has ceased, and probably a sufficient amount of urine is in
the bladder. Washing will frequently start the haemorrhage
again. (If we wish to increase the capacity of the bladder,
we must inject the fluid forcibly with the syringe, and not
use the irrigator ; and even then we may sometimes be un-
successful.) Only in this way, by training our eyes to in-
spect the surface of the properly and more or less always
equally expanded viscus, can we hope to learn by and by
how to avoid the many pitfalls which await the cystos-
copist. If the surface of the prostate begins to bleed at
the slightest touch of a solid instrument, I at once try to
examine with the irrigating cystoscope and have the nurse
throw water in while the beak passes the posterior urethra
and neck of the bladder.
We also have to pay attention to the magnifying power
of the Nitze telescope as well as to the fact that the nearer
the prism the larger the object. If after a careful examina-
tion and deliberation there is still doubt with reference to
explaining and identifying the image observed, a second
cystoscopy should be insisted upon.
Lastly, the cystoscopist should accustom himself, espe-
cially in cases which he sees in consultation, first to obtain
a thorough history, then to make a general examination,
especially with reference to tuberculosis, to carefully analyze
the urine, to palpate the lumbar region of each side, the
testicles, and the prostate, and test the caliber of the urethra.
The operator should always start with the case as if he did
not yet possess the cystoscope to enable him to view the
interior of the bladder, lie should push his means of diag-
nosis as far as possible by rational signs and examination
of the urine. But the first instrument he then takes in
hand should be not the sound, but the cvstoscope. Only
when a stone in the bladder is strongly suspected should
the sound be used first.
Here are a few examples, for the beginner as well as for
him who uses the cystoscope without a previous general
examination, as just explained, and also possibly fails to
read the literature beforehand and thus benefit by the ex-
perience of others :
He will easily take the taggy shreds of necrotic tissue,
hanging at the edge of a tuberculous ulcer and floating in
the fluid, for a polypus, without at all noting the ulcer,
especially if the prism is brought close to it (the experi-
enced and careful examiner has probably found before tu-
berculosis of the testicles, or an enlarged kidney, or tubercle
bacilli in the urine, or such a detritus under the microscope
which will lead him to suspect the existence of an ulcer and
thus make him look out for it) ; he will take the prolapse
of the ureter for a sessile growth (but if the prism is car-
ried near by, this growth is entirely transparent, and on
careful inspection it will be seen that out of one spot of its
perfectly round and smooth surface a whirl of urine will
suddenly be expelled).
He will take an incrusted growth for a stone (a touch
with the beak will quickly dispel any doubt) ; a deposit of
coagulated blood around one of the ureteral cones will per-
haps puzzle him (the experienced will take it as a hint at
hematuria of renal origin, most probably on the same side),
as will also the picture of the enlarged median lobe of the
prostate.
Success will not be with him if the just injected
clear fluid turns murky at once after a long-continued
irrigation, or is found to be so as soon as the cysto-
scope has entered the bladder. (The experienced man
at once suspects kidney trouble, will exchange the ordi-
nary for the irrigating cystoscope, and watch, after a
quick glance at the interior of the bladder, the ureteral
orifices. Most probably pains or the already palpated
swelling in one lumbar region will guide him on which side
to look first.)
Of course an infiltrated spot in the wall of a blad-
der which can not be properly distended, or greatly
hypertrophied and easily bleeding rugae in a case of
localized chronic catarrh, will also easily mislead the well-
trained eye and induce one to diagnosticate a tumor
where the suprapubic incision will merely show infiltra-
tion. Also many other mistakes may occur. But they
will become rarer with increasing experience ; and if,
nevertheless, they still occur, the physician may console
himself with the reflection that mistakes occur just as
often and as easily in the other and older branches of
surgical diagnosis.
( To be concluded.)
Feb. 6, 1892.]
GOULEY: DISEASES OF THE URINARY APPARATUS.
147
DISEASES OF THE URINARY APPARATUS.
By JOHN W. S. GOULEY, M.D.,
SURGEON TO BKLVEVUE HOSPITAL.
(Continued from page 128.)
PART I. — PHLEGMASIC AFFECTIONS.
Section IF. — SPECIAL CONSIDERATIONS.
XI.
Consequences of Acute Urethritis continued ; Gone-
cystitis, Trachelocystitis, Pyelitis, Septicemia,
Pyosapr.emia, and Rheumatism.
The investigations upon which is based the part of this
conference relating to the seminal vesicles began in 1879,
but were interrupted by other occupations, and were not
resumed until the year 1889. The majority of the dissec-
tions exhibited were made during 1889, 1890, and 1891.
The specimens for dissection were kindly contributed by a
number of medical friends interested in pathology.
Gonecystitis — phlegmasia of the seminal vesicles — is
of much more frequent occurrence than is generally sup-
posed. It exists more commonly as a chronic affection,
often associated with trachelocystitis and prostatitis, for
both of which it is very frequently mistaken.
Most practicing physicians have had their share of cases
of chronic urethral discharge accompanied with phenomena
variously styled " genital hypochondriasis, sexual neuras-
thenia, diurnal spermatorrhoea, sterility, impotency," etc.
The majority of these are cases of chronic gonecystitis.
Their cure is very difficult, slow, uncertain, and sometimes
impossible. It is not easy to persuade the patients that the
disease is local and that there is no great danger of impli-
cation of other organs. Dwelling much upon and magni-
fying their infirmity, their moral condition is soon not a
little impaired. They are often unheedful of good advice,
and, after having " gone the rounds " of the regular profes-
sion, fall into the meshes of greedy charlatans, while some
of them end their days in asylums for the insane.
In its acute type gonecystitis frequently occurs as one
of the consequences of urethritis with orchitis. It is then
very often overlooked, because the phenomena of the or-
chitis occupy so much of the attention of the patient that
the subjective symptoms referable to the region of these
vesicles are masked by those of the orchitis. Therefore, in
order to ascertain the existence or non-existence of acute
gonecystitis, it is necessary to put well-directed questions to
patients suffering from urethritis and consecutive orchitis
accompanied by abnormal sensations in the intrapelvic
organs. Prior to the further study of this phlegmasia it
may be advantageous to rehearse the main points of the
anatomy of the parts involved.
The seminal vesicles, physiologically considered,
are diverticula of the spermatic canals serving as reservoirs
of the semen in man and most of the mammalia, notwith-
standing the opinion of John Hunter to the contrary. The
assertion that the seminal vesicles are physiologically diver-
ticula of the spermatic canals is based upon the following
facts : The dilated part of the spermatic canals correspond-
ing in longitudinal extent to the seminal vesicles is iden-
tical in structure with the seminal vesicles ; the same kind
of fibrous, muscular, and mucous coats exist in both ; the
mucous coat is rugous and reticulated and lined with the
same kind of epithelium in both ; the same kind of mucus
is secreted by the same kind of mucous glands in both ;
certain expansions and diverticula are found in both ; con-
cretions abound in both ; and both are tubular in character.
The anatomical differences are : The tube of the vesicles is
more convoluted than the spermatic canals; the walls of
the vesicles are thinner than those of the spermatic canals;
the caliber of the tube of the seminal vesicles is greater
than that of the spermatic canals; and the seminal vesicles
have twice as many pouches as the spermatic canals. Each
vesicle is therefore only an extension of the spermatic canal.
In some animals — the dog kind, for instance — there are no
seminal vesicles, the slightly expanded extremity of the
spermatic canals doing all that is necessary toward diluting
the semen before it reaches the prostatic region of the ure-
thra. The seminal vesicles of a horse dissected in 1890 do
not consist, as in man, of a single convoluted tube with
diverticula, but each vesicle is an oblong sac capable of con-
taining at least two ounces of fluid. The mucous membrane
is rugous at the posterior extremity of the sac ; the re-
mainder is smooth.
One vesicle lies on the right and the other on the left of
the median line, each with a spermatic canal on its inner
border, widely separated posteriorly and converging ante-
riorly to the base of the prostate, which is traversed by their
excretory ducts, and to which their anterior extremities are
closely united ; the vesicles and accompanying spermatic
canals forming two sides of an isosceles triangle, and being
attached to the lower fundus of the bladder, with it rest
upon the rectum. The close relations of the vesicles to the
prostate, bladder, rectum, and peritonaeum explain how
these parts are liable to be reciprocally involved in disease.
When, in health, the bladder is empty, the space between
the posterior extremities of the seminal vesicles is two
inches and three quarters in extent, but while this part of
the bladder is thus increased in width it loses in antero-
posterior extent, for the peritonaeum descends to within half
an inch of the base of the prostate ; and in some cases even
overlaps the base of the prostate. When the bladder fills
up with urine the peritonaeum ascends with it and this an-
teroposterior space is more than doubled, while the trans-
verse— i. e., the space between the posterior extremities of
the seminal vesicles — loses three quarters of an inch.
Each vesicle has a proper fibrous tunic, and the two
have besides a common fibrous envelope containing a con-
siderable amount of smooth muscular tissue, which connects
them superiorly with the bladder, while they are attached
to the rectum by loose connective tissue. The vesicles de-
rive their nutrition from branches of the inferior vesical
and middle luemorrhoidal arteries. Their veins are large,
and form a plexus which pours its blood into the efferent
veins of Santonin's plexus, and which renders excision of
the vesicles so bloody and dangerous an operation as it has
proved to be. The lymphatic vessels are abundant and end
148
GOULEY: DISEASES OF THE URINARY APPARATUS.
[N. Y. Med. JorK.,
in two or three trunks on each side, which enter certain
glands on the sides of the pelvic excavation. The nerves
are derived from the hypogastric plexus.
The seminal vesicles are conical in general outline, their
bases are rounded and in close proximity to the recto-vesi-
cal cul-de-sac of the peritonaeum, and their apices are buried
in the base of the prostate. They are slightly flattened
superiorly and convex interiorly, and when distended show
very distinctly their convolutions, which are bound together
by connective tissue. They measure rive centimetres (about
two inches) in length and when unraveled twelve centi-
metres (about four inches and three quarters) in extreme
length, exclusive of their eight or ten diverticula. The
caliber of the tube of the vesicles averages six millimetres.
This tube, like the spermatic canal, is made up of three
layers — an external fibrous, very thin layer ; a middle, con-
sisting of smooth muscular tissue, the thickest of the three ;
and an internal, mucous layer. The mucous layer is ru-
gous, alveolar, lined with a cubical epithelium, and contains
caecal glands — such as are found in the terminal part of the
spermatic canals. These glands are parallel to each other,
are ordinarily single, but here and there are double, triple,
quadruple, or even quintuple, converging to a common duct
which opens between the ruga?, the clear mucoid sub-
stance they secrete serving to dilute the semen.
Each vesicle has its excretory duct, which, uniting with
the spermatic canal, forms the common ejaculatory duct,
which is about sixteen millimetres in length, slightly conical
in form, and opening by a slit on each side of the veru
monfanum on the floor of the prostatic region of the
urethra. The caliber of the common ejaculatory duct is
about two millimetres at its upper extremity, decreasing to
about one millimetre at its terminal extremity in the urethra,
and is extensible to a considerable degree. Its parietes are
very thin as compared with those of the seminal vesicle, and
its mucous membrane is smooth.
The seminal vesicles, as is seen from their peculiar con-
struction, serve the double purpose of reservoirs of the
semen and of accessory glands to the genital apparatus,
their alveoli, diverticula, and convolutions preventing them
from completely emptying themselves during ejaculation.
In them the semen is detained long enough not only to be
diluted by their mucoid secretion, but for the spermatozooids
to attain full maturity. In the semen of men given to ex-
cessive sexual intercourse, immature spermatozooids have
been found still inclosed in their parent cells. This seems
to sustain the view that the spermatozooids do not reach
perfection until they have lingered for a time in the lower
part of the spermatic canals and in the seminal vesicles.
Besides secreting the mucoid substance already referred
to, the seminal vesicles contain certain very small calcareous
concretions, few in number and not constantly found except
in disease. Civiale mentions Carmann, Riedlin, Stalpart
Vander Wiel, Ilartmann, Meckel, Hemman, and Baillie as
having cited examples of calculous concretions formed in the
seminal vesicles, and likewise names Mitchell as having found
two hundred small calculi, of earthy appearance, in the right
seminal vesicle of a phthisical subject. Rokitansky also
speaks of the presence of calculous concretions in the semi-
nal vesicles. In addition to these calculous particles, there
is a great abundance of other concretions, irregular in form
and size, nearly colorless in health, amber-colored in dis-
ease, very friable, and resembling inspissated mucus.
These last-named concretions, whose use is unknown, were
carefully studied by Ch. Robin, who called them sympexia,
which means concretions, and who thought them analo-
gous to the concretions found in the thyreoid body, the
spleen, the glands of the uterus, the lymphatic glands, and
the prostate. These sympexia are found in great quantities
also in the expanded extremities of the spermatic canals.
Microscopic in dimensions, they are lodged in the alveoli of
the mucous membrane, increase in size from phlegmasia of
this membrane, and become sources of further irritation,
and even obstruct the excretory duct, as observed in some
of the specimens exhibited. In these specimens they vary
from one to four millimetres in mean diameter, and among
the specimens illustrating chronic gonecystitis many are
oblong, like grains of rice, three by eight millimetres in
dimensions. The large sympexia sometimes consist of ag-
gregations of small concretions cemented by pus and im-
prisoning spermatozooids, blood, and epithelial cells. They
fly to pieces on slight pressure.
The normal seminal vesicles of a man, aged thirty-nine
years, who died of pneumonia, were carefully dissected
and the contents of the left vesicle examined microscopically,
with the following results : The fluid was viscid, of a
brownish color, and consisted of mucus, with innumerable
spermatozooids, spermatic cells, leucocytes, a few cubical
epithelial cells, and great numbers of sympexia of a yellow-
ish color, globular in form, some of them about half the
diameter of red blood-corpuscles, others of nearly the size
of red corpuscles. Here and there these sympexia were
aggregated in masses from the one five-hundredth to the
one three-hundredth of an inch in size.
The viscid, brownish contents of the seminal vesicles of
a man, seventy-three years of age, who died of a head in-
jury, examined microscopically, twenty-four hours after
death, consisted of epithelial cells of different form ; some
were polygonal, some cubical, some oval ; a few spermatic
cells, many sympexia of amber-color, varying in size from
one third the diameter of red blood-cells to the size of
leucocytes; some of them were round, the majority poly-
hedral and irregular, and the smallest were often aggregated
in masses of four, six, eight, or ten. No spermatozooids
were discerned. Other observations gave similar results.
The cubical character of the epithelium and the existence
of mucous glands were verified in the vesicles as well as in
the spermatic canals.
Gonecystitis does not appear to have attracted much
attention until Lallemand published his observations of this
affection in connection with "spermatorrhoea," which is
often one of its phenomena, while some form of urethritis
is almost invariably its exciting cause. Civiale, Vidal,
Gosselin, Verneuil, Founder, Rapin, and other authors,
French, German, English, and American, have, to a greater
or less extent, discussed the question of phlegmasia of the
seminal vesicles in special essays, general surgical treatises,
Feb. 6, 1892.]
GOULEY: DISEASES <>F THE URINARY APPARATUS.
149
inaugural theses, or journal articles. Among the essays
that have appeared in the last few years upon this topic is
a paper with the title of Seminal Vesiculitis, by Mr. Jordan
Lloyd, of Birmingham, in the British Medical Journal,
April 20, 1889. Each of these writers has contributed his
share toward the elucidation of the subject, but much re-
mains to be done by other laborers.
Gonecystitis seems to occur with greatest frequency
among men who habitually commit venereal excesses,
and among those addicted to masturbation, either render-
ing the seminal vesicles more or less vulnerable. This
vulnerability generally consists in abnormal expansion of
the ejaculatory ducts, or in persistent erethism of their
mucous membrane and that of the seminal vesicles. Acute
phlegmasia of the urethra in such subjects is thus propa-
gated through the ejaculatory duct to the seminal vesicle
and spermatic canal on one or both sides, generally accom-
panying orchitis, but sometimes without the association of
orchitis, just as orchitis often occurs without involvement
of the vesicle. It arises most commonly as a consequence
of chronic urethritis, but violent catheterism is not in-
frequently its exciting cause, particularly when a very
small instrument enters or tears the ejaculatory duct.
In the acute types of gonecystitis the mucous membrane
of the ejaculatory duct may be swollen to the extent of oc-
cluding its lumen, or a large sympexion may be dislodged
from the vesicle, forced into, and plug the ejaculatory duct,
so that in either case pus may accumulate and greatly dis-
tend the vesicle whose attenuated, or perhaps ulcerated,
walls are finally perforated, possibly at several points, allow-
ing this pus to infiltrate the ambient connective tissue and
to form a vast abscess pointing in the direction of the
ischio-rectal fossa, of the bladder, of the rectum, or even
of the peritonreum. This process belongs generally to
superacute or to acute phlegmasia. In the case of subacute
phlegmasia there is a minor degree of swelling; resolu-
tion being slow or failing, there follows chronic gonecystitis,
interstitial as well as parenchymatous.
In the chronic type there is sometimes ectasia of the vesi-
cles, which contain large sympexia, as shown in several of
the thirty-four carefully dissected specimens exhibited, or
the vesicle shrivels sometimes in an extraordinary degree,
as seen in three of the specimens, and becomes useless. One
specimen illustrates three interesting points : occlusion of
the right spermatic canal, shriveling of its accompanying
seminal vesicle, and apparently compensatory enlargement
of the left vesicle and spermatic canal. Another specimen
also illustrates occlusion of the right spermatic canal, but
probably of recent date, because the seminal vesicle does not
appear to have undergone the shriveling process.
Interstitial is generally secondary to parenchymatous
phlegmasia of the vesicle and is chai acterized by plastic in-
filtration of the intertubular connective tissue. Suppura-
tion may take place primarily in the intertubular connective
tissue, but this can occur only from the destructive action
of asuddenand superabundant exudate. Generally the exu-
date becomes imperfectly organized, undergoes sclerous de-
generation, and the vesicle shrivels. Sometimes the exudate
is better organized and the vesicle remains large and is some-
what indurated. Several of the specimens presented illus-
trate this point and show both vesicles to be considerably
enlarged, hard, and filled with large sympexia. The shriv-
eled condition of the seminal vesicles is common in cases
of prostatic enlargement demanding frequent evacuative
catheterism of the bladder for several years, the patients
having had repeated attacks of orchitis with involvement
of both vesicles.
Of sixty dissections of the seminal vesicles made in cases
of prostatic enlargement, three fourths of these vesicles were
shriveled and hard. The remainder, though not diminished
in size, were more or less indurated. In a few instances
they were enlarged, and in one case they were cancerous.
In a specimen recently dissected, both vesicles were found
reduced to less than half of their normal size and were near-
ly as hard as cartilage. A longitudinal incision made into
the left vesicle showed the lumen of its tube to be reduced
to about two millimetres in diameter, except at the poste-
rior extremity of the vesicle, where its walls were attenuated,
translucent, and expanded into a cyst containing three
grammes of limpid fluid. The right vesicle, which was not
incised, presented the same external appearances as the left.
The prostate was considerably increased in size, very hard,
and had for several years impeded urination. The patient
died in consequence of pyelonephritis.
The symptoms of acute gonecystitis so far observed are :
Almost constant painful erections of the penis ; frequent and
painful ejaculations of semen mixed with pus and blood,
until the ejaculatory duct is occluded, when spermatic colic
occurs ; pain extending along the urethra to the extremity
of the penis (this, however, is an index of coexistent trachel-
ocystitis) ; difficult, painful, and frequent urination ; burn-
ing pain in the perimeum, at the anus, and at the lower end
of the rectum ; a sense of tension in the rectum ; rectal te-
nesmus ; and very painful defecation. Rigors and febrile
reaction, and throbbing pains in the rectum indicate suppu-
ration. Retention of urine sometimes occurs in case of great
tumefaction of one or both vesicles.
The' diagnosis of acute gonecystitis is arrived at by an
analysis of the symptoms, by digital examination through
the rectum, and by intra-urethral instrumental exploration.
The digital examination reveals more or less tumefaction,
heat, and tenderness in the region of the vesicles on one or
both sides as the case may be. If the swelling is in the
form of a single, hard, oblong tumor extending from the
base of the prostate upward, backward, and outward, the
presumption is that the phlegrnasic process has not extended
beyond the proper capsule of one seminal vesicle. If, how-
ever, there is a diffuse, doughy swelling extending beyond
the median line, it is likely that both vesicles are involved,
that perforation of their walls has taken place, and that the
ambient connective tissue is infiltrated. When one vesicle
only is involved in suppuration together with the prerectal
connective tissue, the pus sometimes points in the direction
of the ischio-rectal fossa. In such cases the digital exami-
nation indicates the lateral deviation of the abscess. The
instrumental urethral exploration should be made first by
introducing a gum catheter with the object of emptying the
bladder. This done, a moderate-sized rectangular steel
150
GOULEY: DISEASES OF THE URINARY APPARATUS.
|N. Y. Mm.. Jouh.,
sound should be carefully introduced. Though the first
catheterism may have given some pain, the moment the
sound reaches and distends the prostatic region of the ure-
thra and passes over the veru montanum the most acute
burning pain is experienced and continues as long as the
instrument is retained. Without loss of time a finger should
be passed into the rectum and pressure made along the me-
dian line of the prostate in order to break up and cause the
expulsion of a sympexion which may be plugging the ejacu-
latory duct. Several of the symptoms being common to
acute prostatitis, the rectal and urethral explorations are
necessary to distinguish acute gonecystitis from acute pros-
tatitis. The connections of the ejaculatory ducts with the
urethra, the seminal vesicles, and the spermatic canals ex-
plain how gonecystitis and orchitis may occur at the same
time. But, as before stated, the phenomena of the orchitis
are generally such as to mask those of the gonecystitis. It
is therefore wise in most cases of orchitis to make by the
rectum a digital exploration of the seminal vesicles, which,
if found tender to pressure, swollen, and hot, should be
treated accordingly.
In the treatment of the acute types of gonecystitis the
chief indication is to prevent interstitial suppuration. For
this end a similar course to that pursued in acute prostatitis
should be adopted. After thoroughly cleansing the rectum,
three or four leeches may be applied to its mucous mem-
brane in the region of the affected vesicle, with the aid of a
tube such as that recommended by Dr. Hughes, of Dublin,
for leeching in acute prostatitis. When the well-gorged
leeches have cast themselves away, irrigation of the rectum
with warm water should be made until it is judged that a
sufficient quantity of blood has been lost. If it is found
impracticable to leech by way of the rectum, a greater
number of leeches — ten or twelve — may be applied to the
anal and perineal regions. Enough blood will thus be drawn
to unload the congested prerectal plexus of veins. As soon
as possible after either of these modes of local depletion,
the lower end of the rectum should be packed with cracked
ice. When the ice melts, the water is allowed to flow out,
while the anus is stretched open for the introduction of
more ice suppositories, a process to be repeated at least
every hour while the patient is awake. These frequent ap-
plications of ice should be continued two or three days, and
longer if necessary.
This antiphlogistic treatment is valuable only during the
period of increase or of stasis of the phlegmasia. Begun
later, it is apt to be worse than useless. If, however, it is
employed at the right time and faithfully carried out, much
suffering is prevented, and resolution is likely to be hast-
ened. Otherwise suppuration occurs, and, to prevent the
pus from finding an outlet which may be dangerous to the
patient, the sooner a free exit is artificially given to this
pus the better for his safety. The particular process of re-
lief should he adapted to the condition of the individual
and to the extent of the abscess. When it is ascertained
bv digital exploration that the abscess is not large but well
defined on one side or the other of the median line, the
presumption is that the pus has not passed beyond the
boundary of the proper fibrous capsule of one vesicle. In
such a < ase aspiration through the rectal walls is indicated.
The parts should be brought to view by means of a Sims
speculum, and a slightly curved aspirating needle, not less
than two millimetres in caliber, should be thrust into the
abscess and the cavity quickly emptied and then well irri-
gated with a warm sublimate solution (one to five thousand).
A single aspiration may suffice ; but in case the cavity refills,
the aspiration and irrigation should be repeated. If from
superacute phlegmasia there is reason to believe that much
necrosis of the tissues has occurred, or if the pus has
broken through all barriers and has already infiltrated the
prerectal connective tissue, a Sims speculum should be in-
troduced, and a free incision through the wall of the rec-
tum should be made into the abscess, whose cavity should
be well disinfected and lightly packed with a tent of anti-
septic gauze. This dressing to be renewed every day.
Whenever the abscess is large, and this is generally the case
when it has been of very slow development, almost chronic,
it is likely to point laterally toward the ischio-rectal fossa.
In that case it should be reached by the way of the peri-
naeum, as suggested by Mr. Lloyd. The incision may be
central or lateral, and directed so as to avoid the urethra
and rectum. In case of doubt — that is to say, in case, from
the extent of the purulent collection, there is a suspicion
that both vesicles are affected — it is wise to make a crescentic
incision three quarters of an inch in front of the anal mar-
gin and deepen the cut by careful dissection between the
rectum and prostate, care being taken to avoid wounding
the urethra. After giving free vent to the pus, the abscess
cavity should be disinfected and very loosely packed with
a tent of antiseptic gauze, so that the healing process may
begin at the bottom of the cavity.
Chronic Gonecystitis. — Though acute gonecystitis
often resolves without suppuration, it becomes chronic in a
considerable proportion of cases, while in a great majority
of instances chronic gonecystitis begins independently of
the acute types.
The common causes of chronic gonecystitis are venereal
excesses and masturbation, both giving rise to chronic ure-
thritis, which is the immediate cause.
The syinptoms of the chronic are similar to those of the
acute type, but the suffering is less, and there is no febrile
reaction. One of the most constant symptoms is a burning,
itching sensation in the perinamm, anus, and rectum, such
as occurs in the acute type, but not so intense, though
continuous in some cases, and very harassing month after
month and year after year. Another phenomenon is pain-
ful spasmodic contracture of the anal sphincter. When a
seminal vesicle is in a chronic phleginasic state, there is
often a persistent urethral discharge consisting of pus, a
little blood, some epithelium, and a few dead spermato-
zooids.
Spermatic colic is another, though not very frequent,
symptom of chronic gonecystitis. It is due to the lodg-
ment of a large sympexion in the ejaculatory duct and
consequent retention of semen, mucus, and pus in the semi-
nal vesicle.
Pus intimately mixed with semen is regarded by Chris-
Feb. 6, 1892.]
151
tian Smith as a pathognomonic symptom of chronic phleg-
masia of the seminal vesicles. The only means, says Dr.
Smith, of ascertaining the source of this pus is by examin-
ing the semen that has dried on the patient's linen after
coitus or after an involuntary pollution. " The stain made
upon linen by normal semen is of a uniform grayish-white
with a darker border, which never contains any element of
yellow, while in case of phlegmasia of the seminal tract the
dried stain presents a more or less yellow coloring, either
throughout or at the border, which is the most highly
colored. When the pus originates in the urethral or pros-
tatic crypts, its mixture is never so intimate as in the first
case, and the yellow coloring shows itself in minute zones
or in disseminated spots upon the gray stain."
Progress. — When, in the chronic type of gonecystitis,
the ejaculatory duct becomes occluded, the secretions gradu-
ally accumulate and cause ectasia of the vesicle and some-
times also of the spermatic canal. Such cases are of rare
occurrence, and their symptoms are not easily interpreted.
Dr. Nathan R. Smith, of Baltimore, reported in the
Lancet, 1872, vol. ii, p. 558, with the title of Hydrocele of
the Seminal Vesicle, a case of cyst of the left seminal vesi-
cle which filled the pelvis and extended into the abdominal
cavitv to a point above the umbilicus, and was at first mis-
Taken for retention of urine. The cyst was tapped by the
rectum and ten pints of a brown serous fluid were drawn.
In four weeks the cyst filled again and was again tapped.
This time it did not refill. Reference to this case is made
by Mr. Lloyd.
A remarkable example of ectasia of the spermatic canal
is recorded by Troussel-Delvincourt in the Noaveau journal
de medecine, October, 1820. The right spermatic canal
formed a cylinder measuring nearly two inches in diameter,
soft, smooth, filled with a thick, pulpy, yellow material,
similar to that of softened tubercle. The seminal vesicles
contained a similar but less consistent material.
These two are very exceptional cases, the ectasia rarely
exceeding twice the normal caliber of the vesicle and canal,
as shown by the specimens exhibited.
Subacute and chronic phlegmasia sometimes end in cal-
careous infiltration of one or both vesicles and spermatic
canals. Among the specimens exhibited is a good illustra-
tion of calcareous infiltration of the spermatic canals.
Since phlegmasia of the spermatic canal is ordinarily as-
sociated with gonecystitis, sterility is one of the sequels of
the chronic type when both sides are affected, the sperma-
tozooids being destroyed by the abnormal secretions of
the spermatic canals and seminal vesicles. When the two
spermatic canals or the two ejaculatory ducts are perma-
nently occluded, impotency is the result, erection of the
penis being imperfect and sexual desire finally extinct.
In elderly men, as seen by the results of the dissection
of sixty pairs of seminal vesicles, there is often shriveling
of the vesicles from chronic phlegmasia. In younger sub-
jects the chronic phlegmasia is generally confined to the
mucous membrane and the vesicles are more likely to be
dilated and filled with large sympexia. In several of the
thirty-four dissections first mentioned a sympexion was
found blocking the ejaculatory duct. In these younger
subjects the symptoms are ordinarily distinct, while in
elderly persons they are frequently wanting, and the al-
tered condition of the vesicles is ascertained only at the
necropsy.
The treatment of chronic gonecystitis should consist in
endeavors to cure the existing chronic urethritis, and in
emptying the distended vesicle every day by pressure with
the finger passed into the rectum. This may be followed
by very warm enemata and the occasional use of rectal sup-
positories containing half a grain of belladonna extract and
one grain of opium. From time to time the passage of a
steel sound and digital pressure thereon through the rectum
should be resorted to for the purpose of effecting the ex-
pulsion of sympexia from the ejaculatory duct. The pro-
cess should be employed as well for purposes of diagnosis
as for relief at the same time, the extraction of the sym-
pexion allowing the distended vesicle to be emptied and
relieving a painful spermatic colic.
Trachelocystitis — phlegmasia of the neck of the blad-
der— having already been examined, needs now only to be
named.
Pyelitis and nephritis very rarely occur in conse-
quence of acute urethritis and are-generally indirectly caused
by urethritis — that is to say, they are among the ill effects
of imprudent treatment, such as the long continuance of
balsamics in excessive doses, particularly copaiba balsam,
which has been known to cause acute parenchymatous ne-
phritis and pyelitis, and finally chronic diffuse nephritis
with albuminuria. Balsamics can not be too cautiously em-
ployed in the treatment of urethritis. The use of copaiba,
or any other balsamic, should be discontinued, and on no
account resumed, in the cases which show their suscepti-
bility to its toxic effects by a profuse exanthem, an urti-
caria, or a papular eruption on the face and body. These
are the cases which are likely to be complicated with ne-
phritis. Some observers think they have detected a mild
subacute pyelitis in the majority of cases of urethritis,
whether acute or chronic. May not this pyelitis be owing
to the heroic treatment too often employed in the manage-
ment of the several types of urethritis '.
Septicemia and pyosapk.-kmia very seldom occur as
consequences of urethritis.
Septicaemia — putrid infection of the blood — is due to
the evolution of ptomaines or of leucomaines, the first
being the product of bacterial ferments developed in parts
of the body that have become putrescent from injury, the
second indigenous to the body and evolved in disease in-
dependently of bacterial ferments. Septica'inia consequent
upon urethritis is probably sometimes a leucomainal intoxi-
cation, and is manifested by a violent rigor with much con-
stitutional disturbance in some cases of superaeute ure-
thritis. This intoxication may be so profound as to be
uncontrollable. In all cases there is constitutional disturb-
ance, but in the majority it is of comparatively minor in-
tensity. The poison is apparently less virulent, but this
lesser virulence is rather in degree than in kind. Neverthe-
less, the poison is very gradually eliminated, and the suf-
I.') 2
farer — :pale, emaciated, and feeble — makes a slow, lingering
recovery, convalescence requiring six or eight weeks. In
the first-named type of cases the indication is to insure
rapid elimination of the poison. To that end free catharsis,
diuresis, and diaphoresis should be promptly established,
and during the action of the remedies employed the vital
powers should be sustained by stimulants and reconstitu-
ents. If these means are successful, the case may be man-
aged as in the second type, which permits the more delib-
erate selection of agents likely to safely expedite the elimi-
nation of the poison. The cathartics should be replaced
by aperients, and the diaphoretics and diuretics should be
mild, but continued two or three weeks. Five grains of
chloride of ammonium thrice daily, and ten minims of
tincture of chloride of iron, both largely diluted, should be
given from the beginning to the end of convalescence. The
diet should be mild, but nourishing and easily digested.
Milk at first, then more substantial food, and generous
wines.
Pyosaprcemia — putrid pus infection of the blood — dif-
fers from septicaemia clinically and pathically. Septicaemia
often occurs before the formation of pus, while pyosapne-
mia may not be manifested until several weeks after the in-
fliction of a wound or tlje formation of an abscess. In
septica-mia there are generally no secondary abscesses. In
pyosaprsemia, infective thrombi swarming with micro-organ-
isms are found in the neighboring veins and carried into the
circulation to cause multiple abscesses, sometimes in the
viscera, sometimes in other parts of the body distant from
the point of injury. These thrombi contain great numbers
of staphylococci and streptococci. The favorable cases are
generally those in which the viscera have escaped contami-
nation, and the thrombi have lodged in muscles or in super-
ficial connective tissue.
Pyosapnemia occurs as a consequence of urethritis in
case of a solution of continuity, as occurs from "breaking
the chordee," or from some other injury, or in case of ab-
scess in any part of the urogenital tract. In these two
circumstances infective thrombi are formed in the ambient
veins and their migration begins. Septica-mia is mani-
fested by one violent rigor and much febrile reaction, while
pyosapnemia is characterized by recurring slight rigors of
short duration, with less febrile reaction than septicaemia.
When death occurs in consequence of acute urethritis there
is either septica-mia or pyosapra?mia. It is almost impos-
sible to ascertain the percentage of mortality from these
canses, for such cases are very seldom reported.
A few years ago, at Bellevue Hospital, a death occurred,
which may be regarded as an excellent illustration of pyo-
sapraunia originating from urethritis. The subject of this
affection was a boy, seventeen years of age, who was suffer-
ing from superacute urethritis and a consequent perineal
abscess. He had slight recurring rigors and other signs
of profound pyosaprasmia, and died three weeks after his
admission to the hospital.
Rheumatism as an occasional consequence of urethritis,
occurring in a little less than two per cent, of all cases, was
first specialized in the latter part of the last century (1781)
[N. Y. Med. Jock.,
by Swediaur and by Selle. Swediaur's chapter on the sub-
ject is short, bears the title of Arthrocele, Gonocele, or
Blennorrhagic Swelling of the Knee, and begins as fol-
lows: "A very considerable swelling of the knee, some-
times of both knees and the heel at once, attended by ex-
cruciating pains in the joint, sometimes occurs in men after
a blennorrhania. These pains, accompanied bv more or
less symptomatic fever, continue for two or three weeks
and gradually go off, leaving a stiffness in the joint, which
lasts for many months. The disease particularly affects
young men who, after a debauch, have been infected with
•blennorrhagia, with which it seems to be intimately con-
nected. ... It is not very uncommon, for in the course of
my practice I have seen six or eight cases, each of which
came on about the eighth or sixth day of the blennorrhagia,
and in every instance the discharge froiu the urethra was
either sensibly diminished or totally suppressed. ' For want
of sufficient observation, T have not been able to determine
the character of this disease ; but in all the cases which
have come within my knowledge the disease appeared to
partake of the character of gout, with this exception, that
all the persons were about the age of twenty-three or thirty,
that the color of the skin was not changed, and that the
swelling bore handling without exciting pain. The swell-
ing gradually disappears by the free use of diluting drinks
and by frictions with the amnioniacal liniment. . . ." This
laconic description contains nearly all that is now known
of the gross pathology, aetiology, diagnosis, and therapeusis
of the affection. Additions, but no subtractions, have been
made to Swediaur's chapter by more than three hundred
writers on the subject since his time.
The character of these additions is far from exhibiting
a general consensus of views respecting the nature of
"urethral rheumatism," which still remains unexplained.
A synoptical presentation of a few of these diverse views
will answer the purpose of this conference.
Swediaur, Lagneau, and Cullerier attributed " urethral
rheumatism " to metastasis, and the affection was afterward
treated in accordance with that hypothesis.
There are others who thought "urethral rheumatism"
to be the effect of the cubeb and copaiba treatment of ure-
thritis. Still others, among whom are several French, Eng-
lish, and American writers, have regarded " urethral rheu-
matism " as one of the effects of pyosapraemia.
Fereol spoke of a blennorrhagic diathesis analogous to,
but not identical with, the syphilitic diathesis, and of an
acquired diathesis corresponding to an individual predispo-
sition, which individual predisposition Founder admits.
Tixier, who has written an extended essay on the sub-
ject, also believes in a blennorrhagic diathesis.
Bonniere asserts that arthropathy and blennorrhagia are
nothing more than the expression of the same vice — the
rheumatic diathesis.
Thiry believed that the so-called blennorrhagic arthritis
is merely coincident with urethritis, without being related
to it in the slightest degree.
It has been noticed that individuals suffering from " ure-
thral rheumatism " are often affected with eczematous and
other cutaneous eruptions.
GOULEY: DISEASES OE TEE URINARY APPARATl s.
Feb. 6, 1892.]
153
Ample experience has shown that simple non-virulent
nrethritis is as liable to be accompanied by "urethral rheu-
matism " as the virulent species.
While Founder, the highest authority on the subject,
believes in the existence of a " blennorrhagic rheumatism,"
he admits that rheumatism arises also from non-venereal
urethral phlegmasia, and for that reason gave it the name
of " urethral rheumatism," which, after all, is no better
than gonorrhoea!, blennorrhagic, or genital rheumatism, and
in reality means simply rheumatism of the urethra.
These views, the outcome of one hundred years of dis-
cussion of the question of rheumatism occurring among in-
dividuals suffering from genital phlegmasia, are all incon-
clusive, for they fail to explain the true nature of the affec-
tion, and seem to relate more to its phenomena than its
essence.
Of the many arguments made to establish a distinctness
of "genital rheumatism" from common rheumatism, not
one seems to adduce evidence sufficient to warrant such
specialization. Nor do the contrary arguments seem better
founded. A critical examination of both sides of the ques-
tion brings into bold relief their weak as well as their strong
points. Both strive to prove too much and thereby injure
their cause. Those who wish to specialize "genital rheu-
matism " make urethritis its essential cause, and assert that
it has few if any of the characters of common rheumatism,
though they acknowledge that it is sometimes acute, the
great majority of cases being subacute, and often chronic
and affecting the knee. They further acknowledge that it
affects parts winch are just as commonly involved in ordi-
nary rheumatism, and some of the contestants even point
out sequela? which belong to ordinary rheumatism. They
thus enumerate the parts affected in "genital rheumatism,"
arthritis, hydrarthrosis, and arthralgia of the large and
small joints, bursitis, sciatica, myalgia, ophthalmia, and
affections of the heart, of the membranes of the brain,
spinal cord, etc. Those who take the contrary side
say that the rheumatic manifestations are merely coinci-
dent and do not bear the slightest relation to genital phleg-
masia.
It seems that the extreme views of both contesting sides
should be rejected, because the assertion that genital phleg-
masia is the essential cause of the rheumatism is not proved,
and because it is not proved that the rheumatism bears no
relation to the genital phlegmasia.
Is it not likely that the affection is ordinarily a subacute
rheumatism, excited in a vulnerable subject by the genital
phlegmasia, just as it might be excited by any other phleg-
masia, and that it therefore does bear a distinct and close
relation to its exciting cause ?
It is hoped that bio-chemists and patho-histologists
will re-examine the lactic-acid and other questions, and
ere long enlighten the profession respecting the essence
of what is called rheumatism, and help to determine if
its association with genital phlegmasia is or is not a coin-
cidence.
Whatever may be the nature of the ailment commonly
styled "gonorrhoea! rheumatism," its treatment differs little
if at all from that of acute or that of subacute rheumatism.
G A L LAC ETOP H EN ON E,
A NEW DERMATO-T1IERAPEUTIC AGENT.
By HERMANN GOLDEN BERG, M. D.
The object of this article is to introduce and recom-
mend a new remedy for psoriasis and similar skin diseases,
with the hope that it will not share the fate which falls to
the lot of so many new drugs.
In the September number of the Therapeutische Monats-
hefte Dr. L. von Rekowski recommends " gallacotophenone "
(I suppose erroneously spelled) as a substitute for pyrogallic
acid. The commercial name of this new drug is " alizarine-
yellow C." It is prepared by treating pyrogallic acid with
acetic acid in the presence of chloride of zinc. It is a
yellowish powder which readily crystallizes in yellowish
needles, scarcely soluble in cold water, easily soluble in hot
water, alcohol, ether, and glycerin.
Messrs. William Pickhardt & Kutroff, of New York, the
general agents of the " Badische Anilin- und Sodafabrik,"
were kind enough to supply me with a quantity such as is
used as a dye-stuff, which was converted into pure gallacet;
ophenone by my friend Dr. H. Schweitzer.
< iallacetophenone has the formula —
CO
C.HJOH = CH3COC6H,(OH)3,
( on
and is pyrogallic acid in which CH3CO are substituted for
H. It differs from pyrogallic acid in that it is oxidized in
alkaline solutions so slowly that its reducing abilities are
much less.
It is well known that pyrogallic acid is by no means a
harmless drug. After its introduction into dermatological
practice Neisser lost a patient after one application. The
patient died on the third day with symptoms of intoxica-
tion. Vidal has likewise reported the death of a patient,
eighteen years old, who had used a teu-per-cent. pyrogallic
ointment for two weeks. This poisonous effect of pyro-
gallic acid is to be attributed to the great readiness with
which it is oxidized in alkaline solutions (being so intensely
reducing).
The new drug does not possess this quality and is abso-
lutely harmless, as has been proved by experiments on ani-
mals.
It displays strong antiseptic qualities. A one-per-cent.
solution added to chopped meat prevented its becoming pu-
trid for twenty-one days, and destroyed the Streptococcus
aureus within twenty-four hours.
Since the middle of October I have employed gallaceto-
phenone, both in private and in dispensary practice, on at
least thirty patients suffering from various skin diseases.
On account of its resemblance to pyrogallic acid, it
seemed to be indicated in psoriasis. I have been so much
more inclined to use it in that disease, since von Rekowski,
who tried it in a few cases only, maintains " that the effect
of this new preparation (used as a ten-per-cent. ointment) is
noticed within twelve hours. "
154
Altogether, I have thus employed it in twelve cases of
psoriasis — in all of them with good results. Within a few
days the patches became paler and thinner, the desquama-
tion ceased or became less, and involution took place in the
centers. Usually after the lapse of from ten to twelve days
only a slight hyperemia was left. Within from two to three
weeks the patches disappeared entirely without leaving any
pigmentation.
A ten-per-cent. ointment did not produce any marked
irritation or discolor the skin. It stains the clothes slight-
ly yellowish, much less than pyrogallic acid or chrysarobin.
I do not wish to go into the details of the cases, but would
like to state that in a case of psoriasis of the face and scalp
it really acted like a specific. The eruption, which was
quite profuse, disappeared within five days. A ten-per-
cent, ointment was applied twice daily. There was no other
treatment.
Another patient with a universal psoriasis of sixteen
years' standing, who applied to my department at the Mount
Sinai Dispensary for some other trouble, was induced to
use a ten-per-cent. salve of gallacetophenone for the fore-
head and scalp, which were thickly covered with psoriatic
patches. When he returned, two weeks later, there was
nothing left but a pigmentation of the forehead, while the
psoriasis of the body which had not been treated was in
statu quo ante.
My friend Dr. G. T. Elliot lias, at my request, used gall-
acetophenone on a patient with psoriasis of eight years' stand-
ing, distributed over the trunk, knees, elbows, scalp, and face in
patches of various sizes. The case had been under treatment
the whole time and had proved exceedingly rebellious. Arsenic
caused an increase of inflammatory symptoms. Pyrogallic acid
had been used with but moderate success. Chysarobin did well,
if used persistently. At the time (November 21st) when the
use of a ten-per-cent. gallacetophenone ointment was begun, the
patches were bright red, burning, and with abundant desquama-
tion. A week later the patches were paler and breaking up into
small papules. The centers had undergone involution and the
desquamation was very little. Under the further use the im-
provement continued. Dr. Elliot concludes his report with the
following words: "From this slight experience, gallacetophe-
none appears to me to promise to be the most satisfactory local
remedy for psoriasis and superior to all others. It produces no
inflammatory reaction or pigmentation, but seems to influence
immediately the lesions."
From my experience, I feel justified in recommending
gallacetophenone as an excellent remedy for psoriasis, for
it acts in some cases more promptly than chrysarobin — in
all the cases w hich I have treated, as well if not better than
the other remedies at our disposal. As it is harmless and
does not discolor the skin or hairs, I hope it will be found
to be one of the best local remedies for psoriasis of the
body, face, and scalp.
My results in a number of cases of eczema psoriatiforme
and seborrhoicum have been so gratifying and encouraging
that I should like to include these affections in its field of
usefulness.
Messrs. Breyer and Schweitzer, consulting chemists, 159
front Street, will furnish the chemically pure gallaceto-
phenone to physician and druggist.
211 East Sixty-second Street.
[N. Y. Mko. Jock.,
THE
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by Edited by
I) Appi.eton & Co. Frank P. Foster, M. D.
NEW YORK, SATURDAY, FEBRUARY 6, 1892
THE AMBULANCE SURGEONS OF NEW YORK.
It rarely seems necessary or desirable to take notice of the
misapprehensions or misrepresentations of medical matters in
the public .journals. They usually carry, for professional read-
ers at least, such evident marks of error that they are their own
antidote. Hut a recent occurrence has been so grossly misrep-
resented, and such vile assaults have been made upon innocent
persons, that it becomes a plain duty to state the facts and to
take an open stand in support of our fellows.
The story, as told, is that between six o'clock in the even-
ing and eight o'clock the next morning an ambulance was called
three times from one of our hospitals to a man who had had a
fall; that each time the ambulance surgeon refused to take the
man, giving as the reason that he was drunk ; that the man
was then taken to the Tombs and sent thence to Rellevue Hos-
pital, where he died twelve hours later; and that the autopsy
showed that he had died of a fractured skull.
The facts, very briefly stated, are these: The man, a sailor,
had been drinking at the time of his fall : when first examined
he showed no other injury than a bruise of the forehead and
an abrasion on the nose; he was not only conscious, but vio-
lently abusive; the ambulance surgeon, who had a woman with
a broken leg in his ambulance, told the man's employers to no-
tify the police to take charge of him. The second call, three
hours later, was sent from the station-house because the door-
man noticed fresh blood about the man's mouth. The ambu-
lance surgeon washed the man's face, wiped out his nose and
mouth, and found that the blood came in part from a broken
tooth and in part from the abrasion on the nose. During his
stay of twenty-five minutes he was steadily cursed by the
patient, who actively opposed his ministrations. The occasion
of the third call, at eight o'clock the next morning, was the
patient's allegation that his leg was painful and that he could
not walk to the police court. The surgeon was asked for au
opinion as to the leg. Again he made a careful examination,
spending nearly an hour in the station-house, for the man was
still intractable and resisted examination. The surgeon pro-
nounced the leg sound.
The man was then taken to the Tombs, and thence sent as a
vagrant to Bellevue Hospital, where he was placed in the " alco-
holic ""cells. About three hours after his admission he became
unconscious, and was transferred to the wards, where an ex-
ploratory incision was made and a stellate fracture of the front-
al bone, without depression, found. He died during the night.
The post-mortem examination, which was limited to the head,
disclosed the fracture that had been found before death, and in
' addition fissures running across the orbital plates and the mid-
LEADINO ARTICLES.
*
Feb. 6, 1892.]
MINOR PARAGRAPHS.— ITEMS.
155
die fossa of the skull. There had been no intracranial hroraor-
rhage and no laceration of the dura or brain. The deputy
coroner who made the autopsy stated at the inquest that the
fracture could not have been recognized without an incision,
and that none of the usual signs of fracture were present.
Ii is easy to be wise after the event; it is easy to say that
the man should have been taken to the hospital, drunk or
sober; but who would have taken a different, course from that
taken by the ambulance surgeon, on the facts and the informa-
tion obtainable at the time? The coroner's jury recommended
that all drunken men who had met with any injury should be
taken to a hospital, a recommendation which not only is utterly
impracticable and impertinent, but which, if the attempt should
be made to carry it out, would cause greater scandal and noisier
remonstrances than even the occasional failure to recognize a
Iractured skull.
Advantage has been taken of this occurrence to abuse not
only the ambulance surgeons of the hospital concerned in it,
but the ambulance surgeons of New York as a class; they have
beeu held up to the scorn and reprobation of the community.
It is high time that a word should be spoken, and loudly
Spoken, in behalf of the young men in our hospitals. A more
meritorious, intelligent, hard-working, conscientious set of
young men can not be found. They work hard and long to
obtain their positions, which they do by giving proof of supe-
rior intelligence and acquirements, and they work hard and
long while they hold them, in order the better to tit themselves
for the practice of their profession. In a word, they are the
flower of the younger men, and in a few years they will stand
fully ahead of the best of the older ones. If they can not do
the work well, it can not be done well. But, notwithstanding
all that has been said, notwithstanding their liability to error,
and notwithstanding their inability to see what is invisible, and
to touch what is intangible — an inability which they share
frith the rest of mankind — their work is well done. The super-
intendent of one of our largest hospitals, when recently asked
by a reporter if the present system of ambulance service was
satisfactory, replied that it was, and "eminently so." And in
this opinion of an impartial, and necessarily even an exacting,
superior we are confident that all who have personal knowledge
of the matter will heartily concur.
MINOR 1 >A It A GRA Pllti.
THE MEDICAL SOCIETY OF THE STATE OF NEW YORK.
The eighty-sixth annual meeting was held in Albany this
week. The programme was long and sufficiently attractive,
but many of those who were expected to read papers, on the
first day, at least, were absent. Especially was there on that
day an absence of many of the well-known New York men
whose custom it has been for many years to be present. Of
the papers that were presented it can fairly be said that there
has been no deterioration as to quality in comparison with the
experience of previous years, and we can infer from this fact
that the work done by the members of the society is still such
as would be creditable to any meeting of this kind. We wish
to note particularly the unusual excellence of the president's
address. It was broad and scholarly, embracing in its scope
subjects that are of interest to every member of the profession
who has regard for its well-being and usefulness.
COMPARATIVE ANATOMY AND ZOOLOGY FOR MEDICAL
STUDENTS.
We have received a pamphlet containing two addresses by
Dr. Harrison Allen, of Philadelphia, advocating the teaching of
comparative anatomy as a part of the medical curriculum, and
on the teaching of anatomy to advanced medical students. Dr.
xYllen has recently reassumed the chair of zoology and compara-
tive anatomy in the University of Pennsylvania. The object of
the papers is to excite an interest in the study of zoology and
comparative anatomy by medical students. The broader the
learning and greater the erudition the better the physician, aDd
we commend most highly Dr. Allen's efforts to introduce these
studies into the medical curriculum iu this country. Dr. Allen
is a competent and conscientious instructor, and those who come
under his teaching will have advantages which can be obtained
in few if any other schools.
THE HARRIS CASE.
In view of the possibility of a new trial of Oarlyle W. Har-
ris, who on Tuesday was convicted of having murdered his wife
by morphine poisoning, it would be improper for us to com-
ment on the character of the medical testimony in the case.
We think it proper, however, to express our sense of the excel-
lence of the Recorder's charge to the jury, and to congratulate
the medical profession on the probability that Harris will
never be able to enter its ranks, for, whatever disposition may
finally be made of him with reference to the crime for which
he is awaiting sentence, he is branded as a thoroughly bad
man.
ITEMS, ETC.
Infectious Diseases in New York. — We are indebted to the Sanitary
Bureau of the Health Department for the following statement of cases
and deaths reported duiing the two weeks ending February 2, 1892 :
DISEASES.
WceU fending Jan. 26.
Week ending Feb. 2.
Case>-.
Dtaths.
Cases.
Deaths.
8
2
11
2
211
26
192
19
2
?.
2
1
128
9
137
12
Diphtheria
122
38
87
30
11
0
5
0
5
0
0
0
18
0
0
0
•1
0
I
1
0
0
»
The Cartwright Lectures of the Alumni Association of the College
of Physicians and Surgeons will be delivered at the Academy of Medi-
cine on the 12th, 19th, and 26th hist., at 8 p. m., by Professor Henry F.
Osborn, of Columbia College. The general title of the lectures is Pres-
ent Problems in Evolution and Heredity. The purpose of these lect-
ures is to discuss fairly the theory of the transmission of acquired char-
acters (effects of habit, use, anil disease) and to show how it simplifies
the problem of evolution and renders much more difficult the problem
of heredity. The evolution of man as going on at the present time is
discussed in the first lecture, in order to show that this is following va-
rious changes of habit connected with civilization and that each organ
in the body has a distinct line of evolution of its own. The laws of
variation (anomalies) and reversion are thus brought out as part of the
elements of a complete heredity theory. The second lecture traces the
history of the theory of heredity as considered by Lamarck, Darw in, Gal-
ton, and Weismann. The advantage of Weismann's continuity of the
156
ITEMS.— PRO ( 'EE DINGS OF 80 CJETIE8.
[N. Y. Mkd. Joph.,
germ-plasm idea as an explanation of the phenomena ol repetition and
reversion are contrasted with the difficulties in wl ich evolution bj natu-
ral selection only involves us. On the other hand, it is shown how far
we are at present from a heredity theory which will explain the trans-
mission of ihe effects of use and disuse. In the third lecture the dis-
cussion is turned up >n the ova and sperinatozooids, the origin of sex,
a:.d the meaning of the metamorphoses in these cells in relation to he-
redity. The studies of Balfour, Van Beneden, Hertwig, Boverie, and
Weismann are reviewed to show what portion of the cell bears the he-
reditary characters and how they reach various portions of the body.
The Harlem Medical Association. — The programme for the no eting
of Wednesday evening, the 3d inst., included a paper on The Treat-
ment of External Injuries to the Eye, by Dr. G. H. Cocks; also the
presentation of a patient with an aneurysm of the supra-orbital artery,
by Dr. O'Brien.
The New York Surgical Society. — Dr. Robert H. M. Dawbarn has
been elected a member. At the next meeting, to be held at the Acad-
emy of Medicine, on Wednesday evening, the 10th inst., Dr. V. 1'. Gib-
ney will read a paper on The Prognosis in Compression .Myelitis from
Pott's Disease, to be followed by a discussion on its surgical treatment.
The Lenox Medical and Surgical Society. — At a meeting to be held
on Monday evening, the 8th inst., Dr. J. Blake White will read a paper
entitled Pneumonotomy Twice on the Same Patient for the Belief of
Tubercular Abscess of the Lung ; Recovery.
The Society of Medical Jurisprudence. — At a meeting to he held on
Monday evening, the 8th inst., the Hon. Austin Abhott, LL. D., is to
read a paper entitled Physicians on the Witness Stand.
The New York State Medical Association. — The eighth annual
meeting of the Fifth District Branch will be held in Brooklyn on Tues-
day, May 24, 1892. All "fellows desiring to read papers will please
notify the secretary, Dr. E. H. Squibb, P. O. box 94, Brooklyn.
The Death of Sir Morell Mackenzie, of London, the well-known
laryngologist, is announced as having taken place on Wednesday, the
3d inst. He was fifty-four years old.
Changes of Address. — Dr. J. T. Clegg, from Siloam Springs to No.
121 Thomas Avenue, Dallas, Texas; Dr. Wilbur P. Marple, to No. 29
West Thirty-first Street; Dr. Albert C. Stannard, to No. 119 West
Thirty-fourth Street.
Society Meetings for the Coming Week :
Monday, February 8th : New York Academy of Medicine (Section in
General Surgery); New York Ophthalmological Society (private);
New York Medico-historical Society (private — anniversary); New
York Academy of Sciences (Section in Chemistry and Technology) ;
Lenox Medical and Surgical Society (private) ; Boston Society for
Medical Improvement; Gynaecological Society of Boston; Burling-
ton, Vt., Medical and Surgical Club ; Norwalk, Conn., Medical So-
ciety (private) ; Baltimore Medical Association.
Tuesday, February 9th : New York Medical Union (private) ; Medical
Societies of the Counties of Delaware (semi-annual) and Rensselaer,
N. Y. ; Kings County Medical Association ; Newark, N. J., and
Trenton (private), N. J., Medical Associations ; Baltimore Gynaeco-
logical and Obstetrical Society.
Wkdnksday, February 10th : New York Surgical Society ; New York
Pathological Society; Ameiican Microscopical Society of the City
of New York ; Medical Society of the County of Albany ; Pittsfield,
Mass., Medical Association (private); Franklin, Mass., District
Medical Society (quarterly — Greenfield) ; Philadelphia County Medi-
cal Society.
Thursday, February 11th: New York Laryngological Society; New
York Academy of Medicine (Section in Paediatrics) ; Society of
Medical Jurisprudence and State Medicine; Brooklyn Pathological
Society ; Medical Society of the County of Cayuga ; South Boston,
Medical Mass., Club (private) ; Pathological Society of Philadelphia.
Friday, February lith: Yorkville Medical Association (private); Medi-
cal Society of the Town of Saugerties, N. Y. ; German Medical So-
ciety of Brooklyn.
Saturday, February 13th : Obstetrical Society of Boston (private).
flroceeoings of Societies.
NEW YORK SURGICAL SOCIETY.
Meeting of October 28, 1891.
The President, Dr. Oiiarj.es K. Bnmno.v, in I be Chair.
Rupture of the External Popliteal Nerve in Jumping.
— Dr. L. A. Stimson presented a patient, twenty-seven years of
age, w ho. on July 22, 1890, had ruptured the right external
popliteal nerve during the effort of making a running jump ; he
fell tit the end of the jump, but the fall was apparently the re-
sult, not the cause, of the rupture. When he rose there was
pain and powerlessness below the knee. This patient had come
to the speaker six months after the injury. There was then
well-marked paralysis of the anterior and external groups of
the muscles of the leg. Sensation was lost, in part, over the
region supplied by branches of the cutaneous nerve. An in-
cision was made behind the tendon of the biceps and the nerve
was exposed. A mass of cicatricial tissue was found, and im-
bedded in tliis were the ruptured ends of the nerve, separate*
from each other about an inch. There was considerable loss in
freeing the nerve, and its ends could not be approximated, su-
tured, and maintained in place without Hexing the knee. The
leg was accordingly dressed in this attitude and kept so until
some time after healing of the wound. Dr. Starr had kindly
seen the patient some six weeks after the operation, with a view
of hastening, if possible, restoration of nerve function by elec-
trical treatment. Before beginning this it was found that the
reaction of degeneration was present in the tibialis anticus,
while the peronei were still normal. The man received electri-
cal treatment once a week for several month-. It would be
seen that his present condition was extremely satisfactory. The
only symptom of the previous trouble was inability to raise the
front part of the foot actively, though the foot did not drop at
all in walking. The case was interesting as demonstrating that
such an injury was possible as the result of jumping, and that
an operation six months after the rupture of the nerve had given
complete restoration of function for all practical purposes.
Prolapse of the Rectum. — Dr. F. Kammekeh showed a
man, forty-five years old, upon whom he had operated for pro-
lapse of the rectum according to Robert's modification of Dief-
fenbach's method. The condition had existed since boyhood,
and the patient had been subjected to a great deal of medical
treatment. The rectum protruded for about three inches and a
half from the anal orifice. When the bowel was replaced three
fingers could with ease be introduced into the rectum through
the much-relaxed sphincter. This, then, seemed to be a suitabl
case for a narrowing of the sphincter and lower part of the r
turn. An incision was carried in the median line from the coc
cyx to the upper border of the sphincter, and then along the
latter to both sides for about an inch. These incisions were
now carried down to the rectum, separating the levator ani
muscle, which was drawn to either side. Thus, a V-shap:
portion of the posterior rectal wall was laid bare, the point o
the V lying at the coccyx. This was excised, corresponding to
about four inches of the rectal wall and tin inch and a half of
the sphincter. The walls of the rectum were first united by a
running catgut suture, and then the remaining soft parts in
similar manner, but it was impossible, however, to entirely clo
that part of the wound cavity lying under the coccyx. This w
packed with iodoform gauze. The sutures through the sphincte
were strengthened by several deep silk-worm threads, exter-
nally as in Robert's case, and also in Bell's, both lately reported
in the Annals of Surgery. A rectal fistula developed at the upper
Feb. 6, 1892.)
PROCEEDINGS OF SOCIETIES.
157
angle of the wound, which was definitively closed only at the
end of the third month after the operation. In the two other
eases referred to it existed even a longer time. The result of
operation, which was dane about six months ago, had been a
complete success; no recurrence of the prolapse, cessation of
catarrh and ulceration of the rectum, and perfect control over
RBces and flatus.
The Treatment of the Graver Forms of Pelvic Suppura-
tion by the Intraperitoneal Iodoform Tampon.— This was
the title of a paper by the President. (See vol. liv, page 564.)
Dr. J. A. Wyeth said that his experience with the iodoform
tampon was limited to its use in some hall-dozen cases, in
which the operations had, for the most part, been done in the
neighborhood of the vermiform appendix. The inflammatory
processes were, of course, acute, and he could hardly call them
abscesses, although in one case pus was present, but without
limitation or encapsulation. The tampon had been invariably
satisfactory when he had used it. In one instance a f.eeal
fistula had been established, which had to be watched. In an-
other case, in which he had removed the appendix twelve
hours after the occurrence of perforation, he had come upon
some fluid that looked like pus. The tampon was used and
removed on the tenth day. He considered the iodoform tam-
1 f great value in this class of cases, and believed that noth-
ing else in the way of dressing gave such security.
Dr. Parker Syms thought that this was the only practical
way of draining the abdominal cavity. In the cases treated by
him be had removed the gauze on the fifth day and had found
adhesions fully formed by this time.
The President said he now used the tampon in all cases of
appendicitis where he found suppuration, and had in no in-
stance regretted doing so, but he had regretted its omission in
some cases.
Cleft Palate. — Dr. Wyetii presented photographs of a case of
cleft palate affecting the anterior half and not the soft parts in
which there was complete lateral hare-lip. He said he had
mentioned the case to call attention to a little point in correct-
ing the deformity of the nose. When the bone was deficient
on one side, the ala nasi resting upon the short side was always
flattened out and receding. In order to correct this it was
necessary to divide the upper maxilla on the short side, bring
the anterior fragment forward to the level of the normal bone
of the opposite side, and wire or pin it in this position un-
til it united with the opposing maxilla. The ahe nasi of both
sides then rested on the same plane, and the deformity disap-
peared. When there was a projecting process of bone on one
side, his practice was to crush this piece back and suture it in
line with the short maxilla. In the case reported this opera-
tion had met with success.
Dr. Stimson had obtained good results in cases of double
cleft palate by dividing the premaxillary bone a little poste-
riorly and dropping it back to the line of the other two ami
fixing them in place, lie thus saved all the lip and often some
of the incisor teeth.
Tubercular Pyelitis ; Nephrectomy ; Death ( reported by
Henry II. Forbes, M. D.) —The President showed a specimen
and narrated the case of Joseph C, thirty-five years old, who
had been admitted into his service in the Presbyterian Hospital
on October 8th. There was no morbid family or personal his-
tory, save of a gonorrhoea three years before, the discharge last-
ing about a year, with bladder symptoms. The patient was
suffering from pain in the right lumbar region, which radiated
down the front of the thigh. It was present nearly all the
time, and was sufficiently acute to interfere with .sleep. I!i-
tnanual palpation detected tenderness and a tumor in the right
costo-iliac region; the tumor had the configuration of the kid-
ney and was of considerable size The diagnosis was made of
pyelitis from infection ascending from the bladder, and the man
was put upon treatment with fluid extract of pichi. The urine
was acid, of a sp. gr. of 1*018, and contained traces of albumin,
with twenty percent, of pus, by volume. His condition remained
unchanged, save that there was a slight diminution in the quantity
of pus, but he had nightly elevations of temperature to between
103° and 104° F. He also complained of cough, and on question-
ing him it was found that he had suffered more or less from the
same for some time. His chest was examined by the attend-
ing physician, who said there was slight consolidation at the
left apex, which would not contra-indicate nephrectomy. It
was done by a vertical incision. On opening the capsule, the
surface of the enlarged kidney was found studded with tubercu-
lar foci, and the operator thought it better to remove the
organ; so the pedicle was transfixed below the distended pelvis
and securely tied with a heavy silk ligature. On making the
section on the distal side of the ligature, the pelvis was found
distended with pus. The specimen showed innumerable foci
of tubercle, with deposits of the same character on the lining
membrane of the pelvis. The patient never rallied, and died
from the effects of shock forty hours after the operation. No
examination of the body was permitted, which was much to be
regretted, as the condition of the kidney made it not improba-
ble that its fellowT was unsound.
Tumor of the Thyreoid Gland ; Thyreoidectomy ; Re-
covery (reported by Henry II. Forbes, M. D.). — The President
then showed another specimen and detailed the following his-
tory: Jane II., twenty-six years old, single, a domestic, Irish,
was admitted into his service in the Presbyterian Hospital on
September 29th. There was no morbid personal or family his-
tory, and her menstruation regular. A year and a half before, she
had first noticed a lump in the front of the left side of the neck ;
it had not been painful or tender to the touch, but had caused
considerable inconvenience in swallowing and impairment of
phonation. She was also troubled with palpitation and giddi-
ness. She had tried internal and external medication for some
time without effect, and the rapid increase of the tumor of late
had made her nervous and desirous of an operation. Examina-
tion revealed a tumor of about half the size of a billiard ball on
the left side of the neck, moving with the trachea during the
act of swallowing, and manifestly a part of the thyreoid body;
it felt solid and the case was believed to be one of struma hyper-
plastics fibrosa. On September 29th a long vertical incision
was made just internal to the anterior border of the sterno-
cleido-mastoid muscle, the tumor was exposed by a careful dis-
section, and, when exposed, was examined for fluctuation, which
was not discovered. The superior thyreoid artery was tied en
masse. The inferior thyreoid was isolated and tied. The isth-
mus was secured and the tumor removed with the loss of scarce-
ly any blood. On section, it was found to contain a cyst, « hich
probably could have been enucleated without sacrificing half of
the gland. Recovery was uninterrupted and the patient was
discharged, cured, on October 15th.
Meeting of November 11, 1891.
The President, Dr. Chari.es K. Bkiddon, in the Chair.
Talipes Equino-varus.— Dr. Charles MoBi kni is showed a
patient to illustrate a result after an extensive operation in a
case of highly developed talipes equino-varus. The boy bail for
seven years previous to active surgical interference hem under
careful treatment at different institutions, ami had undergone
five operations, such as tenotomies, division of fascia, etc. This
had gone on for seven years with the use of various forms of
apparatus. Finally the conclusion was reached that nothing
158
PROCEEDINGS
OF SOCIETIES.
[N. Y. Med. Jour.,
more could be thus accomplished, and the patient had come
under the speaker's care. At this time he was walking on the
outer edge and dorsum of the feet. About a year ago the
speaker had done a quite extensive cuneiform osteotomy upon
each foot, which had enabled the feet to be drawn into very
good position. Still, though the wounds healed well, yet after
the splints were removed there was a slight degree of the origi-
nal varus position. A second operation was therefore done six
months subsequently. Another wedge was removed, almost on
the line of the original operation, which allowed the deformity
to be completely corrected, it would be seen that the result
was very satisfactory, considering the condition which had
previously existed. No mechanical apparatus had been used
since the operation ; the patient had now very useful feet. The
more cuneiform osteotomy was done the more it would impress
surgeons with its advantages over division of tendons and the
long-continued use of apparatus in these aggravated cases.
Dislocation of the Head of the Fibula.— Dr. L. A. Stim-
son presented a man, twenty-three years of age, who had been
admitted into the House of Relief, Chambers Street, on the 26th
of October, about an hour after an injury to the left leg. The
patient, while hauling a heavy box, had slipped, and had then
found himself unable to walk. There was no external evidence
of violence, but a very marked prominence on the outer side of
the upper part of the leg. Examination showed that the head
of the fibula was dislocated outward and forward. All attempts
at reduction by manipulation failed. The speaker therefore
made an incision over the dislocated head of the fibula and
then endeavored to pry the head of the bone back into place
with a periosteum elevator. After further division of a strong
fibrous layer running from the head of the fibula to the front of
the tibia the reduction was effected. The wound united pri-
marily, and the patient was discharged in a week. The injury
was a very rare one, some eight or ten cases only having been
chronicled. The speaker had already presented a similar injury
to the society. As to the mechauism of the luxation, he was in
doubt. It might arise through traction by the anterior and
peroneal group of muscles, or possibly through the pressure of
the astragalus against the lower end of the fibula.
The Presidext, speaking of Dr. McBnrney's case, thought
that it was a success, and commended cuneiform resection. lie
had also done the operation with good results after various
tenotomies had been performed and apparatus worn to no pur-
pose.
A Contribution to the Surgery of the (Esophagus.— This
was the title of a paper read by Dr. A. G. Gerster. (See page
141.)
Dr. Stimsox thought that, even if feeding was carried on
through a tube, regurgitation was possible, with the result of
sepsis of the trachea. In a case under his observation, in which
a tooth-brush was removed, the wound had been closed and the
patient fed by a catheter, perhaps too heartily. At any rate,
after the third day the food had shown itself in the wound.
Dr. McBorxey was surprised to note how little the practice
obtained, after operations of the class under consideration, of
employing rectal alimentation exclusively for a period. He had
found it altogether the best thing to do. The wounds did bet-
ter, the stomach had complete rest, and there was really no
difficulty in securing to the patient ample nourishment for from
three to five days. The introduction of the catheter was not
without objections, while its withdrawal favored the introduc-
tion of deleterious matters into the wound in the neck. He
thought the method of sewing up the oesophageal wound and
packing the external one covered the ground, provided the
(esophagus was left at rest, and the patient nourished for sev-
eral days by the rectum.
Dr. F. Lange suggested the method recommended by Lang-
enbeok ns worthy of trial in cases where the foreign body was
of a certain shape and was located in certain positions. He had
lately been successful in dislodging a whistle, of the diameter
of a twenty five-cent piece, from a child's throat by this [dan.
By pressure against the lower circumference of the body it was
dislodged and withdrawn through the mouth. He did not think
that the act of swallowing could be excluded in these patients-
mucus would always accumulate, and it seemed hard to debar
them so long from fluids. Of course, a great deal depended upon
the extent to which the oesophagus had been exposed to con-
tamination during the operation. If septic trouble was appre-
hended, special care must be taken to guard against it.
Dr. Gerster said he had stated in his paper that leakage
was frequently observed during the first few days after sutures
had been applied. In spite of this, union took place unless sep-
tic complications arose. Healing was hastened by the mechani-
cal approximation of the edges of the wound, even if primary
union did not take place. He believed the success of the suture
depended upon the condition of the parts.
Appendicitis. — Dr. Stimson showed an appendix vermifor-
mis that he had recently removed. The patient had come to
the hospital a week ago and had given a history of previous at-
tacks of appendicitis. On operation, the appendix was found
lying behind the caecum, and closely adherent to it without
a mesentery. Microscopical examination had demonstrated
that the mucosa was lost and replaced by fibrous tissue and
small, round cells. The follicles of Lieberktihn were also de-
stroyed.
Ten cases of acute appendicitis had come under the speak-
er's notice lately. All of these had been treated expectantly,
some of them by himself. In three suppuration had occurred.
Two of the patients had died. Operation had apparently saved
the third. He thought the facts worth consideration when the
propriety of early operation was under discussion.
Dr. Laxge thought that statistics were very deceiving, and
from such a small number of cases it was impossible to draw
conclusions. The number of such cases, in order to decide
whether early operation or the expectant plan should be the
rule, was too small. He was inclined at times to agree to the
expectant plan, and did not see the use of operating on an ab-
scess through the free peritoneum at an early stage, w hich he
thought was hardly likely to cause mischief. He thought that
if at the end of the first week an operation was done, pus would
most probably be fouud in contact with the anterior abdominal
wall or could be reached through the rectum or by a lumbar in-
cision. It would then be found unnecessary in by far the ma-
jority of cases to do a serious operation. The question was,
any way, not yet solved, but by temporizing treatment in a large
number ot cases nothing was likely to be lost. There was a mi-
nority, however, in which operation could not come too early, and
to distinguish those was a trial more worthy of surgical science
than indiscriminate laparotomy, which for some time past had
promised to become the fashion of the day.
Dr. Stimson said he had not offered his cases as general, but
as individual statistics. The two fatal cases had been treated
expectantly by others and then sent to him for operation after
general peritonitis had developed.
Dr. Parker Sy.ms thought that some sort of ability to classify
these appendicitis cases was essential before formulating rules
as to operating. In cases which required operative interference
at all the early operation was the proper one. In cases that had
gone on to suppuration and in those that were dealt with by
simple incision, extraperitoneal^', the patients were not neces-
sarily in a safe condition. He did npt think the patient who had
gone on to extraperitoneal abscess and had escaped the early
Feb. 6, 1892.]
PROCEEDINGS OF SOCIETIES.
159
dangers was by any means in a sate condition. If we could as-
certain by symptoms what cases were going to call for operation,
the early one would be the one to choose.
Dr. F. Kammerer thought that cases in which circumscribed
suppuration had taken place about the appendix, which after-
ward led to general peritonitis, did not argue for early opera-
tion ; when suppuration hud started in the peritoneal cavity,
on whatever day, we ought to interfere surgically. To diag-
nosticate this condition in its incipiency was of greatest impor-
tance. Then we should not meet with cases of general perito-
nitis from primary circumscribed abscess.
Dr. F. W. Murray cited a case in which he had just oper-
ated. The patient had had two attacks previous to the opera-
tion— his first attack seventeen and his second fifteen years ago.
This case simply illustrated that under the expectant plan of
treatment one could never be sure that the patient was perma-
nently cured, a fact which decidedly lessened the value of the
statistics quoted by advocates of this form of treatment.
Dr. R. F. Weir did not think enough was known as yet on
this subject to warrant the formulation of a hard and fast rule
which could be adapted to the doubtful cases. The natural his-
tory of the catarrhal form was yet incomplete. He was yet un-
willing to believe that this variety had such danger connected
with it as the perforative and gangrenous forms. Each case in
its acute stage required so far a special judgment. The question
of an operation hinged, then, largely upon the presence of the
signs of advancing peritonitis.
Gangrene of the Testicle. — Dr. Gerster reported the fol-
lowing case : George 0., a butcher, aged thirty-nine, was ad-
mitted on February 2, 1880, into the German Hospital, with an
enormous emphysematous swelling of the left testicle. The or-
gan had nearly the size of a man's head, was dusky, red, and
hot, showed crepitus, and gave a tympanitic percussion sound.
The patient, a powerfully built man, showed symptoms of most
acute septic intoxication. He stated, on being shaken out of
pis stupor, that the swelling had come on three days before,
suddenly, with much pain, after an exploratory puncture. Im-
mediate ablation of the organ was done. The skin was pre-
served, and a very large wound cavity was filled with a packing
of carbolized gauze. An almost immediate improvement of the
patient's general condition had followed. The wound had healed
rather rapidly by granulation. On February 26th the patient
was discharged, cured.
The speaker also showed a specimen of a testicle, recently
removed, with the following history: Abraham G., aged twenty-
eight years, married, a peddler, was admitted into Mt. Sinai
Hospital on November 11, 1891. He had had a chancre about
three years before, and five months later a gonorrhoea. Had
never noticed any evidence of secondary syphilis. Shortly after
his attack of gonorrhoea lie noticed that, the right testicle was
beginning to swell, but wms not painful, and there was no fever.
This swelling bad increased slowly until it had attained nearly
the size of his fist, when it remained stationary, and had been
so for about a year.
His present illness had begun five days before. On return
ing home from his day's work, he began to have pain along the
right spermatic cord, and the next day it was so bad that he
went to a dispensary, where the doctor aspirated the tumor
three times, drawing off a bloody fluid, but did not inject any-
thing into the scrotum. That evening the pain became very
severe and the testicle increased to nearly twice its size ; ho also
had a chill, fever, and headache, and felt generally weak, lie
had had a chill every day since, and fever. The pain bad been
very severe, so that he had been unable to sleep. There had
been no trouble in urination. The bowels were regular. I be
patient had vomited once. On his admission, bis pulse was 100,
his respiration 20, and his temperature 103-4°. His general con-
dition was good. His tongue was a little coated. The scrotum
was of about the size of a large cocoanut. There was no im-
pulse on coughing. The scrotal wall was tense, inflamed, and
quite tender on pressure. There was slight tympanites. The
left testicle, of normal size, was felt posteriorly and freely mov-
able.
The operation consisted in ablation of the gangrenous tes-
ticle, the parenchyma of which was found converted into a brit-
tle, semi-liquid pulp of a brownish-red color, containing abundant
bubbles of gas. The tunica albuginea was throughout very
much thickened, of a dirty greenish-yellow, and evidently ne-
crosed. The necrosis was apparently extending here and there
into the scrotal tissues, which were oedematous and also con-
tained gas around the necrosed areas.
In four hours after the operation the temperature was 99°
and he was feeling better. (Note, January 29, 1892. — The pa-
tient made a rapid recovery.)
Dr. Weir had seen several cases in which the introduction
of a foul aspirator needle had been followed by necrotic pro-
cesses. Two instances followed puncture for serous pleuritic
effusion, and in two other cases the testicle became gangrenous
from a similarly badly conducted exploratory puncture. He had
also seen gangrene of the testicle from other causes.
Dr. F. La:nge had operated in one case where previous sur-
gery had not led to infection. There was some constitutional
disturbance and subacute fever. This condition had lasted for
some time. The speaker had seen the patient in the second
week. At that time the organ was considerably enlarged. On
removal, it was found to be necrosed. There was no pus forma-
tion, there were no symptoms of decomposition, but there was
considerable bloody infiltration. Embolism of a nutrient artery,
most probably of a spermatic artery, seemed to have caused the
trouble.
Dr. Gerster added the history of another case of spontane-
ous gangrene of the testicle in a young man who, about nine
months after castration, was readmitted into the German Hos-
pital with an evident renal tumor to which he succumbed.
Post-mortem examination revealed an enormous renal sarcoma
involving more or less of the adjoining tissues, of course also the
radical portion of the spermatic artery. There was no evidence
of sarcoma about the scrotal cicatrix, but the assumption was
very plausible, in view of the sudden, apparently embolic char-
acter of the gangrene, that a sarcomatous plug might have been
carried into the terminal part of the spermatic artery, thus caus-
ing acute gangrene. The speaker referred to an excellent paper
on the subject of spontaneous gangrene of the testicle by the
late Professor Volkmann, of Halle.
NEW YOKK NEUROLOGICAL SOCIETY.
Meeting of January 5, 1892.
The President, Dr. Landon Carter Gkat, in the Chair.
Thomsen's Disease.- Dr. C. L. Dan a exhibited a male pa-
tient, thirty-three years of age, who presented the typical phe-
nomena of this disease. The family and personal history of the
patient were good. There was no specific trouble and had been
no previous nervous disturbances. The first symptom noticed
had been a weakness of the muscles, which had come on at the
age of seventeen. Three years subsequently it had been found
th.it, when the fists were closed, they could not be opened again
voluntarily for some little time. These conditions bad increased
until at the present time the only muscles not involved in the
process were those of the thighs and upper arms. The myotonia
was most marked in the muscles of the forearms and legs. No
160
PROCEEDINGS OF SOCIETIES.
[N. Y. Mkd. Joub.,
contractions of the pillars of the fauces were observed. There
were no sensory disturbances. Reflexes were nearly abolished
and could only be obtained byre-enforcement. There was slight
increase of reaction to the galvanic current, but not to the fara-
daic. The author felt convinced, from very careful tests of the
muscles, that the phenomena were confined to the muscles them-
selves, and that it was not due to a reflex influence, but that the
disease was a purely muscular one.
Peripheral Neuritis, or Possible Lesion of the Posterior
Nerve Soots. — Dr. W. M. Leszynsky presented a patient with
the following history : A woman, fifty-three years of age, while
trying to raise a heavy weight had injured the shoulder joint.
Neuritis of the brachial plfiXm had developed within a few days.
When she had first come under treatment, nearly six months
after the accident, she had been suffering from extreme pain and
tenderness in the course of the median and musculo cutaneous
nerves. There had been no circumscribed paralysis, but a gen-
eral weakness of the, entire limb. The pain had been relieved
by treatment. Within two weeks the entire extremity had grad-
ually readied a condition of complete anesthesia, including los-
of muscular sense. Subsequently the adductor pollicis and the
flexor longus pollicis had becom e paralyzed. This paralysis had
disappeared, however, within ten days, and simultaneously there
had been a restoration of all forms of sensibility, including the
muscular sense, over the thenar group of muscles and the entire
thumb, the rest of the limb remaining anaesthetic. There had
been diminished faradaic irritability in the thenar, bypothenar,
and interossei muscles. Any hysterical element could be ex-
cluded. He thought the diagnosis rested between a peripheral
neuritis affecting the sensory nerve branches and a possible le-
sion of the posterior nerve roots.
Dr. Mary Putnam Jacobi did not see why Dr. Leszynsky
was so positive in excluding hysteria as the probable cause of
the condition in his case. The distribution of the anaesthesia
was such as one might expect in an hysterical patient. The fact
that there had been no other exhibition of any recognized symp-
toms of hysteria did not exclude the disease in such a case as
just presented.
Spasmodic Screaming. — Dr. J. A. Booth [(resented a pa-
tient, aged seventy-three, a peddler by occupation, who had
been under observation in the Nervous Department of the Man-
hattan Eye and Ear Hospital for the past four years. He had
also been a frequent visitor to the various clinics in the city.
The patient had enjoyed good health up to nine years ago; about
that time, after a week of great headache, he had had an at-
tack of left hemiplegia with disturbance of speech. He had been
ill in bed fourteen weeks, and during this time had suffered in-
tense and constant pain in the head. The paralysis had grad-
ually improved ; the disturbances of speech had disappeared and
he had returned to his business of peddling one year after the
attack. Ever since the onset of illness he had had more or less
head pain, localized over the right parietal region, and this he
described as appearing in a sp smodic manner, shooting up to
that portion of the head. The attack had been ushered in by a
flexion of the ring and middle fingers of the right hand, the other i
fingers being straight ; the whole hand had then been rapidly ro-
tated, the attack culminating in a loud scream and the placing
of the hand on the right side of the head, lie had also com-
plained of not being able to sleep, and his wife had corroborated
this statement, by adding that he was a nuisance to her and the
neighbor- by these attacks of screaming at night. These parox-
ysms could also be brought on apparently by suggestion, although
the speaker had never been aide to get the patient under the
hypnotic influence. After going over the ease carefully the
speaker was inclined to believe that at the present time the pa-
tient was more of a simulator than anything else.
Debate on the Therapeutic Value of Hypnotism.— The
Chairman said that his object in calling for such a discussion
was to ascertain the opinions of New York neurologists in re-
gard to the value of hypnotism therapeutically. lie did not
want to hear any historical data on the subject, but the personal
experience of those who had given the matter serious attention.
Dr. Dana referred briefly to the work of the late Dr. Beard
as being the only contributions made by an American author on
this subject. From a long series of experiments that writer had
been convinced that hypnotism was a real condition and not a
mytb. lie had not been able, however, to produce complete
hypnosis, although he had attached some value to suggestive
therapeutics. The speaker had been able to produce complete
hypnosis in fifteen per cent, of the cases submitted for experi-
ment and only a partial state in from thirty to fifty per cent.
As to its value as a remedy in any of the known neuroses, it was
doubtful if it had any efficacy. There were many therapeutic
measures which were so much easier of application and which
possessed recognized virtues, that it seemed to the speaker un-
wise to exchange them for something with t>uch subtle power
and so difficult of control as was hypnotism. Taken alto-
gether, it was a remedy that could rarely, if ever, be used with
benefit.
Dr. G. W. Jacoby said that he had been through two epi-
demics of hypnotism, the first lasting from 1880 to 1884, and
the second in 1888. In order to indicate just what position he
occupied in regard to the value of hypnotism as a therapeutic
remedy, it was necessary for him to review his work in this
direction. In old note-books he had found a record of nine
cases marked " cured '' in which hypnotism had been the reme-
dy. On following out the further histories of these cases, wmich
had been of various forms of hysterical neuroses, it had been
found that 'in every instance there had been relapse of the
trouble. This result had been the cause of the speaker's aban-
doning hypnotism as a therapeutic agent. While it might pos-
sibly be good for some subjects, for the control of some symp-
toms temporarily, why should we use a method that was labori-
ous and surrounded by mysticism and charlatanism, wheu other
remedies had to be resorted to ultimately anyway? The only
way in which any conclusion could be arrived at in regard to
the therapeutic value of hypnotism was by means of statistics,
and these so far had been more or less unreliable.
Dr. Walter Yought described the method of producing
hypnosis employed at the Vanderbilt Clinic. Some briirht object
was held before the patients' eyes, and at that tbey were told to
gaze while the physician encouraged them to try and sleep. Such
means had r .rely failed to produce the desired hypnotic condi-
tion. In no instance bad bad effects been observed to follow
its use ; in some a slight pallor had come on, but nothing of
further consequence. The therapeutic application of hypnotism
was successful in most of the cases— such as neuralgias and
persistent pain. The speaker thought that it was to be recom-
mended in this class of cases.
Dr. E. I). Fisher said that, so far as his experience and per-
i sonal observation went, he did not favor t'le use of hypnotism
as a therapeutic remedy. He had not as yet seen or heard of
any permanent successful issue from such procedure, lie
thought that it might also be a dangerous measure in many
cases, especially in certain mental conditions. At any rate, if
hypnotism was to be used at all, it should be only with the
greatest precaution.
Dr. J. W. Collins had used hypnotism in thirteen cases, and
was able to report a cure in five of these. It was not his practice
to use the remedy promiscuously, but when he had decided that
the case was suitable for hypnotism he had carried out the sys-
tem of mental suggestion, and had been able to get good results
Feb. 6, 1802.1
PROCEEDINGS OF SOCIETIES.
161
from it. While he did not maintain that hypnotism was a rem-
edy for all nervous diseases, he was satisfied that it possessed
therapeutic value in certain cases. lie thought that it was a
great, mistake to say that patients were non-hypnotizahle if they
did not succumb to the influence in a short time. He had seen
j the masters in this branch at work at patients one and two,
and even three, hours in some instances before they could be
brought under the hypnotic influence. He did not want to ap-
pear as an enthusiastic advocate for hypnotism, but he was con-
vinced that it had a field in certain psychical conditions, and es-
pecially in moral perversions. Considering the fact that the
present method of dealing with these cases offered but little in
the way of cure, there should lie no hesitancy in at least giving
hypnotism a fair trial, and not being satisfied with simply an
attempt or two, but persisting until such a condition of the pa-
tients was brought about, so that mental suggestion could be
responded to. If carried out consistently, the speaker was sure
that hypnotism would offer more as a moral educator than any
other measure that had ever been advanced.
Dr. Leszynsky thought that the length of time that it took
to get the patient under the hypnotic influence was a matter of
indifference. As yet there were no statistics to show the bad
influence of hypnotism, but in cases where he had failed to pro-
duce hypnosis the patients had been left in an uneasy, uncom-
fortable state. He did not think hypnotism by any means de-
i void of danger. lie reported the case of a child twelve years of
age whom he had treated for hysterical attacks of laughing and
crying. She had improved very much under ordinary attention,
and had finally passed out of his hands. Some time subse-
quently there had been a slight return of the trouble, and the
mother had taken the child to some one who had tried hypno-
tism, the first attempt being unsuccessful; but it had been per-
sisted in until complete hypnosis had been brought about three
or four times. From this time on all of the symptoms had be-
come exaggerated, and when the author had seen the patient
again she had developed all of the phenomena of hysteria. He
felt satisfied that hypnotism was responsible tor the deteriora-
tion in the nervous tone and the development of hysterogenic
zones. It had been two years since he had practiced hypnotism.
The last patient upon whom he had tried it had been suffering
from singultus; during the hypnotic state the spasm had been
abolished. Suggestion at this time that the paroxysm would
not return when consciousness was restored had proved a
failure, as the spasm had returned in an aggravated form. As
for hypnotism being applicable in insanity, it was thought rather
doubtful that it could be done at all, for the reason that the de-
gree of concentration necessary could not be obtained in this
class of patients.
Dr. Booth had during the past four years made use of hyp-
notism in twenty-four cases — fifteen in females and nine in males,
i Of the fifteen females, ten had been hypnotized easily and had
responded to suggestion; in five no hypnotic effects had been
produced, although repeated attempts had been made. Of the
nine cases in males, six had been failures. The histories and
treatment of four cases were then read in detail. Case I. — A
young girl, aged seventeen years, suffering with tremor of the
' left upper extremity, had been hypnotized daily for a week,
i during which seances proper suggestion had been made. At the
end of that time the tremor had entirely disappeared and had not
' returned a year alter treatment. Case II. — llysteroid attacks in
I 1 a girl aged nineeten years. She had been easily hypnotized, and
had been markedly lethargic, going into a deep sleep from which
it had been difficult to arouse her either by suggestion or strong
measures. Subsequent seances had not produced such marked
effects, and had been successful in lessening the number of at-
tacks. One attack only had occurred during the past year. Case
III. — Double ptosis. The patient had been easily hypnotized,
and after fourteen seances there had been marked improvement.
Case IV was another patient with hysteroid attacks, which had
been ultimately cured by hypnotism.
Dr. B. Sachs had not been able to do much with hypnotism,
and as yet had accomplished nothing therapeutically. He had
tried the method in cases of hystero-epilepsy and where per-
sistent pain had existed for years; in every instance the thera-
peutic effect had been absolutely nil. The only two cases in
which a certain amount of benefit had seemed to be derived
from hypnotism had been of nerve-deafness occurring in two
young women. The improvement had continued during four
weeks in one case, and three months in the other, fie thought,
however, that hypnotism, so far as any real therapeutic value
was concerned, was only a fashion at present, and that it would
soon be laid on the shelf.
Dr. Jacobi described a case which had recently come under
her observation, the course of which possibly bore some analogy
to the way *in which hypnotism operated upon the nutritive
states through some controlling mental emotion. The patient,
a woman of emotional characteristics, had complained of severe
pain in the shoulder joint. There had been present much swell-
ing and anassthesia. Despite all treatment, the condition had
increased in severity. After the tenth day hysterical attacks of
screaming had come on, followed, fourteen days after the onset
of the trouble, by considerable vomiting of blood. About this
time the patient's child had become dangerously ill and had died
in a few days. From this time on all her symptoms connected
with the shoulder and the general condition had gradually sub-
sided and had finally disappeared. Health in a short time had
been completely restored. The speaker thought that this was a
clear case of great mental emotion having the power of reor-
ganizing and controlling the nutritive states, as shown in the
rapid recovery when the mind was concentrated on the illness
and death of the child.
The Chairman had practiced hypnotism since 1886 in hun-
dreds of cases in his hospital wards, but had finally given it
up in this class of patients, as he had found that it had a de-
moralizing influence, and that moral control over them was lost
by persisting in its use. In some cases where he had tried hyp-
notism he had found that his patients would leave him and go
to some one else. He thought, however, that in the present
study of hypnotism we were only on the verge of a great de-
velopmental knowledge of psychical laws which might prove to
be of great value. From his experience in the use of this agent
as a therapeutic measure he was not able to say in what class of
cases or individual case it would or would not he beneficial. If
he could draw any deduction, he would say that the hysterical
cases offered the best results. No one understood the nature
of hysteria, and there were no conclusive criteria by which
hysteria could be diagnosticated ; but in the symptoms laid down
as such, hypnotism had produced some amelioration, although
relapses occurred. In functional symptoms, such as delusions
of fear, fright, timidity, and so forth, good results were ob-
tained by hypnosis. In other neuroses, such as neuralgias and
organic diseases of the nervous system, the benefits were not
so good as from other known remedies. The speaker had never
been able to hypnotize an insane patient, and the practice had
tilled paranoides full of delusions. Altogether, no good results
were obtained in these two classes of patients, but much harm
in the latter. There need be no difficult; in hypnotizing pa-
tients; if it could not be done in one way it could be done in
another. The author had found that, where patients were hard
to get under the influence, they were apt to sink into coma
afterward. He had had such a case, where the patient, when
observed for a short time after being hypnotized, had been al-
162
iVE W IN VENTIONS.—MISVELLA N ) '.
[N. Y. Med. Joi r.,
most in a comatose state, and ha<] been very ill for the remainder
of the day. He had never heard of a death being produced by
hypnotism, but did not think it unlikely that it might happen.
He would not, however, condemn hypnotism until it had had a
further and more conscientious trial.
|tcto Jutbcntioiis, etc.
AN INSTRUMENT FOR THE REMOVAL OF HYPERTROPHIED
TISSUE FROM THE BASE OF THE TONGUE.
By Wallis F. Chappki.l, M. D., M. R. C. S.
The increased glandular tissue so often found at the base of the
tongue is usually treated by the cautery, caustics, and astringents.
These methods are not so satisfactory as we could wish, on account of
the frequent applications necessary and the unpleasantness to the pa-
tient from the tardy healing of the cauterized surface. The instrument
shown in the accompanying cut is intended to take the place of the
cautery in most cases. It should not be used where there is a collec-
tion of vascular nodules accompanied by a vaiicose condition of the ves-
sels at the base of the tongue, but on the large pale masses which so
often completely surround the epiglottis. It is not necessary to remove
fftisc ellartD .
every particle of this tissue, but simply to pare off sufficient to relieve
the symptoms. Before using the instrument the throat should be
sprayed with a one-per-cent. solution of cocaine and then, either by the
guidance of a laryngeal mirror or after pulling the tongue forward, the
instrument is placed in position and the necessary amount of tissue re-
moved. The haemorrhage is slight and the cut surface heals rapidly.
This instrument will also remove the uvula more satisfactorily than any-
thing I know of, and, with a little experience in using it, is invaluable
for the removal of adenoid or granular tissue from the posterior wall
of the pharynx.
22 East Forty-second Street.
The Nervous and Mental Phenomena and Sequelae of Influenza.
— At a meeting of the Philadelphia County Medical Society held on
January 13th, Dr. Charles K. Mills read the following paper:
All practitioners have been struck by the prominence of nervous
and mental phenomena in influenza ; and much has been written, but
mainly in a desultory way, about the symptoms of the disease which
are referable to the nervous system, and its more or less persistent
nervous and mental sequelae. The part played by the nervous system
in the aetiology and history of the disease has been variously inter-
preted. One holds that it is a " nervous disease," without explanation ;
another describes it as a pneumogastric neurosis ; another as a neuropa-
thy due to ptomaine poison. According to Blocq, cited by Church,*
the primary infectious action takes place upon the nervous system dur-
ing the disorder, while sequela? are to be attributed to secondary infec-
tion from ptomaines. Cheston Morris, f of Philadelphia, advances the
* Church. Chicago Med. Record, 1891.
f Morris. American Lancet, March, 1891.
theory that the general symptoms of influenza may be traced to a
derangement of function, or partial paralysis of the pneumogastric
nerve, and that the affection is brought about by conditions of the at-
mosphere which particularly tax the cardio-pulmonary apparatus which
is regulated by tins nerve, a view which, after all, relegates the disease
to an atmospheric or infectious cause. Graves long ago refei red the
bronchial and pulmonary symptoms of grippe to lesions of the nervous
power of the lungs, ami Wakiston regarded it as a disorder of the nerv-
ous system, with concomitant derangement of the organs of digestion,
circulation, etc. Levick,* who cites the last two authorities, holds that
certain symptoms are produced when the poison is expended on the
sensorium, and certain others when its influence is chiefly exerted on
the respiratory centers.
The analogies or relationships between influenza and other diseases
generally recognized as belonging to the nervous system, either pri-
marily or because of the situation of their most notable lesions, have
been strongly brought out by able writers, as by Levick, for example,
who has even suggested that epidemic cerebro-spinal fever, or cerebro-
spinal meningitis, may be simply a malignant form of influenza, a view
to which he was led because of the resemblance in the symptoms of
the two diseases, which differ in degree rather than in nature, and also
because for three centuries the two have occurred coincidently or in
close sequence.
Grasset and Rauzicr,f in a monograph on the grippe of 1889-'90,
Jay great stress on the enormous predominance of the nervous over the
catarrhal elements in the epidemic, as evidenced in the high fever
great cephalalgia, the marked delirium, the wide-
spread pain, and the excessive nervous irritability.
They refer to cases communicated by M. Coustan,
in which the entire symptomatology of the dis-
ease seems to have reduced itself to a horrible
migraine. They review the literature, which
shows that writers of various countries are unani-
mous in proclaiming the importance of the nerv-
ous element — referring to Austrian, Russian, Belgian, German, English,
and Polish contributions.
According to Schmitz,^ who read a paper on the subject before the
Psychiatric Society at Bonn, influenza is a disease of the nervous sys-
tem with secondary involvement of the heart, lungs, and digestive
organs. In several hundred cases which he observed the nervous
symptoms were always primary, followed in every case by secondary
involvement of the other organs.
What seems to be needed is an analysis and practical grouping of
the facts, almost too numerous to handle, which show the important
part played by the nervous system in the development, progress, and
results of the disease. How is the nervous system affected by influ-
enza? What are its primary or direct effects on the nervous system,
and what are some of the more persistent and permanent impair-
ments, and how are these determined by the disease? What are its
acute nervous and mental phenomena, and what are the most common
sequences ? What is the probable pathology of these states, and
what treatment is best in view of the neurotic characteiistics of the
affection ?
The briefest consideration of the subject brings forcibly to mind
the fact that all diseases of infectious or toxic origin — epidemic, en-
demic, sporadic, or accidental — may strike any or all parts of the
nervous system with a result which will be proportionate, first, to the
virulence of the infecting agent; and, second, to the resistance of the
individual, whether this is due to constitutional predisposition or to
reductions, the result of previous injury or disease. The microbes
may differ, but a bond of union and close resemblance can be recog-
* Levick. Am. Jour, of tlie Med. Sci., January, 1864, and republi-
cation in pamphlet form, with notes of the influenza of 1889-'90.
+ Grasset and Rauzier. Lecon sur la grippe de Vhiver 1889-'90.
Montpellier and Paris, 1890.
| Schraitz. AUgemeine ZeiUchrift fur Psychiatrie und psychi.sch-
gericMichc Medtzin, 179, 1891. Cited in American Review of Insanity
and Nervous Disease, December, 1891.
Feb. 6, 1892.]
MISCELLANY.
163
nized between the effects on the nervous system of all contagious and
infectious diseases, as variola, scarlatina, diphtheria, measles, whoop-
ing-cough, typhoid or typhus fever, leprosy, mumps, cholera, erysipe-
las, puerperal fever, influenza, or cerebro-spinal meningitis ; of all of
such constitutional and diathetic affections as tuberculosis, gout, rheu-
matism, and diabetes ; and of all such toxic agents artificially intro-
duced into the system as alcohol, mercury, lead, arsenic, copper, and
poisonous gases. These diseases, these diatheses, and these poison-
ous metals and gases produce, or may produce, nervous and mental
phenomena of the same character, differing in degree in particular
cases and for special reasons.
In all these affections at the time of acute onset, if the illness is of
a serious character, such symptoms are present as great mental and
nervous debility, irritability, restlessness, sleeplessness, or the opposite
states of torpor, stupor, hebetude, or coma; delirium; vertigo or syn-
cope; headache, browache, napeache, backache, and limbache; pains
of all degrees of severity referred to various nerve areas ; hypera?sthe-
sia of the skin, of muscle-masses, or confined to nerve-tiunks or
branches; spasms, local or general, and with or without unconscious-
ness ; sometimes mental disturbance amounting to a true mania or
melancholia. During the progress of such affections any one or
several of these enumerated symptoms may be present. Supra-orbital
pain, for example, may be the only prominent nervous symptom in a
case of influenza ; headache and backache in diphtheria; hyperesthe-
sia in mumps, diabetes, or gout ; and mania in a case of puerperal in-
fection. Any infectious or toxic disease may, in brief, produce the
same symptom, syndrome, or train of phenomena ; and — which is the
main point — for the same reason, namely, because of the introduction
into the system of an agent which directly and powerfully poisons
nerve centers, and possibly also nervous conducting tissues.
Following all infectious, diathetic, or toxic diseases, moreover, or
directly springing from them, common experience teaches that we may
have great nervous or general weakness ; forms of insanity of the de-
pressive type ; paresis and paralysis of every grade from an affection of
a single muscle to that of all the extremities, and even more ; localized
spasm or cramp ; general convulsions ; pains in nerves, muscles, and
joints ; and losses or perversions of sensation.
These symptoms and conditions, which may occur at the onset, dur-
ing, or after the subsidence of any infectious or toxic disease, are those
which constitute the nervous features of the prevailing epidemic. I
have introduced the subject in this way because it seems to me that it
is this comprehensive grouping of generically similar phenomena which
enables us to most readily grasp a subject even for practical purposes.
We differentiate phenomena in our daily labor, which we can onlv un-
derstand by properly grouping them, and by referring them to a com-
mon or to related causes.
Any attempt to classify the nervous and mental phenomena of influ-
enza must be attended with great difficulties. These are, in the first
place, symptoms and conditions which, although manifested in non nerv-
ous organs, are directly traceable to a nervous origin ; secondly, affec-
tions which would be recognized by all as properly referred to the nerv-
ous system ; and, thirdly, affections occurring in nervous tissues and
organs, although, strictly speaking, not nervous diseases.
I will refer very briefly to the first of these classes, although of
much importance. J will not, however, discuss the nervous origin of
the fever of influenza, nor will I attempt to explain the catarrh, indi-
gestion, etc., on some neurotic theory, as such a method might lead us
anywhere, and for our present purposes would be unprofitable. I wish
simply to emphasize the fact that some of the most prominent pulmo-
nary, cardiac, and vascular affections of influenza can best be explained
on neural theories. Many personal observations have led me to the
conclusion, not new, which has recently been well presented by Elliott,*
of New Orleans, that the pneumonias of influenza are often due to vaso-
motor paralysis, that they are, in fact, forms of blood stasis or passive
congestion from vaso-motor paralysis, which in its turn is dependent
upon the action of the infection upon the pneumogastric centers and
the nervous system in general. A distinct difference can be made out
between the true pneumonic lung and this ,l grip-lung," as it has been
* Elliott. Climato/ogist, i, 1, August, 1891. '
termed by Elliott. Graves long ago attributed the oedema of the lungs
which occurs in influenza to an affection of the vagus.
" The grip-lung," according to Elliott, " has a long and very vary-
ing condition of passive blood stasis unaccompanied by rales. If reso-
lution occurs within three or four days, it is accompanied by large mu-
cous rales, and no time is given for the slow appearance of bronchial
breathing or bronchophony ; but during the long continuance of the
blood stasis an exudation occurs, increasing slowly, which will give, in
time, some bronchophony and bronchial breathing, but never so com-
plete as in pneumonia. Resolution never occurs in these cases with the
suddenness that characterizes it in acute pneumonia. The condition
passes off as gradually as it formed. The sharp, clear-cut, and sudden
phases of the pneumonic attack separate it clearly from the obscure,
irregular, and slow phases of the grip-lung. "
Many disorders in various parts of the body are best explained on
this theory of local vaso-motor paralysis, although it is not necessary to
attempt to force this explanation for all. Haemorrhages, minute, or
even of considerable size, occurring in diverse localities, as in the retina,
membrana tympani, and internal auditory apparatus, or in the skin, or
mucous or serous membranes anywhere, may be due to deficient vaso-
motor tonus. Brain, kidneys, liver, or pelvic organs may suffer from
forms of passive hyperemia, subacute or ehrouic, which are in fact due
to forms of vaso-motor palsy. Occasionally we meet with cases of vaso-
motor disorders of the extremities, such as flushed or pallid fingers.
Even trophic affections have occasionally been observed. Wilson,*
for example, refers to gangrene of the lungs as one of the less com-
mon complications. Abscesses of the limbs have been recorded. Gras-
set records two observations of eschars occurring in young subjects in
the absence of prolonged decubitus. The greater tendency in surgical
cases to suppuration may have its best explanation in the depression of
healthful vaso-motor and trophic influence.
The peculiar forms of pulse, and the uncertain or perverted action
of the heart, extending in some cases to cardiac palsy and death, are in
a strict ser.se nervous phenomena due to paralysis, partial or complete,
of the inhibitory apparatus of the heart.
Let me take up those symptoms and affections which would clearly
be recognized as belonging to the nervous system.
I believe, with Church, " that the infection of influenza has a marked
action upon the nervous system which may give rise to immediate
acute manifestations or to remote and persistent conditions ; and that
in the predisposed, grippe is competent to cause marked excitement
or great depression of the motor, sensory, and mental nervous appa-
ratus."
Great nervous and mental prostration, both as an acute manifesta-
tion and as a persisting sequel, has engaged the attention and required
the treatment of all practitioners. The mental depression often pres-
ent as an initial symptom has been in some cases simply overpowering.
Some of the patients are affected like individuals whose mental and mo-
tor centers have been poisoned to the limits of human endurance, while
still permitting the retention of consciousness. In other cases even
consciousness itself has been overwhelmed.
Not a few patients who suffered from attacks of influenza during
the early period of the present epidemic are still victims of profound
neurasthenia. I refer now to cases which are not distinctively of the
melancholic type. These neurasthenics are unable to endure a fair
amount of work ; their nervous forces are soon routed ; they are weak,
worrisome, and unrecuperative. The cardiac weakness which has been
left is undoubtedly in part the cause of this neurasthenia, and with ref-
erence to this Church says that " the persisting neurasthenic condi-
tion which so usually follows influenza is attributed by some to cardiac
weakness of nervous origin, and this contention is not without weight,
if it is observed that, even after appetite, sleep, body-weight, and physi-
cal functions have long been restored, the slightest exertion immediate-
ly produces disproportionate fatigue, accompanied almost invariably by
either a retarded or more frequently accelerated pulse, and rarely by
pran-ordial distress and even by angina pectoris."
Curtin and Watson, f whose experience in influenza has been enor-
* Wilson. American System of Practical Medicine, vol. i, p. 870.
f Curtin and Watson. Climatologist.
10+
MISCELLANY.
[N. Y. Med. Jouk.,
mous, say that, although general nervous prostration often extended
over long periods without any discoverable local cause, it was always
worth while to examine the urine with care. "Sometimes a nephritis,
sometimes a faulty digestion or hepatic inaction, seemed to underlie the
general condition in latent form. These cases, by enforced rest and
attention to local complications, gradually recovered. These cases, and
nervous cases generally, were very disappointing when sent to the sea-
shore during convalescence."
Among organic nervous diseases which have developed during the
influenza or have been left in its wake are in the order of their fre-
quency, so far as my personal observation has gone, neuritis, meningi-
tis, myelitis, and cerebiitis, or various combinations of these inflamma-
tory affections — as, for example, concurrent neuritis and myelitis, me-
ningo-myelilis, or meningo-encephalitis.
Probably no single affection of the nervous system has been so com-
mon during and after the grippe, and particularly as a sequel of the
disorder, as neuritis. Almost every variety of neuritis as regards loca-
tion and diffusion have been recorded, and have come under my per-
sonal notice. Multiple neuritis, while not common, has not been rare;
and I have seen a concurrence of this affection with poliomyelitis in the
same case. Isolated neuritis of almost every cranial nerve has been
recorded, with such resulting conditions as optic atrophy, loss of smell
and of taste, ophthalmoplegias, both internal and external ; oculo-
motor, facial, and bulbar, or pseudo-bulbar palsies of various types, in-
cluding true pneumogastric paralysis. Several cases of specially located
affections of the sympathetic ganglia or nerves have been recorded. Of
the forms of local neuritis most common might be mentioned the supra-
orbital, intercostal, sciatic, and plantar.
An interesting case of neuritis with a myxoedemoid condition of the
limbs presented herself at the Philadelphia Polyclinic recently. She
had a sharp attack of influenza five weeks ago, having been in good
health up to that time, except five years since, when she suffered for
several weeks with inflammatory rheumatism. On recovering from the
influenza, the attack not having been especially maiked with nervous
symptoms, she was extremely weak in the legs, and was scarcely able
to drag herself around. In a few days her feet and legs began to swell
and to be painful, and soon became of enormous size and exquisitely
tender. She has gradually improved, but still has a condition of firm
swelling, which does not pit on pressure, from her knees to her ankles,
and she also still has great tenderness on squeezing the feet or ankles,
or in handling the nerves or muscles of the limbs. She has no cardiac
affection.
The articular pain and other so-called rheumatic manifestations so
numerous during and after attacks of the grippe are, after all, best
explained on the theory of infectious neuritis or myositis.
These cases with articular and other pains, and with swelling, recall
the endemic or epidemic form of multiple neuritis known as beri-beri,
in which the chief phenomena are oedema and paralysis of the limbs,
with marked pain, hyperesthesia and paresthesia, followed later by
anesthesia, lost knee-jerk, and depressed electrical reactions. Myositis
certainly, and probably also periostitis, occur as complications or se-
quences of the influenza, and usually in association with neuritis of
some type.
Many of the reports speak of the frequent occurrence of various
neuralgias. Doubtless a distinction is seldom made by observers and
recorders between neuralgia and neuritis, which are or may be separate
affections. Practically these cases should be regarded as neuralgic, in
which pain is referred to certain nerve lines or radiations, but in which
pain on pressure, and the other phenomena of neuritis, such as anaes-
thesia, vaso-motor and trophic disorders, and even paralysis, are absent.
In" my own experience the cases which could properly be diagnosticated
as neuritis are by far the most common. The distinctively neuralgic
pains arc probably due to toxemieally depressed or exhausted sensory
nerve-roots or centers in the cord and bulb.
Of diseases of the spinal cord proper, occurring as complications or
consequences of influenza, the reported cases are not numerous, but
they are none the less important. A few cases of myelitis have been
put on record by native and foreign observers — one that I recall in
which all four extremities were paralyzed. As would be expected, in
accordance with the analogies with other infectious and toxic diseases,
anterior poliomyelitis is the most common type. I have had several
cases of temporary paralysis of one or more limbs, which, owing to the
absence of pain and of cerebral symptoms, were apparently spinal in
their origin, and probably light forms of inflammation. Concurrent mul-
tiple neuritis and poliomyelitis has already been referred to as having
been observed by me in one case, in which the neuritis, which was not
severe, soon disappeared, but a limited paralysis, evidently spinal in
character, was left behind.
Several observers have reported cases of bulbar paralysis, and one
striking example of this disease, attributed to the grippe, has come
under my own observation, although exactly how far the influenza was
responsible it is difficult to say. This patient, a clergyman, had a
severe attack of influenza in May, 1890, and during its progress
continued to work, and ate but little. In a very short time he
noticed he was losing power in his hands, which soon atrophied.
In January, 1891, he began to have difficulties of speech, and, brief-
ly [stated, the case went on until November, 1891, when he was
first seen by me ; his symptoms were those of well-marked bulbar
paralysis, with progressive muscular atrophy, chiefly involving the
upper extremities.
In accordance with analogy, we would expect the occasional occur-
rence both of nuclear polio-encephalitis, and even rarely StriimpelPs
cortical polio-encephalitis. One or two of the few cases of probable
polio-encephalitis of the latter type have occurred in patients suddenly
stricken with fever, loss of appetite, and other symptoms which mav
have been due to infection.
Priester* has reported the case of a man, fifty-four years old, who
was taken with influenza'in February, and in the beginuing of March
was seized with extremely violent headache which resisted all medica-
tion, and later the patient became deeply somnolent, remaining in this
condition for four weeks ; he could be aroused, but was apathetic and
soon slept again. Reflexes and temperature were normal ; pulse from
40 to 60. The patient had no paralytic symptoms, and slowly im-
proved. His affection, according to the reports of the case, closely
resembled Gerber's disease — paralyzing vertigo — although the latter is
a disease of the warm weather. Tumor could be excluded by the ab-
sence of all focal symptoms a year before the attack. The most
probable cause he believed was a pathological process, involving the
central gray matter of the third ventricle, which would bring the dis-
ease into close relation with polio-encephalitis of the nuclear type. Dr.
G. J. Kaumheimer, who translated this report for the Review of In-
sanity and Nervous Disease, December, 1891, observed an exactly
parallel case which originated in April, and lasted into July before re-
covery took place.
That meningitis, either cerebral, spinal, or cerebrospinal, occurs
during the decline of the influenza can not be doubted in the light of
the evidence which has been presented by various observers, and par-
ticularly during the epidemic of the last three years, it is, however, a
comparatively rare concomitant or complication. Some of the facts
adduced as proofs of the existence of meningitis, and some of the cases
reported as examples of the disease, are clearly instances of improper
interpretation. The intense cephalalgia and rhachialgia ; the atrocious
pains variously localized in the face, trunk, limb-nerves, muscles, or
joints; the vigilant delirium, with hallucinations and delusions, some-
times assuming great gravity; the intense vertigo, with or without
nausea and vomiting — these and other well-known nervous manifesta-
tions which are so prominent in many cases at the initiation of the dis-
ease are not necessarily evidences of meningitiSj or even of meningeal
hyperemia. Rather they are due to an overwhelming toxemia of the
nerve centers and of the brain. Severe and terrible in character at
first, they frequently pass away almost as rapidly as they came, which
would not be the case if they were the evidences of a true meningitis-
The enormous prostration which is left behind shows that the centers
of nervous energy have been subjected to a depressing agency of great
virulence, not that merely enveloping membranes composed mainly of
fibrous tissue and blood-vessels have been congested or inflamed. No
* Priester. Wien. med. Woch., No. 27, 1159. In American Review
of Insanity and Nervous Disease, December, 1891.
Feb. 6, 1892.]
MISCELLANY.
165
reason could be given why such congestion or inflammation should
leave such results.
The reports of cases terminating fatally because of meningitis, and
even the reports, personal or official, of the frequent occurrence of this
affection, must be received cautiously, and sometimes incredulously.
They are only to be relied on when confirmed by autopsies, or when
from observers who are accustomed to closely differentiate the mean-
ing of nervous symptoms, and particularly of pain.
It may also be worth while at this point to refer to the somewhat
frequent diagnosis of chronic meningitis as on« of the sequela? of the
disease. This diagnosis is usually made because of the presence of
more or less persistent pain in or on the head. Experience has led me
to believe that this pain is usually neuritic rather than meningeal.
Even deep-seated intracranial pain does not necessarily indicate men-
ingitis. It may be due to neuritis, just as certainly as a pain in the
hand or foot. The fifth nerve has an immense distribution within as
well as outside the cranium, largely to the dura mater but also to other
tissues and parts. It is a pathological possibility to have dural neuritis
without a pachymeningitis, and this is the true explanation of some
pains, both acute and chronic, which are present in other diseases as
well as in influenza.
The form of meningitis most likely to be present in influenza is in-
flammation of the pia-arachnoid or soft membranes, now often desig-
nated leptomeningitis. From observations, corroborated by autopsies,
I know that this affection may exist without pain, while pain of vary-
ing degree of severity, and usually intense, is practically invariable in
pachymeningitis. Leptomeningitis, however, is not usually without pain
and hyperesthesia as symptoms, but it may be absent, and its presence
or absence will depend upon the location, extent, grade, and complica-
tions of the meningitis.
While believing that these criticisms upon the sometimes hasty and
the too frequent diagnosis of meningitis in influenza, and indeed in
many other infectious and febrile diseases, are just, and can be sus-
, tained, it remains true that a genuine meningitis, sometimes of malig-
nant type, may appear during the progress or closely following influ-
enza. Some very competent observers have reported cases of this
character, and in a very few instances the diagnosis has been confirmed
by autopsies. The diagnosi.-, should be made to hinge upon the signs
and symptoms which would be satisfying as to the occurrence of men-
ingitis from any cause ; not alone on the presence of such phenomena
as headache, vertigo, and vomiting, but on such more convincing mani-
festations as optic neuritis, and localized spasms or palsies, either cor-
tical or of cranial nerves.
The fact that meningitis, and even the cerebro-spinal form, does
occasionally occur in influenza, is by no means proof that this disease
, and epidemic cerebro-spinal fever are identical. It simply emphasizes
the point with which I started — namely, that every infectious or poison-
ous agent introduced into the economy may produce the same or simi-
lar pathological results in the nervous system. Largely according to
the vulnerability, special or general, of certain tissues and organs, will
be the preponderance of this or that form of so-called disease — for in-
stance, of neuritis, myelitis, meningitis, cerebritis, or of combinations
of these affections. All infectious and toxic diseases give neuritis as
the most common acute or chronic inflammatory manifestation, al-
' though myelitis, cerebritis, and meningitis may occur. Even in cerebro-
spinal fever, as I was perhaps the first to point out, multiple neuritis is
a common complication; but the infection being virulent and over-
, whelming, we may not only have meningitis, but even meningo-encepha-
litis, or meningo-myelitis, with all their malignant phenomena and
permanently disastrous results.
Vertigo is another symptom like pain, often improperly referred to
' meningeal or cerebral inflammation. It is sometimes due to such dis-
ease, but, occurring in influenza, it may arise from other causes, as, for
\ instance, from extravasations into the labyrinth or other portions of
the auditory apparatus.
Miiller* reports the case of a man, fifty years old, who after influ-
* Miiller. Berlin, klin. Worh., No. 37, 1890. Cited in American
Journal of Insanity and Neroous Diseases, December, 1891.
enza presented great physical exhaustion. In a few weeks his mind
seemed affected and he became somnolent, so that he could be roused
only with difficulty and would then fall asleep again. In this respect
the case was much like the one reported by Priester. Pain upon press-
ure was present over the vertebra;, the neck was rigid, the pulse was
small and irregular, the skin reflexes were diminished, and the tendon
reflexes were absent. In two weeks he began to improve. The author
believed the case was one of spinal cerebro-spinal meningitis, similar to
that seen after infectious disease.
Without entering into a discussion of their pathology or their pe-
culiarities, I will briefly mention a few other forms of nervous disorder
occurring during or as apparent sequela; of the influenza, examples of
which have come under my personal observation. Convulsions have
been reported by various observers, and in a few instances the convul-
sive habit has been established, and the patients have remained up to
the time of report as cases of epilepsy. I have seen two such cases.
Hystero-epilepsy and other grave hysterical phenomena have been ini-
tiated, or have recurred in cases in which the symptoms had long been
dormant. Of local spasmodic affections I have seen no records, but
one case of persistent clonic tort icollis, with some pain and tenderness
in the spinal accessory distribution, has been in attendance at the Phila-
delphia clinic. Two cases of facial paralysis, occurring immediately
upon the heels of influenza, have come under observation.
Many affections not of, but occurring in, the nervous system have
been reported as complications or sequences of the influenza. These
include such affections as apoplexy, due either to hemorrhage, throm-
bosis, or embolism. One of my Polyclinic patients, a man thirty-seven
years old, was attacked with influenza in January, 1390. He was not
confined to bed, but suffered severely from headache, cough, and per-
sistent general weakness, and in February he was suddenly paralyzed
in the right half of his body, and completely aphasic. Well-marked
cardiac murmurs were present, and the grippe in this and similar cases
is probably causative by lighting up old endocardial trouble, or through
the blood dyscrasia and general prostration which it leaves.
Various observers have reported cases of monoplegia and hemiple-
gia, without indicating the pathological character.
Recently, in consultation, I saw a typical hemorrhagic apoplexy
occurring in a ease of influenza in a woman, about sixty years old, who
had previously been in fair health, and was not known to have had any
disease of the kidneys or heart, although her vessels were somewhat
atheromatous. Dr. S. S. Prentiss,* of Washington, has reported three
cases of cerebral apoplexy occurring during the progress of the influ-
enza: one was a man of fifty-seven years of age; another in a man of
eighty-seven; a third in a woman of sixty-seven. One of these was
probably hemorrhagic ; the other two, from the histories, were probably
from thrombosis. In cases of this character the infection of the dis-
ease acts to bring about an apoplexy both by the changes which it pro-
duces in the blood, by its effects upon cardiac action, and by the gen-
eral debility induced. Such apoplexies might occur from other depress-
ing causes ; they are to be regarded not as phenomena, but rather as
accidents of the epidemic.
Uremic convulsions in patients suffering from chronic Blight's
disease have been precipitated by the influenza, and it has seemed to
me to have been active in lighting up linking syphilitic diseases.
In one case of paretic dementia of somewhat irregular type, seen
in consultation, the initial symptoms of the disorder were observed
soon after recovery from a severe attack of grippe, the wife and friends
of the patient, in fact, attributing the mental disorder to this attack.
Tlic probabilities arc that syphilis was present, but latent, prior to the
epidemic.
Purulent meningitis and brain abscesses have been somewhat fre-
quently noted in connection with the numerous instances of purulent
otitis media.
The relations of influenza to insanity have not received much atten-
tion from writers. Mairet,f of Montpellier, has recently published a
* Prentiss. Medical News, August 29, 1891.
{ Mairet. Grippe et alienation tnentale. Montpellier ami Paris,
1891).
160
M IXC ELL ANY.
[N. Y. Med. Jocb.,
lecture on the subject delivered at hi* clinic for mental and nervous
diseases. Rush, who is referred to by Mairet, speaking of the epi-
demic which lasted from 1789 to 1791, and particularly of the year
1790, mentions that several persons were stricken with symptoms of
insanity, and that one attempted suicide ; he also speaks of several
having had hallucinations of sight. Bonnet, reporting on the epidemic
of 1837, cites one case which was stricken with a furious mania as the
result of the grippe ; and Petrequin, referring also to the same epi-
demic, records several patients tormented by melancholy ideas, and
states that four or five suicides were accomplished or attempted at the
hospitals in Paris.
The following conclusions compress into small compass so much
that is valuable with reference to the relation between influenza and
the psychoses that I can not do better than quote them. They are re-
ported as the conclusions arrived at by Dr. Leledy, and were presented
to the Medical Society of London by Dr. Savage : * 1. Influenza, like
other febrile affections, may establish a psychopathy. 2. Insanity may
develop at various periods of the attack. 3. Influenza may induce any
form of insanity. 4. No specific symptoms are manifested. 5. The
role of influenza in the causation of insanity is a variable one. 6. In-
fluenza may be a predisposing or exciting cause. 7. In all cases there
is some acquired or inherited predisposition 8. The insanity is the
result of altered brain nutrition, possibly toxic. 9. The onset of the
insanity is often sudden, and bears no relation to the severity of the
attack of influenza. 10. The curability depends on general rather than
on special conditions. 11. The insane are less disposed to influenza
than are the sane. 12. In rare instances influenza has cured psvchoses.
13. The insane may have mental remission during the influenza. 14.
There is no special indication in treatment. 15. Influenza may lead to
crimes and to medico-legal issues.
I can indorse from experience almost every one of these conclu-
sions. With reference to the statement that no specific symptoms are
manifested, it should be said that while this in a general sense is true,
the most frequent type is a form of melancholia.
The cases of active insanity have been observed at the onset of in-
fluenza and during its height, but more particularly during its period of
decline and convalescence. The published cases have been recorded
chiefly as instances of acute mania or melancholia. The commonest
type of grippe mental disorder, as I have just stated, is a form of mel-
ancholia or lypemania ; but as this not infrequently assumes the form
of melancholia agitata, it is often regarded as mania by practitioners
not accustomed to differentiate the varieties of insanity. These pa-
tients are intensely depressed and emotional; they are filled with appre-
hensions of disgrace and ruin ; they believe that they will never recover
their former health ; they are suspicious and delusional with reference
to those who surround them ; they are frequently unwilling to eat, or
to rest, or to take medicine ; and in some cases they have definite delu-
sions of terrible character, for the most part hypochondriacal or relig-
ious. They are frequently plagued with the thought of suicide, and
sometimes make successful or unsuccessful suicidal attempts. They
have been deprived by the ravages of the disease of mental and moral
stamina. In the majority of these cases, but not in all, some heredi-
tary or acquired predisposition is present. While, however, the grippe
usuallv gives us mental disorder of special type — a form of delusional
melancholia — under special conditions it may be the starting-point or
exciting cause of any variety of meutaV disorder, as mania, paranoia,
paretic dementia, hebephrenia, etc., but I can no moie than glance at
this phase of the subject.
The investigations of Church show that in each year in Cook County,
Illinois, the epidemic of influenza has been attended by an increase in
the number of proceedings for the commitment of the insane, which he
believes can not be explained by increase or movement of the popula-
tion of the county.
Of the influenza occurring in hospitals for the insane, I have had
no opportunity for observation except in connection with the insane
department of the Philadelphia Hospital. A great disproportion has
been observed between the number of cases occurring among the women
and the men. One hundred cases are recorded as having occurred among
four hundred and sixty female patients; and only three in a larger num.
ber of men. The disease did not prove particularly disastrous among
these patients, only three deaths having occurred from pulmonary com-
plications. The cases were, as a rule, not of severe type ; less severe J
than in an equal number of sane patients.
K. Helweg* has recorded the results and action of influenza in the
Asylum at Aarhus. Denmark, and Pritchard has translated and sum-
marized this paper for the Jievieva of IntanUy and Nervoux Dixeaxe
for December, 1891. The account is of such interest that I will give
it in detail: "The disease appeared in the asylum January 4th, a few
weeks after it had first been observed in the neighborhood. Out of
520 insane, 41 were so severely attacked that they were confined to
their beds. The disease seemed decidedly contagious. It spread with
difficulty on account of the wards being divided one from another.
Eight of the twenty-five wards were spared altogether. When a ward
would be invaded, the disease would rapidly run its course to proceed
to another. The transmission of the contagion could be distinctly
seen in the sick wards where those stricken down in the other wards
would bring the disease with them and transmit it to patients there.
Seven patients had pneumonia. A relatively large percentage (six) died,
of which four were from pneumonia. Among these was a man with
such a severe cerebral disease that he must be excluded (the post-
mortem results in the remaining five, which were women, were all
more or less similar). The most essential results were extreme byper-
iemia of the cranial bones and membranes, where the dura and the
brain mass itself twice presented fresh and strongly vascular pseudo-
membranes with small haemorrhages as well. The veins and arteries
of the thinner cerebral membranes were filled to bursting with blood;
the large basal arteries were so filled with coagula that they stood out
'ike cords, or those of an injected specimen. The brain substance it-
self was very hyperamie, and its consistence increased. The average
weight of these brains was about the ordinary of those of Aarhus.
The writer also gives the history of the man mentioned, and those of
the three other cases where influenza could not be diagnosticated
during life, including the post-mortem findings of a case of influenza
in a (sane) nurse who died of pneumonia. Here also was great hyper-
emia of the brain and its membranes, yet not so pronounced a* in the
insane cases. The writer has seen iufluenza accompanied by severe
psychic symptoms. In a few eases the condition resembled acute de-
lirium, which, however, is transient, and seems easily controlled by
antifebrine. On the contrary, in two hopeless cases of insanity the
disease had such a favorable and curative action that they may be re-
garded as cured. In both cases there was pneumonia."
The epidemic influenza has impaired the morak of the community.
Lack of spirit in work, and an apprehensiveness with reference to
health, business, and all matters of personal interest, aie abnormally
prevalent. The hysterical have become more hysteric ; the neuras-
tbenical more neurasthenic. Hypochondria has displaced hopefulness
in individuals commonly possessed of courage and fortitude. In brief,
certain neuropathic and psychopathic features have been impressed
upon the community. We can not afford even to dismiss entirely from
consideration the bearings of the epidemic upon the increase not only
of suicides, but of other grave crimes
Many interesting questions in connection with treatment might be
discussed; but as the subject of treatment has been assigned in this
discussion to Dr. Hare, I will only speak of one point.
The use in influenza of hypnotics, narcotic-, sedatives, and motor
depressants is a question of particular interest in connection with the
study of the nervous and mental phenomena of the disorder. The viewB
of practitioners and writers are here decidedly at variance. Serious
mental and nervous complications or actual insanities occurring during
influenza have been attributed to the too free t'se of such chemically
powerful remedies as \ henacetin, anlipytine, aniifebrinc, chloral, bro-
mides, sulphonal, and paraldehyde ; and our older narcotics — such as
opium, hyoscyamus, conium, and cannabis indica — have aho come in for
a share of blame. Persisting conditions of nervous prostration, and
* Savage. Lancet, No. 3558; and Medical News, January 16, 1892.
* Helweg. Hosp.-Tbhnle, R. 3, Bd. viii, S. 729.
Feb. 6, 1892.]
MisrELLAXY.
167
chronic respiratory and cardiac neuroses, have also been charged to drugs.
Undoubtedly such criticisms have some foundation, but it remains true
that each ot the remedies named has proved itself of some value in the
treatment of influenza, and particularly of its nervous types. The
enormous consumption of a drug like anlipyrine is a practical argu-
ment both for and against its use. What Giasset has said of this
remedy might with almost equal truth be said of almost any of the
rest. " This agent," he says, " vaunted by some as a panacea against
all manifestations of the disease, is considered by others a remedy ab-
surd and irrational in all cases. The truth would seem to reside be-
ween these two extreme opinions."
The Influenza Bacillu9. — The British Medical Journal for January
16th contains the following articles, translated from advance proof-
sheets of the iJcutxrhf met/irhiixcfif Woc/a nsrhrift :
I. Preliminary Communication on the Exciting Causes o f Influenza.
By Dr. R. Pkeikfer. Chief of the Scientific Section. — (From the Berlin
Institute for Infectious Diseases.) The following results are based on
the accurate examination of thirty-one cases of influenza, in six of
which a necropsy was made. A complete report will be published as
soon as possible.
1. In all the cases of influenza a bacillus of a definite species was
found in the characteristic purulent bronchial secretion. In uncompli-
cated cases of influenza these tiny bacilli were found in absolutely pure
cultures, and mostly in immense quantities. They were very frequently
situated in the protoplasm of the pus corpuscles. If the influenza had
attacked persons whose bronchial tubes were already otherwise dis-
eased— as, for example, phthisical patients with cavities — other micro-
organisms besides the influenza bacilli were found in the expectoration
in variable quantity. The bacilli may penetrate from the bronchial
tubes into the peribronchitic tissue, and even reach the surface of the
! pleura, where, in two cases examined post mortem, they were found in
pure cultures in the purulent exudation.
2. These bacilli were found exclusively in cases of influenza. Very
r numerous control examinations proved their absence in ordinary bron-
chial catarrh, pneumonia, and phthisis.
3. The presence of bacilli kept equal pace with the course of the
disease ; with the cessation of the purulent bronchial secretion the
bacilli began to disappear.
4. I had already seen and photographed similar bacilli in the same
enormous quantities two years ago, during the first epidemic of influ-
i enza, in preparations of the sputum of patients suffering from the dis-
t ease.
5. The influenza bacilli appear as very tiny rodlets, of about the
i thickness of the bacilli of mouse septicaemia, but only half the length
of these. One often sees three or four bacilli strung together in the
form of a cSain. They stain with some difficulty with the basic aniline
' dyes. Better preparations are obtained with dilute Ziel's solution and
' with hot Loeffler's methylene blue. In this way it can be seen almost
as a rule that the two ends of the bacilli take the stain more intensely,
eo that forms are produced which can only with great difficulty be
■ distinguished from diplococci or streptococci. In fact, I am inclined to
believe that some of the »arlier observers also saw the bacilli described
'by rne, but that, misled by their peculiar behavior with regard to stain-
I iDg agents, they described them as diplococci or streptococci. They
l can not be stained by Gram's method. In hanging drops they are im-
mobile.
6. These bacilli can be obtained in pure cultures. On l-5-per-cent.
sugar agar the colonies appear as extremely small droplets, clear as
' water, often only recognizable with a lens. Their continued culture on
this nutrient medium is attended with difficulties, and up to the present
il have not succeeded in carrying it beyond the second generation.
7. Numerous inoculation experiments were made on apes, rabbits,
; guinea-pigs, rats, pigeons, and mice. Only in apes and rabbits could
; positive results be obtained. The other species of animals showed
themselves refractory to influenza.
8. In view of these results I consider myself justified in pronouncing
the bacilli just described to be the exciting causes of influenza.
9. It is very probable that infection is produced by sputum charged
with the germs of the disease ; and the disinfection of the sputa of
patients suffering from influenza is therefore urgently required as a
prophylactic measure.
Addendum. — Dr. Kitasato has succeeded in cultivating the influenza
bacilli to the fifth generation on glycerin agar.
II. On the Influenza Bacillus and tin Modi of cultivating it. By
Dr. S. Kitasato — (From the Berlin Institute for Infectious Diseases.)
Gentlemen : It is, perhaps, remarkable that in the case of a disease
which in the last few years has attacked hundreds of thousands of per-
sons, the specific exciting causes have, in spite of extremely numerous
investigations, only lately been discovered. The cause, in my opinion,
lies in the extreme difficulty of cultivating the tiny bacillus here before
you ; and, without pure cultures, a bacteriologist can not, of course,
come before the public with a new specific micro-organism.
The difficulty of obtaining cultures of specific bacteria present in
the sputum depends chiefly on the great contamination of them with
micro-organisms from the mouth, etc. The latter, in consequence of
their more luxuriant and abundant growth, can, on our artificial nutri-
ent media, completely overgrow and hide the particular parasites sought
for. This occurs all the more easily the longer the specific parasitic
micro-organism in question takes to form colonies, as in fact happened
in the case of the tubercle bacillus.
With the view of avoiding the obstacles standing in the way of a
successful cultivation, Privy Councilor Koch has devised a method,
which has not yet been published, which enabled him man} years ago,
and myself again quite recently, to obtain pure cultures of tubercle ba-
cilli directly from the sputum, aud which has also been followed by me
in the pure cultures of tubercle bacilli here before you. The method
to which I have just referred will be published in full detail in an early
number of the Deutsche medicinisclie Wochewschrift.
With regard to the characteristics of the pure cultures of influenza
bacilli here before you, I may emphasize the following points : On a
sloping surface of set glycerin agar the individual colonies present them-
selves as extremely small points like droplets of water, recognizable
during the first twenty-four hours only with the aid of a lens, so that
macroscopically a test tube containing them can scarcely be distin-
guished from a sterile one. The individual colonies are, as has been
said, so unusually small that they may easily be overlooked, and it may
thus have happened that previous investigators have overlooked them.
If a culture obtained from such a colony is placed on a new nutri-
ent agar medium, numerous small colonies arise on the moist agar sur-
face, as may be seen in this tube. A particularly remarkable point
about them is that the colonies always remain separate fiomeach other,
and do not, as all other species of bacteria known to me do, join to-
gether and form a continuous row. This feature is so characteristic
that the influenza bacilli can be thereby with certainty distinguished
from other bacteria.
The possibility of continued cultivation is now demonstrated, and
the tubes here before you already form the tenth generation in pure
cultures. On gelatin they do not grow, as they do not generally multi-
ply at a lower temperature than 28° C, which is the temperature at
which gelatin solidifies. In bouillon they grow scantily. In the first
twenty-four hours single white particles are seen swimming in the bouil-
lon, the intervening fluid being perfectly clear. Later, they sink to the
bottom, and there form a white woolly mass filling the end of the test
tube, whilst the supernatant bouillon remains entirely clear — a proof
that we have to deal wiih an immobile bacillus. In conclusion, I may
remark that I have accurately studied with the microscope and by cult-
ure for a long time back the sputa of tuberculosis in respect to all the
micro-organisms occurring therein besides the tubercle bacillus, and also
the sputa of pneumonia, bronchitis, etc. ; but the present bacillus, so
extraordinarily characteristic in its cultures, and so easy to be recog-
nized, has not come within my experience except in influenza patients.
///. On a Micro-organism in the Blood of Influenza Put ii nix. By Dr.
P. Cason, Assistant Physician, Berliu. — [From the Municipal Moabit
Hospital (Section of Internal Medicine — Director, Dr. P. Guttmann).]
During the last few weeks I have, under the direction of Dr. Guttmann,
examined the blood of twenty influenza patients in stained prepara-
tions, and in almost all cases I have found in the blood one and the
same micro-organism. The examination of the blood was made in the
following way: A drop of blood, obtained by pricking the finger, was
>
168
MISCELLANY.
|N. Y. Meu. J ocb
received on a perfectly clean cover-glass ; this cover-glass was placed
upon another one, and the two then drawn apart. The preparations,
after they had been thoroughly dried, were placed in absolute alcohol,
in which they were left for at least five minutes. They were then
taken out and placed in the following staining solution (Czenzynke's
solution): R Concentrated watery solution of methylene blue, 40
grammes ; ^-per-cent. eosin solution (dissolved in 70 per cent, alcohol),
20 grammes ; distilled water, 40 grammes. The cover-glasses, im-
mersed in this staining solution, were placed in an incubator at
a temperature of 37° C, and left there from three to six hours,
when they were washed with water, dried, and imbedded in Canada
balsam. In the preparations of blood made in this manner where
the red blood-corpuscles were red and the white ones blue, I found
the above-mentioned micro-organism. It is found stained blue,
sometimes in large quantities, but mostly sparingly, and only to be
identified after a long search (about four to twenty in the prepa-
ration). Sometimes it appears as a small diplococcus, sometimes,
especially when it is more deeply stained, as a short bacillus. In six
cases I have found it also in numerous larger and smaller heaps of from
five to fifty individual microbes with a very characteristic appearance.
In these six cases the blood was drawn during a fall of temperature or
shortly afterward ; in three of these no further rise of temperature
occurred. From three to six days later I failed again to find the micro-
organism in the blood in these three last cases. Sometimes I have
been able to make the diagnosis of influenza when clinically it was not
certain, by means of preparations of the blood alone. I have also found
the bacteria in the blood, and indeed in considerable quantities, in cases
where there was no appreciable local lesion, and especially no cough or
expectoration. While making the preparations I have generally at the
same time made streak inoculations of the blood on agar, glycerin agar,
sugar agar, and bouillon. In six cases the bouillon was injected into
mice, partly at once, partly on the following day after it had been in
the incubator. These inoculations and experiments on animals always
yielded a negative result. As on the basis of my researches I am of
opinion that this micro-organism occurs in the blood of all persons suf-
fering from influenza (at least in that of those who have fever), and as
it is not found in the blood of other persons, and as it is a micro,
organism hitherto unknown, I believe that it stands in direct relation to
influenza.
Privy Councilor Koch had the goodness to examine some of my
preparations — for which I tender him my best thanks — and pointed
out that the micro-organism visible in them was identical with the bac-
terium found by Staff -burgeon Dr. Pfeiffer, which has been described
in the preceding paper, which is published at the same time as mine.
I began these researches about the middle of December ; I have, how-
ever, still a large number of preparations to stain and to examine. I
propose to publish the results of the further research in a later commu-
nication. I have to thank Dr. Guttmann and Professor Dr. Sonnenburg,
director of the surgical section of the hospital, for kindly placing pa.
tients at my disposal.
The New York Academy of Medicine. — The following is the pres_
ent list of officers: Dr. Alfred L. Loomis, president; Dr. R. C. M.
Pa^e, Dr. E. L. Keyes, and Dr. Charles McBurney, vice-presidents ;
Dr. Richard Kalish, recording secretary; Dr. 0. B. Douglas, treasurer;
Dr. M. A. Starr, corresponding secretary; Dr. Everett Derrick (chair-
man), Dr. Gouverneur M. Smith, Dr. Abraham Jacobi, Dr. Laurence
Johnson, Dr. F. A. Castle, and Dr. W. F. Cushman (treasurer), trus-
tees ; Dr. T. R. French, chairman of the committee on admissions ;
and Dr. T. M. Cheesman, chairman of the committee on the library.
The special order for the meeting of Thursday evening, February
4th, was a paper by Dr. J. West Roosevelt, entitled Practicable and
Impracticable Plans for diminishing the Spread of Phthisis Pulmo.
nalis.
Section in General Surgery. — Dr. J. D. Bryant is the chairman, and
Dr. W. W. Van Arsdale the secretary. At the next meeting, on
Monday evening, the 8th inst., Dr. T. U. Manley will read a paper on
Primary Amputation, Consecutive Amputation, and Resection in Trau-
matisms of the Extremities, and will show patients illustrating the
subject; Dr. R. H. M. Dawbarn will read a paper entitled Experience
with Senn's Hydrogen Gas Test for Wounds of the Gut, and show
a patient illustrating a cutting operation for the rebel of an old disUv
cation of the inferior maxilla; and Dr. C. A. Powers will show speci-
mens of an elbow joint two years after resection, of a conical sturnp
(physiological) from a child of three years, and of melano-sarcoma of
the lower jaw from a child of four months.
Section in Pediatrics. — Dr. W. P. Northrup is the chairman, and
Dr. F. M. Crandall the secretary. At the next meeting, on Thursday
evening, the 11th inst., papers pertaining to the management of diph-
theria will be read by Dr. J. E. Winters, Dr. II. D. Chapin, Dr. L. E
Holt, and Dr. Abraham Jacobi.
Section in Gcnito-urinary Surgery. — Dr. E. L. Keyes is the chair-
man, and Dr. Samuel Alexander the secretary. At the next meeting,
on Thursday evening, the 11th inst., papers (titles to be announced)
will be read by the chairman and by Dr. Otis.
Section in Ophthalmology ana! Otology. — Dr. T. R. Pooley is the
chairman, and Dr. J. E. Weeks the secretary. At the next meeting, on
Monday evening, the 15th inst., Dr. J. H. Claiborne will read a paper
on The Axis of Astigmatic Glasses, and Dr. R. 0. Myles will read one
on The Normal and Pathological Anatomy of the Ear.
To Contributors and Correspondents. — The attention of all who jmrjiotie
favoring us with communications is respectfully culled to the follow-
ing :
Authors of articles intended for publication under the head of "original
contributions " arc respect fully informed that, in accejtling such arti-
cles, we always do so with the understanding that the following coiuJi-
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of the fact at the time the article is sent to ns ; (2) accepted articles
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conditions which an author wishes complied with must be distinctly
stated in a communication accompanying the manuscript, and ra,
n-cw conditions can be considered after the manuscript has been put
into the type-setters' hands. We are often constrained to decline
articles which, although they may be creditable to tlicir authors, are
not suitable for publication in this journal, cither because they are
too long, or are loaded with tabular matter or prolix histories of
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dressed lo the publishers.
*
THE NEW YORK MEDICAL JOURNAL, February 13, 1892.
(Original Communications.
CLINICAL OBSERVATIONS ON THE
TREATMENT OF TRACHOMA BY EXPRESSION.
Br THOMAS R. POOLEY, M. D.,
NEW YORK,
PROFESSOR OF OPHTHALMOLOGY IX THE NEW YORK POLYCLINIC ;
SUROEON-IN-CHIEF TO THE NEW AMSTERDAM EYE AND EAR HOSPITAL.
Among the most unsatisfactory cases to treat in the
whole domain of ophthalmic therapeutics, trachoma may
justly be placed in the very front rank, and any plan of
treatment which will shorten the chronic duration of this
disease must be considered a boon. That this has been ac-
complished by the recent revision of an old plan of treat-
ment, the experience of ophthalmologists both in New York
and elsewhere, who have tried it in a large number of cases,
would seem to show, and the evidence that it cuts short
the progress of these cases to a wonderful degree is fast ac-
cumulating. This much may fairly be said without run-
ning the risk (as is too often done in our enthusiasm) of
being too sanguine about any new method of treatment.
The purpose in this communication will be to set forth as
concisely as possible the results obtained by the operation
in a few cases, with such observations as the experience thus
obtained would seem to suggest. These cases embrace all
those operated on by this method since November, 1890, a
period covered by one year, and in all cases only those were
selected which seemed especially applicable to this method
— i. e., acute cases which showed a disposition to become
chronic, and where the trachomatous bodies are more or less
numerous, with but little irritation and moderate inflamma-
tory reaction.
The method is not applicable to the third stage of tra-
choma, usually known as diffused, in which another one
known as grattage is now employed by some operators. The
cases from which the writer's experience has been gathered
embrace but a limited number; nevertheless, they have all of
them been followed to their ultimate conclusion, and afford,
therefore, a good criterion of the results to be obtained by
this method of treatment. Seven patients and ten eyes were
operated upon. In all except one the patient was placed
fully under the influence of ether; in one cocaine alone was
made use of, while in several others cocaine as well as ether
was employed. When ether alone is used the haemorrhage
is more profuse than when cocaine is also employed.
Most operators employed specially constructed forceps.
At a recent discussion in one of the medical societies nearly
all present had one of their own invention to show. That
these are sometimes advantageous can not be denied, but
the author greatly prefers for the expression of the contents
of the granules to use the ringers and the thumb-nails, which
should be thoroughly cleansed and scrubbed with a nail-
brush. The lids are everted and then the granules squeezed
out. by the thumb-nail aided by the index finger in the cul-
de-sac, or else both index fingers may be used, the left be-
neath, and the right — which does the most work — above the
lids. The application of this method is especially difficult
in the angles, where the use of forceps may be needed, in
which case either the forceps invented by Dr. Noyes or an
on li nary cilia forceps was made use of.
The success of the operation depends upon the thorough-
ness with which every granule is expressed, or emptied of
its contents, and is therefore an exceedingly tedious proced-
ure. The eyes must be frequently cleansed during the op-
eration by a solution of boric acid or bichloride of mercury.
In six cases, after the lids had been thoroughly cleansed
and dried, their surfaces were rubbed over very thoroughly
with a crayon of sulphate of copper, as recommended by
Dr. Gruening. In four cases this was omitted. At first the
patients were always kept in the hospital for two or three
days after the operation, but as more knowledge was ac-
quired by experience as to the nature of the reactive pro-
cesses, they were in some cases, where there were objec-
tions to this, allowed to return home. Cold compresses
often changed were applied over the lids for about twenty-
four hours — in some instances longer — to combat the reac-
tion, which was usually severe, and in one case even threat-
ened the destruction of the eye. It was usually, however,
confined to swelling and oedema of the lids, which, under the
use of cold compresses, rapidly subsided, and was always
the most severe when copper was used. In a few days after
the operation, if all the granulations had been expressed, no
appearances of trachoma remained, but a good deal of con-
junctival swelling and secretion, which continued for some
time, gradually subsided, leaving the lids in a comparatively
healthy condition. All of the cases were practically cured
in from three to five weeks, except one in which there was
dense corneal pannus and a good deal of reaction from the
treatment as well ; this case will be reported in full as Case
III, and is the only one of the series in which the cornea
was affected or the sight impaired ; in all the others the dis-
ease was confined to the lids alone. In all but one instance
only one eye was operated upon at a time. The experience
of the operator in the one case where this was deviated from
will probably deter him from repeating it again. Without
going into a tedious detail of all the cases, it may be of in-
terest to give briefly the notes of several, and a more ex-
tended account of the case in which the character of the
reaction was alarming.
Case I. — Anna Y., aged nine years, left eye operated on in
the New York Polyclinic, November 20, 1890, under ether. Both
lids, especially the lower, were studded over with large, fresh
spawn-like granulations, and were squeezed out by Noyes's
forceps and the finger-nails, care being used to attack all the
granulations. The upper lids operated in the same manner, but
they were not so abundant. After the evacuation of all the gran-
ules the surfaces of the lid were thoroughly rubbed over with sul-
phate of copper in crystal. Patient was sent to the New Am-
sterdam Eye and Ear Hospital ; cold applications made. There
was but little reaction swelling of the lids and oedema. Right
eye operated on in the same manner November 21st, but the
expression was entirely accomplished by the use of the thumb-
nails and fingers. There was a more brisk reaction than from
the first operation, but under the same treatment it soon sub-
sided, and November 23d the patient left the hospital. She
was under treatment for about two weeks more in the dispen-
sary, and then dismissed entirely cured.
170
MEYER: THE PROGRESS OF CYSTOSCOPY.
[N. Y. Med. Jock.,
Case III is the one in which there was such excessive reac-
tion.
Mary M., aged fifteen years, entered the New Amsterdam
Eye and Ear Hospital March 18, 1891, with trachomatous pan-
ous, and the upper lids, which were especially affected, studded
over with large, fresh granulations. The granulations were less
abundant in the lower lids. There was dense pannus of both
cornese, and vision was reduced to counting fingers. She had
been practically blind for two years, and had already had the
lids operated, probably by expression. With the patient thor-
oughly etherized, the granulations were expressed, in the manner
already described, from both eyes, and then their surfaces rubbed
over with the copper stick. The following morning, notwith-
standing the use of cold compresses, both lids were terribly
swollen, tense, and brawny, as seen in diphtheritic ophthalmia,
so that it was almost impossible to evert them, on accomplish-
ing which their inner snrfaces were covered by a croupous-look-
ing membrane, which could be detached with difficulty. Both
cornea? were infiltrated, and in the left there was a deep ulcer.
Cold applications were continuously applied both during the day
and night until the next morning, reducing very greatly the
excessive swelling of the lids, and atropine used as well.
November 20th. — There is now an ulcer of the right cornea
as well, while that of the left seems about to perforate. A
solution of eserine, one tenth of a grain to the ounce, wa< in-
stilled every two or three hours, and atropine three times a
day, while warm applicatipns, fifteen minutes at a time three
times a day, were substituted for the cold ones. She now be-
gan to improve rapidly, the corneal ulcers, which fortunately
were not central, healed, the corneae cleared, and she could see
much better than before the operation.
March 28th. — She was discharged. Right eye, Y. =
L. V. = She came from this time on until April 7th to
the clinic, and there was continued improvement without any
further treatment Vision rose to -gfo in the right and f£ in
the left eye. The lids were almost entirely free from any ap-
pearances of trachoma.
Case IV. — Mary S. entered the hospital May 1, 1891, with
recent trachoma of both eyes. The granulations were abund-
ant, fresh, and covered the entire lower cul-de-sac of both eyes,
the upper lids being comparatively free. The left eye was oper-
ated on in the same manner as already described, the operation
followed by very considerable swelling and cedema of the lids,
rapidly subsiding under the continuous use of cold applications.
On May 3d the right eye was operated upon, and in like manner
followed by a good deal of swelling of the lids, which, however,
soon subsided. The patient was discharged May 10th, made
thereafter occasional visits to the clinic, and was dismissed
from treatment with the trachoma quite well in about three
weeks.
To sum up the advantages of this method of treating
trachoma, it seems not too much to say that by it we
can cure in a few weeks cases which, under the old plan by
the use of nitrate of silver and sulphate of copper, would
last for months and years, and this, too, by an operation
which is comparatively free from danger. The success of
the operation will, no doubt, be in direct relation to the
thoroughness with which it is done. Although many of
the granulations may be absorbed by the reaction conse-
quent upon the operation, still, should some of these remain,
there will still be trachoma to some extent which may
spread again over the whole conjunctiva. And it may even
be necessary to resort to a second operation.
The operation in which the sulphate of copper is used
gives the best results, although a cure may be effected with-
out it if care is taken to be thorough in the expression of
the contents of all the granulations. It is desirable to
operate upon only one eye at once, because of the possible
dangerous reaction when both are done at once ; besides,
the operation, if carefully done, would be too tedious and
long an operation. The treatment by this method is far
less dangerous than inoculation of pus, sometimes practiced
in severe cases of trachoma, and is also less dangerous and
more efficacious than the treatment by jequirity. We may
therefore hope that at last we have a means of effectually
combating this hitherto intractable disease — and that our
hospitals and dispensaries will soon cease to be crowded by
the daily attendance of chronic trachoma patients — by a
procedure which not only arrests but cures the disease in
its first stages.
That the old cases — those which have been modified by
a long course of treatment with caustics and diffused tra-
choma— will as readily be cured by the operation of grattage
does not seem to the writer as probable ; but should this be
so, we shall then have at our command two procedures
which will render us masters of the situation.
THE PROGRESS OF CYSTOSCOPY
IN THE LAST THREE YEARS.
By WILLY MEYER, M. D.,
ATTENDING SURGEON TO
THE GERMAN AND NEW YORK SKIN AND CANCER HOSPITALS.
(Concluded from page 1^6.)
III. Cystoscopy with Reference to Diseases of thk
Kidney.
Nitze, Fenwick, Goldschmidt, Poirier, Tuffier, Janet,
and many others have published interesting cases where
negative vesical evidence gave a positive diagnosis of renal
disease and where cystoscopy not only proved the formerly
obscure trouble to be of renal origin, but gave the means for
exactly locating the lesion and distinguishing which kidney
is diseased or whether both are affected.
Under ordinary circumstances it is not difficult to de-
termine whether the urine propelled from the ureteral cones
is clear, murky (purulent), or bloody. We simply have to
place our prism just opposite and comparatively close to the
mouth of the ureter, and then carefully watch. Some ex-
perience and patience, a quiet hand, and close attention are
all that is needed. But, as mentioned above, this task at
once grows more difficult if the injected clear water rapidly
becomes turbid. The inspection can then only be effected
by means of the irrigating cystoscope.
Case I. Pyuria; Cystoscopy; Nephrotomy ; Nephrectomy ;
Recovery. — Mrs. X., aged forty-five years, had noticed since
several years that her urine was now and then cloudy; had also
occasionally experienced some pain in her left side. The latter
was attributed to a fall the patient had received while out sleigh-
riding in the country twenty years ago. Otherwise she had
always been in apparently good health. At the middle of June
this year she was suddenly taken very sick with high, continu-
ous fever, enlarged spleen, and general symptoms, which were
suspicious of typhoid. But a tumor was palpated in the left
Feb. 13, 1892.]
MEYER: THE PROGRESS OF CYSTOSCOPY.
171
lumbar region, and the urine contained pus. The gentleman
who bad been consulted proposed cystoscopy, and I was called
in to perforin it. After a short irrigation the water returned
clear. Quickly the elements of the battery were screwed down
into the acid, the full strength of the current allowable for get-
ting a bright light determined, and the circuit broken. The
catheter, corked, had been left in the bladder meanwhile. In
extracting it then a few drops of water escaped, perfectly tur-
bid. Of course only renal trouble could have done that. Again
the fluid in the bladder was changed and the irrigating cysto-
scope introduced. One glance in bright illumination, showing
a healthy bladder ; and a dense fog suddenly came up and threw
a heavy veil over the whole landscape. Now the irrigating
cystoscope was put at work. The prism was turned to the left
and the murky fluid allowed to run off, while the hand-syringe
threw in short jets of clear water. The fog lifted, and I clearly
perceived the left ureteral opening, and out of it nearly at the
same moment a forcible eruption of a snowy-white, milky fluid.
Spurting forward into the medium, which was contained in the
bladder, in the shape of a fire-sheaf, the first rather thick mass
at once dispersed and was dissolved into myriads of minutest
snow-flakes, which slowly came down and at once put a stop to
all further examination. The manoeuvre was now repeated on
. the same side and the diagnosis of suppurating kidney clearly
established. The very frequently descending jets, which always
are pathognomonic of an irritative process in the pelvis of the
respective kidney, could be attributed to the coexisting pyelitis
or the presence of a stone in the pelvis. Of course the urine of
the right kidney was now analyzed in the same manner. It was
clear.* A few days later I performed nephrotomy and found a
pyonephrotic kidney with a large stone in the greatly enlarged
pelvis. Only the debilitated condition of the patient prevented
me from removing the diseased organ at once. Primary ne-
phrectomy seemed to me to be fully justified in view of the
cystoscopic result, and would have spared the patient a second
operation. The kidney was, however, left in and drained, with
the intention of extirpating it as soon as the lady's health would
permit it. Nephrectomy was done by me four months later, on
account of an annoyingly running renal fistula. To-day the pa-
tient is cured.
A number of patients with intermittent abundant hema-
turia have been under my care in whom the cystoscope
demonstrated a perfectly healthy bladder. In only one of
them have I been so lucky as to make the examination just
at the time of the bleeding-, and I then saw a red, rapidly
propelled whirl crossing the prism, and slowly mix with the
transparent water, slightly coloring the same. None of the
patients, who just happened to be examined at the bloodless
period, reappeared at the time of the next ha3inaturia as
ordered. Perhaps they were unable to come. The one in
whom I had diagnosticated unilateral renal hsematuria —
which, according to the symptoms, was evidently caused by
a new growth — declined the proposed operation. She died
after an abundant haemorrhage not long afterward. A few
cases of this kind are published by Xitze, Fenwick, and others.
'I * I want to state here that even with the able-help of the irrigat-
ing cystoscope it is extremely difficult, if not in many cases impossible,
to make out a urine which is only very slightly turbid or which is clear
and contains long shreds of tissue, as I have seen it in one case. Gen-
erally a certain amount of turbidity is required before it becomes visu-
ally apparent and perceptible. Bimanual palpation of the suspected
diseased organ cr pressing it will frequently help in making the evsto-
i scopie diagnosis of renal pyuria.
But the transparency, color, and frequency of the de-
scending jets of urine are not the only points which have to
be observed and noted in exploring the bladder with the
electric light. We are able to still further analyze and
specify the character of the whirls as they can be seen jet-
ting from the ureters.
The history of a few more cases of renal disease, which
lately occurred in my own practice, will well illustrate this.
Case II. — Cystoscopy ; Suprapubic Lithotomy ; Cystoscopy;
Nephrolithotomy ; Recovery (the continuation of a case previ-
ously mentioned in this paper).* On the 10th of March, 1891,
Mr. D., of whom I had lost sight since the summer of 1888,
again called upon me, a sick man. His stomach was entirely
out of order. Every few days he vomited great masses of
sticky mucus, and was only able to do so by first drinking a
tumbler of very strong salt water. Cathartics were freely
used. Entire loss of appetite. He had been for this trouble
under a physician's care, who was, however, unable to im-
prove his condition in spite of constant careful attendance. The
doctor diagnosticated " nephrolithiasis on the left side :' and sent
the patient to me for operation. The history further revealed
that not long after the suprapubic wound had definitely closed
an attack of epididymitis on the right side had twice set in. The
urine had never entirely cleared up. Last summer (1890) the
left testicle became suddenly inflamed. At the same time, the
former dull and constant pain in his left lumbar region, which
had now and then troubled him during the entire last year, be-
came more marked. For three days the uriue was mixed with
blood. A similar attack occurred in January, 1891. At present
he had a constant nail) and he was obliged to get up twice dur-
ing the night to pass water. In the daytime he urinated about
every four to five hours.
Cystoscopy (cocaine) : Mucous membrane of the bladder com-
paratively healthy. No scar as a result of the operation visible.
Prostate large, easily bleeding. Right ureter is pumping at regu-
lar, though rather short, intervals; ejects clear fluid. The whirl-
ings propelled from the left ureteral opening are by-far less fre-
quent and last nearly as long as three of the opposite side com-
bined. This phenomenon can be noticed with so much greater
precision as the urine of the corresponding kidney is slightly
turbid. No renal hsematuria at present.
Considering all these facts, I diagnosticated "a stone in the
pelvis of the left kidney large enough to partially block the upper
ureteral opening." Taking this conclusion as correct, it was
evident that the urine had to gather in greater quantity and had
to distend the pelvis of the kidney more than ordinary before
finding or rather making its outlet on one or more spots along-
side the necessarily irregular surface of the stoue. And this
again explained best the curious character of the jets as observed
at the left ureteral cone. Taking further into account that the
patient had noticed his very first pain in the left lumbar region
as early as 1880, and that I had to remove a stone from the blad-
der two years later, my diagnosis was well founded that nephro-
lithiasis had been the primary and constantly persistent trouble in
tin- ease. Nodoubt a small piece oi the renal calculus had been
broken o fi' as early as 1886 and carried down to the bladder, and
had there formed the nucleusof the stone which was removed by
me in 1888. Was the other kidney healthy ? I did not venture
to answer this question on the ground of the cystoscopic result.
Certainly the abnormal rapidity of the jets was suspicious and
* Read before the Section in Genito-ui inarv Surgery of the New
York Academy of Medicine, November l'J, 1S!>1, the patient being
present.
172
MEYER: THE PROGRESS OF CYSTOSCOPY.
[N. Y. Me u. J<> lib.,
pointed to an irritation in the pelvis of the right kidney. Jin t
the answer to this question was less important, as only nephroto-
my on the left side seemed to be indicated.
I told the patient my diagnosis, and also my hope of being
able to help him by operative interference. But, to confirm what
I had just seen, I asked for a second cystoscopic examination.
The patient at once agreed. When he returned for this purpose,
he reported that in walking home from my office the other day
he had felt a sharp pain in his right side. This had at first fright-
ened him very much. But, as the pain had not reappeared, he
felt easier now. The second cystoscopic examination fully cor-
roborated the result of the first one.
Nephrotomy was proposed and accepted. On May 5th, this
year, I made the lumbar incision. A large stone, entering the
ureter for some distance, was felt as soon as 1 was down on the
kidney. The pelvis was transfixed with two silk threads which
afterward served as holders, and then incised between them in
the length of fully an inch and a half. To extract the stotie in
one mass proved to he impossible. I broke it with my fingers
by pressing upon the upper portion of the ureter from outside.
Then I was able to pull the two pieces out with an ordinary dress-
ing forceps, the larger upper portion from
the pelvis of the kidney and the more
slender lower one from the ureter. The
whole stone presented a perfect cast of the
enlarged pelvis of the kidney and the up-
per part of the ureter. Its lower pole
was flattened, in a shape not unlike the
mouthpiece of a flute It is in all two
inches long (see Fig. 3). Now I pushed a
long thin rubber bougie down the ureter,
and then a small-sized soft-rubber cathe-
ter cut off at its end, through which I
flushed a syringelul of warm boric water
into the bladder. The ureteral canal evi-
dently was free. Still I carefully pal-
pated with a curved steel sound the in-
terior of the kidney from the pelvis up-
ward. No other concrement was found.
Meanwhile great care had been taken not to tear the cut
surfaces of the pelvis of the kidney by pulling too hard on
the silk threads which held it apart, as such a tear generally
produces urinary fistula. Now the wound of the pelvis was
closed with six catgut stitches, which did not include the mucous
membrane, and the wound loosely packed with iodoform gauze.
A small-sized short drainage-tube led do-\n to the sewn-up
wound in the pelvis of the kidney. The outer wound was closed
with silkworra-gut threads which were only loosely tied.
The patient made an uninterrupted recovery. He never was
feverish. Gauze and drainage-tube were removed after forty-
eight hours. Leakage never set in. The wounds healed by pri-
mary union throughout. The patient left the hospital with the
wound firmly closed on May 21sr, sixteen days after the operation.
When I saw him again lie reported that, four days after hav-
ing returned to his home in Brooklyn, he was suddenly seized
with a very intense renal colic on the right side — that is, the
side opposite to the diseased kidney — which lasted six hours
The pain was so severe that the attending physician had to ad-
minister chloroform for a full hour. When the pain began to
subside. In' passed about ten ounces of urine at two times inside
of an hour. Since that accident he was free from pain. Only
the stomach was still troublesome. He soon left for the coun-
try, where he spent the summer. Lately a throat specialist has
burned his nose and throat, which, according to the patient's
statement, has greatly improved the still slightly rebellious
stomach. A fortnight ago he passed, after some pain in his "left
lumbar region, two round, semi-solid masses, each of a bean's i
size. This was from the side operated on. To-day Ik- appears
hale and hearty, fully able to attend to his business. He is en-
tirely free from pain and trouble. His urine at present is clear,
lie, of course, has to remain under observation on account of
the probable nephrolithiasis on the right side.
Cask III. Suppurating Floating Kidney ; Nephrotomy ; sub-
sequent Cystoscopy ; Nephrectomy ; /iViwery.— Mrs. X., forty-
five years old, came under my care in July, 1887. Two months
previous she had been operated upon for an inflammation which
had set up in the left (floating) kidney. The lumbar incision
had revealed a cystic degeneration of the organ, the cysts being
filled with clear, transparent fluid or pus, or a mixture of both.
A number of cysts were opened, and communication established
between as many as could be reached with Paquelin's thermo-
cautery. The pelvis of the kidney was not opened. The wound
had healed well up to two small sinuses, which remained in the
scar and gave a continuous exit to a small or larger amount of
sero-pus. The patient was greatly benefited by the operation.
For more than two years she felt comfortable and enjoyed life;
only at the time of menstruation she suffered from more or less
intense bladder tenesmus. But after a while this symptom ceased
to be limited to the menstrual periods and became nearly constant.
It increased in such a degree of severity and frequency, in spite of
manifold and persevering trials to fight it, that life was a misery, j
and the question came up, Could the patient still be improved
by operative interference? Of course, this question had been
frequently considered at length before, but it was always re-
jected in view of the clinical tact that cystic degeneration of the
kidney very rarely is a unilateral disease. Usually both organs
are involved.* Cystic degeneration is therefore rather a con-
tra-indication to nephrectomy. And indeed in this case the
lower pole of the right kidney was palpable in the right hypo-
chondrium. But could this enlargement of the organ not be
just as well due to compensatory hypertrophy, in view of the
constantly diminishing size of the left one, which had always
been easily palpable in the slim patient? If we could know
that the right kidney bad already assumed the work of the other
or that the secretion of urine from the left diseased organ was
insignificant in comparison with that of its fellow, the patient
could only be benefited by the removal of this nearly uselesf
cystic mass, provided that she stood the operation. That th<
greatest amount of pain and trouble was dependent upon tb(
presence of the left kidney could be proved by vaginal palpa
tion of the ureters. The left ureter presented a cord as thiol
as a thumb, the slightest compression of which created at onc<
an urgent and painful desire to urinate; the right one was per
ceptible merely to the normal degree. Pressure upon it di<
not irritate the bladder.
Active treatment, however, became imperative when in No
vember, 1890, chills, followed by high though short-lastini
fever, repeatedly set in, apparently due to progressive ureteritis
To determine the exact condition of the right kidney it was, o
course, very templing to compress the left ureter, or even draft
it for some time from the vagina. Either of the procedures
however, would have required narcosis, which, if possible, ha1
to be avoided.
* Of. 0. Riegr.er. Exstirpntion ciner wandci mien C\ stennien
Deutsche mcd. Woekeruchr., 1888, No. 3.— Clark. Case of Cystic Kiel
ney in which Nephrectomy was performed, (ilnxyow Medical Jonrna\
1S89, p. 177.— Newman. A Case of Cystic Disease of the Kidney diaf
nosed during Life. Ibid., 1889, p. 265.— C. A. Ewald. Ein Fall vo J
totaler cystoser Degeneration beider Nieren bcim Envachsenen nebsj
Betnci kungeii zur Klinik dicser Erkrankung. Btrliit. klirt. Woeh., 189!
No. 1.
Feb. 13, 1892.]
MEYER: THE PROGRESS OF CYSTOSCOPY.
173
I mow resorted" to cystoscopy and saw the following condi-
tion: Catarrh of the bladder, minutest and larger blood-vessels
injected. The place where the orifice of the left ureter should
bo seen presented a succulent and curiously fjlded growth —
viz., the swollen and inflamed fold of mucous membrane be-
longing to and surrounding the ureteral opening, the whole
mass resembling a large lamp-shade. Still looking at the pict-
i ure with interest and trying to find the mouth of the ureter, I
suddenly noticed a jet of fluid, mixed with smaller and larger
yellow flakes and shreds, which carne from a somewhat re-
tracted spot, a little to the left from the top of the mass. This
exactly recalled the appearance of an eruption of a volcano, as
drawn by the pencil of the artist. A few minutes later a long
thread of thick, yellow pus was slowly making its wa\ out of
the same opening into the bladder. It took some time before I
found the other, rather rounded, ureteral opening, a portion of
normal though deeply injected mucous membrane, about three
quarters of an inch in length, being interposed between it and
the swelling just described. At tiiis moment I had to stop the
examination, which was made under local cocaine anaesthesia,
as the weak patient felt rather tired. A short time later the
bladder was again illuminated, this time with the intention to
determine, if possible, the character of the jets descending
from the right kidney. The ureteral orifice was quickly found
and carefully watched. This orifice was pushed forward and
retracted alternately, as we see it normally with each jet of
urine thrown into the bladder. The regularity and frequency
of this intermittent movement markedly contrasted with the
I slow and irregular working done on the other side. It struck
tne whether this symptom might not be used in finding out the
, exact amount of work done by each kidney. So I asked the
, assisting nurse to look at the watch and carefully count the
time between my saying " Now,'' which marked each jet. I
i noted a passage of every twelve, fifteen, twenty, twenty five
seconds on the right side, while on the other only every four,
six, eight minutes, the period of the emission of the jet besides
, covering a somewhat longer time on the right than on the left
side. Meanwhile the water had become muddy. It was easily
changed, as I performed the examination with the irrigating
cystoscope, and now I also perceived that the urine of the right
kidney was clear.
What conclusion could I draw from these facts? I believed
this : that the right kidney was doing from twelve to sixteen
, times as much work as the left one.* Was I therefore justified
j in pronouncing the ri^ht kidney healthy ? I did not venture to
make such a definite diagnosis, especially in view of the frequent
bilateral affection in cystic degeneration of the kidneys. The
urine might be at times transparent, while at others turbid.
Only often-repeated cystoscopy might possibly have cleared up
this part of the diagnosis.
But to diagnosticate health or disease of the right kidney
was not the main question. The question really was: "Would
the work of the right kidney be sufficient if the left had been
, removed? " That it would be so seemed to be amply proved by
I the cystoscopy examination, and if it did, the diseased organ,
which caused the repeated weakening attacks of ureteritis and
septic fever, was a burden to the organism and could ami
should be removed.
On these grounds a favorable prognosis was made in regard
to nephrectomy in its future results, provided the immediate
effects of the operation were well borne.
I therefore performed the operation, and the specimen thus
* I think this is the first time that this kind of observation has ever
been used for determining the work done by each kidney, and that its
correctness was afterward proved by the specimen obtained.
obtained showed that only the lower third of the organ con-
tained secreting tissue and that the upper two thirds consisted
of cysts, smaller and larger in size, more or less communicating.
In one of them there was a very small round stone. The w hole
organ was greatly diminished in size.
In the first twenty-four hours after the operation urine was
scarce on account of the loss of blood. From the second day
on the daily average quantity was thirty to forty ounces. The
former chills and fever ceased at once. The patient made an
uninterrupted recovery, and is so far greatly benefited by the
operation.
Case IV. Left Suppurating Kidney ; Cystoscopy ; Nephrec-
tomy ; Recovery. — Mrs. P. M., aged forty-eight years, was sent
to me from Collinsville, Coun. Her father had died of phthisis.
She had had eleven children, of whom seven were still living.
For fourteen years the urine had been muddy and of offensive
smell. Tenesmus changing in severity toward and after the
end of micturition. Two years ago pains in the left lumbar
and hypochondriac region appeared ; the urine became of a
milky color, and had lately contained small particles of coagu-
lated blood. It was voided ten to twelve times in the day-time
and at least four times during the night. The patient had con-
tinuously lost flesh and felt very weak. December 18, 1890,
examination: On deep pressure below the border of the left
false ribs, a hard, not very large, mass can be palpated, which
is rather immovable, painful to the touch, and of apparently
smooth surface. Vaginal exploration reveals a thickened left
ureter, which, if compressed, is quite painful and creates the
desire to urinate. On the left side of Douglas's cul-de-sac an
enlarged, painful, immovable swelling (probably the ovary);
urine of neutral reaction; smells very offensively ; two thirds
of volume sediment; shows pus and mucous cells, a few red
blood-corpuscles, micro-organisms of great variety, crystals of
oxalic acid and ammonium phosphates; detritus; one-per-cent.
albumin in the filtered specimen.
Could this evidently suppurating left kidney still be re-
moved? Did it still partake in the secretion of urine? Were
both kidneys diseased?
Cystoscopy under cocaine: Mucous membrane of the blad-
der hypersemie, and around the left ureteral orifice papilloma-
tous in appearance. Out of the latter a very long, worm-like,
under the electric illumination snow-white, shining thread of
thick pus of the size of a thin pencil is very languidly making
its way at short intervals. No jet whatever. The pus evi-
dently was very viscid, as the long strings settle and curl in the
bladder fundus — a very characteristic picture, which was also
plainly noticed by a number of gentlemen present. It took
some time before the medium became muddy. The right ure-
teral orifice was occupied by a round red growth of the size of
a cherry. On putting the prism quite close to it, it appeared
transparent. It consisted of mucous membrane (prolapse of the
ureter). Out of its left (median) side jets of seemingly clear
urine were thrown at short intervals.
Cystosoopic diagnosis: "Left suppurating kidney. Its secret-
ing tissue entirely gone. Right kidney already does double
duty for its destroyed fellow. Some irritation in the pelvis of
the right kidney."
On account of this cysto.-copic diagnosis I proposed nephrec-
tomy. The operation was done by me at the German Hospital,
December 29, 1890. It was found that the whole greatly en-
larged left kidney was sclerosed and did not present a bit of
normal secreting tissue. It contained many cavities communi-
cating with its pelvis. A large ramified stone entered a number
of Hiem. After the operation the amount of urine never varied
except in the first twenty-four hours. The patient made an un-
interrupted recovery up to the thirty-ninth day, when she was
174
MEYER: THE PROGRESS OF CYSTOSCOPY.
[N. Y. Mkd. Jopb.J
suddenly seized with intense right renal colic and abundant
hsematuria. After five days of serious, nearly hopelc<s. illnc-s
she passed a stone (an excellent demoimtratio ad oculon of the
pathognomonic correctness of prolapse of the ureter). From
that moment on she was again well and remained well. To-day
she is perfectly healthy ; her urine absolutely clear.
These cases present the most interesting ones in which
I have resorted to endoscopic examination of the bladder
for the purpose of diagnosticating disease of the kidneys.
The last two cases especially are, I believe, of so much
more value as not only did cystoscopy enable me to estab-
lish the indication for nephrectomy and to make the prog-
nosis that this operation would most probably not interfere
with the patient's general condition, apart from its possible
immediate consequence's, but the specimen proved in each
case the correctness of the different important points thus
made out.
The catheterisin of the ureters, with the help of still
improved cystoscopic instruments, will, I trust, soon be an
extremely important and never-to-be-omitted factor in cys-
toscopy for renal disease. Its results will greatly reflect
upon and vastly increase the value, correctness, and ex-
haustiveuess of such a cystoscopic diagnosis. The cathe-
terisin of the ureters in this way will easily, simply, and
happily solve the problem on which many an ingenious
mind worked in vain, or at least without general and recog-
nized success — namely, the bloodless, separate collection
and analyzation of the secretion of each kidney.
The only non-operative method which formerly could
be applied to localize and diagnosticate a kidney trouble in
the male,* where a large swelling or growth in one of the
hypochondriac regions did not at once show where to
search for it, was by compression of the ureter. The at-
tempts at solving this task have been very ingenious, but
have not been generally adopted in practice.f Axel Iver-
sen, \ therefore, proposed to open the bladder above the
pubes and then to catheterize each ureter separately. Fully
appreciating the great value of this mode of procedure, and
not looking at suprapubic cystotomy as being a dangerous
operation, I am perfectly convinced that cystoscopy will
ere long make it just as superfluous and unnecessary, in the
majority of cases at least, as it has already made Sir
Henry Thompson's digital exploration of the bladder in
most instances.
Of course, I do not want to be understood as if I
* In the female our non-operative diagnostic means in this respect
have been more ample, however difficult to practice, for a number of
years. Cf. G. Simon. Ueber die Methoden, die weibliche UMnblase
zugiingig zti machen u. iiber die Sondirung der Harnleiter beim Weibe.
Vplkmann's Klin. Vortreige, No. 88. — Lewers, Lancet, 1886, November
13th. — K. Pawlik. Ueber Harnleitersondirung beim Weibe u. ihre prak-
tische Venvendung. Wiener med. Presse, 1886, Nos. 44-51.
f TiK'hmann, Ueber em neues Mittel zur Diagnose der Blasen- u.
Nierenkrankbeiten, Wiener med. Wochensehr., 1874, Nos. 31 and 32. —
Ueber den kuDStlicben Yerschlussu. iiber die Sondirung des Harnleiters,
Deutsche Zeitschr. f. Chirurgie, Bd. vi, p. 560. — O. Silbermann, Ueber
eine neue Methode der tempoi'aren Harnleiterverschliessung u. ihre diag-
nostische Venverthung fur die Kranklieiten des uropoetischen Systems,
Berl. klin. Wochcmchr., 1883, No. 34.
i, Beitragzur Katheterisation der Ureteren bei dem Mamie. Central-
UatUf. Chirurgie, 1888, No. 16, p. 281.
thought that all exploratory operations would now become
obsolete. It is obvious that there will still he a number of
cases where obstacles will render the ocular inspection of
the bladder and of the descending jets of urine im-
practicable; where an insufficient capacity of the bladder,
purulent or bloody urine will make the electric illumination
of the bladder resultless ; where, I may add, the ureters
can not be catheterized, because their orifices can not be
found or approached. In such cases we, of course, have to
operate for diagnostic; purposes. But these cases will hence-
forth be exceptions and their number will still lessen with
the advance of this endoscopic branch, with the increased
dexterity and experience of the cystoscopist, and with the
additional construction of a really useful cystoscope for
catheterisin of the ureters.
In closing my remarks I offer the following conclusions:
1. In all obscure reno-bladder diseases cystoscopy has
to be practiced, if necessary repeatedly, before operative
interference for diagnostic purposes is resorted to.
•>. There are a number of causes which make cystoscopy
impracticable.
3. Cystoscopy is an easy and harmless examination ; but
its successful employment requires experience.
4. It should be performed as a dernier re.sxort after all
other well-known means for making a diagnosis have been
exhausted.
5. If properly applied, cystoscopy will generally clear up
an obscure disease of the bladder.
6. In most cases we can determine, with the help of elec-
tric illumination of the bladder, whether we have to deal
with a disease of the bladder or of the kidneys.
7. We can thus find out whether there are two working
kidneys, also whether only one of the two kidneys is dis-
eased or both.
8. We shall most probably soon be able, perhaps, in the
greatest majority of cases, after sufficient personal practical
experience and with the help of proper cystoscopic instru-
ments designed for this purpose, to catheterize the ureters
and thus gather in a bloodless manner the urine from each
kidney separately.
9. We can make out in certain cases by observing the
character of the jets of urine, especially by timing their fre-
quency and duration at the ureteral orifices, whether the
other kidney is doing the work for the one which is diseased.
10. These facts will tend to make superfluous, in the
majority of cases at least, a preliminary suprapubic or peri-
neal incision for diagnostic purposes, as well as a nephroto-
my performed for determining the action of the other (not
diseased) kidney. They greatly widen and strengthen our
means for making the indication and prognosis of nephrec-
tomy.
1 L With the aid of Nitze's newest instrument, the op-
erating cystoscope, we may look forward to being able to
carry on intravesical treatment under the direct guidance of>
our eyes.
The following is a partial list of the literature of the|
subject since 1887 : *
* Cf. E. Hurry Fenwick, e., and Cecil Kent Austin, /. e., Literature
Index.
Web. 13, 1892.)
MET Ell: THE PROGRESS OF CYSTOSCOPY.
Antal, G6za von. Spezielle chirurgische Pathologie und
Therapie der Harnrohre und Harnblase. Stuttgart, 1888. — Diag-
nostik iler Harnblasenaffektionen. Oystoskop. Bilder. Wien.
tried. Pr., xxviii, 49, p. 1688.
Bangs, L. I?. , ('uses illustrating Some Difficulties in the Use
of the Cystoscope. Report, New York Med. Journal, January
9, 1892, p. 51 ; Med. Record, January 2, 1892, p. 24.
Barling, G. The Electric Cystoscope and the Method of
using- it. With Notes of Cases. Birmingham Med. Review,
1889, pp. 25T-270.
Boisseau du Roe her. He la mcgaloseopie. Cowptes-reiidus
de V Academic den sciences, vol. ei, 1885, p. 829. — Megaloscopie
vesicale. Annates des maladies des organes genitaux-urinaires,
1890, p. 05.
Broca. A. De la cystoscopie on endoscopie vesicale. Gas.
In />■>., 15 mars, 1889. — De l'endoscopie vesicale ou cystoscopie
Annates des maladies des org. gen.-ur., 1889, p 166.
Brokavv, A. V. L. Cystoscopie Explorations. Interna-
tional Journal of Surgery, New York, 1889, ii, pp. 5-7.
Burckhardt, E. Endoskopische Befunde und endoskopische.
Therapie bei den Krankheiten der Harnrohre und der Blase.
Beitriige zur klinischen Chirurgie. Band v, pp. 1 and 261. —
Ueber Endoskopie. Korrespondenzblatt fur schweizer Aerzte,
xix, p. 755. — Atlas der Cystoskopie. Basel, 1891.
Clarke, W. B. Obscure Affections of the Bladder and Diag-
nosis by Means of the Cystoscope. Brit. Med. Journal, 1890,
No. 1,555, p. 893.
Cruise. On Irrigation of the Bladder in Cystoscopy. Lancet,
London, 1889. p. 372.
Davis. Epicystic Surgical Fistula for Cystoscopie Explora-
tion, Intra-vesical Treatment, and Drainage. Jour, of the Am.
Med. Assoc., 1889, p. 685-688.
Desnos, E. Traite elementaire des maladies des voies uri-
naires. Paris, 1890. p. 445.
Dittel, von. Ueber Fremdkorper in der Uarnblase. Wiener
klinische Wochenschrift, 1891, No. 12.
Fen wick, E. Hurry. Electric Illumination of the Male Blad-
der by Means of the New Incandescent Lamp-cystoscope.
Brit. Med. Journal, February 4, 1888. — The Value of Electric
Illumination of the Urinary Bladder (the Nitze Method) in the
Diagnosis of Obscure Vesical Disease. Brit. Med. Jour., April
14, 1888. — The Value of Inspecting the Orifices of the Ureters
by Electric Light in the Diagnosis of Symptomless Hematuria
and Pyuria. Brit. Med. Jour., June 16, 1888.— The Bloodless
Method of removing Vesical Growths controlled by Electric
Illumination. Brit. Med. Jour., September 22, 1888. — The
Prognostic Power of the Electric Cystoscope. Brit. Med. Jour.,
October 13, 1888.— Clay and Wax Modeling of the Living Uri-
nary Bladder under Electric Light. Brit. Med. Jour., 1889, i,
13. — Fifteen Months' Experience of Electric Illumination of
the Bladder in the Diagnosis of Obscure Vesical Disease. Brit.
Med. Jour., 1889, i, 989, 1053.— Precancerous Conditions of the
Mucous Membrane of the Bladder Recognizable by Electric
Light. Brit. Med. Jour., July 6, 1889, ii, p. 13.— Electric Illu-
mination of the Bladder and Urethra. Second edition. London,
1889: J. & A. Churchill.— The Influence of Electric Illumina-
tion of the Bladder upon our Knowledge and Treatment of
j Urinary Disease (abstract). Brit. Med. Jour., 1890, p. 894, No.
1,555.
Goldschmidt, II. Ueber den praktischen Wert der Nitze-
schon Cystoskopie. Therap. Monatshefte, iii, 10, p. 442, und
Allgem. med. Centralzeilung, 1889, p. 2303.
Gruenfeld, J. Eine veremfachte Methode zur Demonstration
endoskopischer Bilder. Allgem. Wiener med. Zeilung, 1888, p.
• 875.— Cystoscopy in General. Medical Press, 1889, p. 670. —
Ueber Cystoskopie im Allgemeinen und Blasentumoren im Be-
sonderen. Wiener klin. Woch., Band ii, 21, p. 423. — Endo-
skopische Untersuchung der Blase. Wiener vied. Blatter, 1889,
xii, 328.
Guyon, J. C. Felix. Lemons cliniques sur les affections chi-
rurgicales de la vessie et de la prostate. Paris, 1888. — ■ Verhand-
lungen des 3. franzosischen Chirurgenkongresses. Paris, 12-17.
Miirz 1888. — Endoscopie pour tumeur vesicale. Gaz. held.. 2(i
avril, 1889.- — Diagnostic des tumeurs de la vessie. Gaz. med.,
27 juillet, 1889. — Neoplasmes de la vessie, diagnostic et indica-
tions operatoires. Annates des maladies des org. gen.-ur., 1889r
p. 449. — Diagnostic precoce des tumeurs malignes du rein. An-
nates des mat des org. gen.-ur., 1890, p. 329. — Diagnostic des
tumeurs vesicales, hematurie et endoscopic, Bull, med., Apr.
22 ; Ann. des mat. des org. gen.-urin., 1891, p. 431.
Harrison, R. Remarks on Endoscopy with the Electric
Light. Lancet, May 26, 1888.
Helferich. Ueber die praktische Bedeutnng der modernen
Cystoskopie. Munch, med. Woch., 1890, p. 1.
Hermann, B. Eine Haarnadel in der Uarnblase. Interna-
tionales Centralblatt fur Physiologic und Pathologic der Harn-
und S&eualorgune. Band i, Heft 1. p. 18.
Hill, B. Irrigation of the Bladder in Cystoscopy. Lancet,
1889, vol. i, p. 169. — Some Affections of the Genitourinary Or-
• gans. Brit. Med. Jour., June 22 to July 6, 1889.
Kaufmann, C. Cystoskopischer Nachweis eines Katheter-
stiicks in der mannlichen Harnblase. Korrespondenzblatt fin-
schweizer Aerzte, 1889, p. 375.
Kutner, Rob. Ueber Photographie innerer Ivorperbohlen,
insbesondere der Harnblase und des Magens. Deutsche med.
Woch., No. 48, Nov. 26, 1891. p. 1311.
Leiter, J. Neue Beleuchtungsapparate. Wien, 18S9.
Linhart. Zur Endoskopie. Archiv fur Derm, und Syphilis,
Band xxi, p. 519.
Malherbe. De la cystoscopie. Progr. med., 1891, Nos.
1, 2.
Meyer, Willy. On Cystoscopy and the New Cystoscope of
Nitze and Leiter, with a Demonstration of the Same. New York
Med. Journal, April 21, 18b8. — A Contribution to the Surgery
of the Bladder. New York Med. Jour., Feb. 23, 1889.— Review
of Nitze's Text-book on Cystoscopy (with Remarks). Annals if
Surgery, June, 1890.
Newell, O. K. Diagnosis of Tumors of the Bladder and
Stone with the Cystoscope. Boston Med. and Surg. Journal,
1889, p. 381.— The Diagnosis of Vesical Tumor by the Cysto-
scope. Med. Record, vol. xxxiii, p. 596. —The Endoscopic In-
struments of Leiter, of Vienna, and the Present Development
of Endoscopy. Boston Med. and. Surg. Journal, cxvii, 528-530.
Newman. Lectures on Surgical Diseases of the Kidney.
1888, p. 415.
Nitze, M. Beitriige zur Endoskopie der mannlichen Harn-
blase. 1887. Langenbeck's Archiv, xxxvi, Heft 3, p. 661.—
Lehvbuch der Cystoskopie. Wiesbaden: J. F. Bergman, 1889. —
Das Irrigations Cystoskop. Centralblatt fur Chirurgie, 1n<s'->.
p. 945. — Das Operationscystoakop. Vorlaufige Mitteilung. Cen-
tralblatt fur Chirurgie, No. 51, December 19, 1891.— Sur le
chirurgie intra-vesicale. Ann. des mat. des org. genit.-urin..
Dec, 1891.
Otis, F. N. Papillomatous Tumor of the Bladder demon-
strated by Means of Leiter's LTeetro-Cystoscope. Med. Record,
May 18, 1888.
Otis, W. K. Recent Improvement in Endoscopic Apparatus.
Med. Record, xxxiv, p. 658.
Poirier. Catheterisinc des ureteres. Annates des mat. des
org. gen.-ur., 1889, p. 625.
Raymond, I'. L'Kndoseupie a Vieline. Anualcs dis mal.dis
org. gen.-ur., 1888, p. 776.
176
cor LEY: DISEASES OF THE URIXARY APPARATUS.
[N. Y. Med. Jour.,
Riviere. L'Endoscopie a Vienne et a Paris. Progres medi-
cal, 1888, 12 mai.
A Cystoscope. The Sei-I-Kwai Medical Journal, Tokyo,
vol. viii. No. 1, 1889.
Southam. On Endoscopy in Tumors of the Bladder. Lancet,
1889, p. 729.
Stein, Alexander W. Some Points in the Differential Diag-
nosis of Bladder and Kidney Affections. Journal of Cutaneous
and Genito-urinary Diseases, 1888, p. 370.
Stelzner. Mitteilung eines durch Operation geheilten Falles
von grossem Blasentumor und Demonstration des neuesten Bla-
senbeleuchtnngsapparats. Jul nshrrichte der Gesellschaft fur
Chirurgie und Ileilkunde in Dresden, 1889, p. 58.
Tnffier et Janet. Endoscopic vesicale appliquee a l'extrac-
tion des corps etrangers. Annates des mat. des org. gen.-ur.,
1889, p. 120.
Ultzmann und Schustler. Die Kranklieiten der Harnblase.
Deutsche Chirurgie. Billroth und Liicke, Wien, 1890.
Verhoogen, J. De l'endoscopie de l'urethre et de la cysto-
scopie. Journ. de med., chir. et pharmacol. Bruxelles, 1889, p.
161.
Vragassy, W. von. Das Megaloskop des Dr. Boisseau du
Rocher in Paris. Wiener med. Presse, 1888, Nos. 3, 4.
Wallace, D. Electric Cystoscopy. Edin. Med. Journal.
February, 1890.— Cystoscopy, etc. Edinb. Med. Jour., Oct.,
1891, p. 324.
Whitehead, W. A New Incandescent-lamp Cystoscope.
Brit. Med. Journal, April 7, 1888.
DISEASES OF THE URINARY APPARATUS.
By JOHN W. S. GOULEY, M.D.,
SURGEON TO BELLEVUE HOSPITAi.
{Concluded from page 153.)
PART I. — PHLEGMASIC AFFECTIONS.
Section II.— SPECIAL CONSIDERATIONS.
XII.
Chronic Urethritis ; its Nature, Causes, Physical
Characters, Diagnosis, and Treatment.
The nature and treatment of chronic urethritis for a
long time greatly perplexed physicians, because the several
pathic conditions which give rise to persistent urethral dis-
charges had not been sufficiently well studied, and because
the characters and sources of the discharges were not ascer-
tained. These discharges were found to be so refractory to
treatment that many empirical methods were used with lit-
tle or no effect. It would be a waste of space to enumerate
the many modes of treatment that have been employed dur-
ing the past century. In speaking of this obstinacy of
chronic urethral discharges, Ricord said to his disciples :
"After having tried everything, try to do nothing"; for
experience had taught him that meddlesome treatment only
served to aggravate the phlegmasia, which he had often ob-
served to subside soon after the cessation of all medication.
Although some light was thrown by Gubler upon the
differential diagnosis of some of the lesions that cause
chronic urethral discharges, little attention was paid to the
teachings of his excellent essay on the anatomy and phleg-
masia; of the bulbo-urethral glands, which show that when
a persistent urethral discharge of a clear and very viscid
mucoid substance occurs, its source is surely in one bulbo-
urethral gland or in both glands, but that when this viscid
discharge is purulent there is chronic phlegmasia of the
bulbo-urethral gland or glands. This clearly indicates that
all urethral discharges are not necessarily signs of chronic
urethritis. An acute urethritis may be cured and leave no
other trace than chronic phlegmasia of a bulbo-urethral
gland or of its duct. In some cases, instead of bulbo-ure-
thral adenitis, chronic cryptitis is consecutive to acute ure-
thritis ; in these cases the discharge is very little viscid, but
has the odor characteristic of the mucous secretion of the
urethral crypts. In other cases chronic prostatitis or gone-
cystitis may be consecutive to the acute urethritis.
Mercier, who made a careful examination of the ques-
tion of chronic urethritis, did much toward disseminating
correct views respecting the pathology and treatment of this
phlegmasia.
Next came the labors of Desormeaux, who demonstrated,
with the aid of the urethroscope, true granular urethritis to
be the most common cause of persistent purulent urethral
discharge. From that time chronic urethritis has been very
diligently studied, and other lesions have been discovered
which give rise to chronic purulent urethral discharge, and
at present the treatment is directed to the cure of the lesions
that have been so well specialized.
Nature of Chronic Urethritis. — Chronic urethritis,
attended with a slight muco-purulent discharge popularly
named gleet, morning drop, military drop, etc., may be a
termination of any of the acute types of urethritis, may be-
gin as a benign urethritis, the first stage of the acute types,
or may be developed far back in the urethra, be latent to
the sufferer, and be discovered by the physician only by
means of the urethroscope or of a microscopical examina-
tion of the urine. It should not be confounded with ure-
thral blennorrhcea, true gleet. The difference between these
two pathic conditions is worthy of note. Chronic urethritis
is a phlegmasia of the urethral mucous membrane yielding
a muco-purulent discharge, whilst blennorrhea is the result
of an excessive secretion of mucus by the urethral crypts or
by the bulbo-urethral glands without the intercurrence of
phlegmasic action, though it may sometimes be a sequel of
phlegmasia. Frequent sexual erethism without copulation
not infrequently causes a persistent blennorrhea arising
from excessive secretion of the urethral crypts and bulbo-
urethral glands, the urinary meatus being constantly moist
with mucus or with the very viscid secretion of the bulbo-s
urethral glands without admixture of pus. This is true
gleet, unconnected with phlegmasic action.
The phenomenon, chronic urethral discharge, unless right-
ly interpreted, is likely often to lead astray both patient and
physician. The inexperienced sometimes look upon chronic
urethral discharge as always an indication of urethral strict-
ure or of some sort of obstruction of the canal. A little re-
flection is sufficient to throw doubt upon such a view, if only
on account of its want of proper qualification, a suitable
qualification being to substitute often for always, and to say
that chronic urethral discharge is often a sign of stricture, or
is sometimes one of the early symptoms of stricture. Such a
Feb. 13, 1892.]
GOULEY: DISEASES OF THE URINARY APPARATUS.
177
view would be indisputable. It is well known that a chronic
urethral discharge may emanate from (1) phlegmasia of the
seminal vesicles, (2) of the prostatic follicles, (3) of the
bulbo-urethral glands, (4) or of the urethral crypts, as well
as from (5) a circumscribed or a diffuse chronic phlegmasia
of the urethral mucous membrane. It may be asked, How
are these several discharges to be distinguished ? The
answer is as follows :
1. The discharge from the seminal vesicles contains sym-
pexia and spermatozooids. Either distinguishes it from all
the other discharges, even though it be mixed with them.
2. The discharge from the prostatic crypts is turbid,
milky, and sometimes contains many prostatic sympexiaand
is very slightly viscous.
3. The discharge from the bulbo-urethral glands is
known by its extreme viscidity ; normally it is of crystal-
line clearness, but becomes opaque when containing pus.
4. The discharge from the urethral crypts is known by
its peculiar odor, which it imparts to semen and which is
called the seminal odor.
5. The discharge from a veritable chronic urethritis is
muco-purulent and characterized by the profusion of pus
cells it contains.
Chronic urethral discharge, no matter what may be its
origin, is generally a source of much unnecessary anxiety to
the patient, who thinks himself the most sorely afflicted of
all mortals, and is almost incessantly watching the drop
which he believes is forever to reappear. Of course it does
reappear as long as he continues to irritate the urethra by
" milking the penis " to find the drop when he thinks it is
too tardy in showing itself. The morbid mind of the pa-
tient sees in this drop a virulent poison with which he is
infected and which he is liable to transfer to any woman
with whom he has sexual relations, and he has a vague no-
tion that this poison may cause almost any disease. A
medical friend related a case illustrating the ludicrous de-
gree to which is sometimes carried the idea that a chronic
urethral discharge from the man is liable to cause grave dis-
ease in the wife. The patient in question had been repeat-
edly told that his urethral discharge, consisting of clear mu-
cus, was not contagious, but he always doubted the cor-
rectness of the doctor's view. However, he finally married
and his wife soon became pregnant, but on or about the
fourth month the abdomen was so much more distended
than it would be even at full term that an examination was
made which revealed a large multilocular ovarian cyst whose
extirpation necessitated an extended median incision. The
anxious husband, who had attributed this condition to infec-
tion by his urethral discharge, watched the operation with
much solicitude, not on account of its gravity but of the
fixed idea that he might be the cause of the disease. When
he saw the enormous tumor, he said that if it had been a
small lump he would have blamed himself, but that then
he could not believe it possible for such a little drop to
produce a growth of this size in the short space of four
months.
Nothing is too absurd for the conception of some of the
sufferers from chronic urethral discharges. They listen
credulously to the ignorant and mendacious dicta of crafty
and rapacious charlatans, while they are suspicious of hon-
est physicians, and obstinately discredit rational advice and
correct views. Many change their medical adviser as often
as they do their erratic notions of the ailment which, owing
to their own perversity, is destined never to be well. The
difficulties experienced in the management of such cases are
too well known to require extended commentary.
The ideas to be impressed upon the minds of patients
suffering from chronic urethral discharges are : 1, That
these affections are not contagious ; 2, that virulent urethri-
tis is generally cured within six weeks, but that in some
instances several relapses occur, the last of which is almost
certain to be followed by a slight but persistent muco-puru-
lent discharge, liable even after four, five, or six months to
increase so as to simulate an attack of acute urethritis, sub-
siding, however, in four or five days to the former few
drops ; 3, that not only is this chronic urethritis non-trans-
missible from the man to the woman, but, on the contrary,
is most frequently aggravated by coition, even with a
woman whose genitalia are sound and remain so after the
coitus ; 4, that the frequently reiterated assertion that a
man who has once had virulent urethritis in his bachelor
days, and marries years after the attack of urethritis, trans-
mits " the gonorrheal virus " to his wife, is without the
slightest foundation ; 5, that this irrational notion arose
from belief in a " gonorrheal virus similar to but not identi-
cal with the syphilitic virus " ; and 6, that the correct view
is that virulent urethritis is a local affection, and does not
become constitutional.
The chief causes of the persistency of urethritis
are :
1. Disregard of hygienic precautions during acute ure-
thritis, or after its apparent cure. Sexual erethism of any
kind, in thought or act, improper alimentation, the use, even
moderate, of alcoholic or fermented beverages, over exer-
cise, and excesses in general, all aggravate the acute type of
the phlegmasia or, after it has begun to decline, cause its
recrudescence, and finally the persistence of the stage of
decline which constitutes chronic urethritis.
2. Inappropriate treatment of the acute types of urethri-
tis— such as the so-called abortive treatment by injections
of nitrate of silver in strong solution, or of strong solutions
of any sort, by the abuse or*he untimely use of balsainics,
antiphlogistics, diluents, and baths — is among the prominent
factors in the causation of chronic urethritis.
3. Vulnerability of the subject — that is to say, an inor-
dinate susceptibility to phlegmasia, owing to the hyper-
lithuria so common among chronic dyspeptics, or to some
diathetic influence, besides a constitution naturally feeble
or impaired by disease or debauch — may be added to the
setical factors of chronic urethritis.
4. Continued local irritation of the urethra is another
potent factor in the maintenance of urethral phlegmasia.
This irritation may arise from frequent coition, from mas-
turbation, from the existence of a stricture, from congenital
stenosis of the urinary meatus, from vesical stones, chronic
cystitis, chronic prostatitis, gonecystitis, haemorrhoids, anal
fissure, eczema, etc.
178
OOULEY: DISEASES OF THE URINARY APPARATUS.
[N. Y. Med. Jodh.,
5. Excessive general and local treatment of the acute
types of urethritis both have the effect of prolonging the
phlegmasic action — the first by disturbing the digestive
function and enfeebling the patient and lessening his pow-
ers#of resistance, besides causing grave complications. The
large doses of balsamics long continued have a baneful ef-
fect upon the digestive apparatus, and often cause distress-
ing cutaneous eruptions, hyperlithuria, and even nephritis.
The too free use of alkaline diluents also tends to disturb
digestion and otherwise defeat the objects for which these
agents may be intended. The second, the untimely or the
excessive use of urethral injections, is a prolific cause of the
persistence of urethritis and of some of its complications
and consequences. The too common tendency to treat the
urethra as if it were not a part of the human body is owing
chiefly to the want of proper interpretation of its morbid
phenomena. It is over-distended, divulsed, or cut indis-
criminately, simply because there is a discharge, and with-
out ascertaining the nature of this flow. The idea that the
discharge is a sure indication of the existence of a stricture
is enough to induce the unthinking to over-distend, divulsc,
or cut the urethra. The patient, impressed with the notion
that his case is unparalleled and demands extraordinary
measures, consents to any proposed mode of treatment,
even to the spilling of blood. He is then contented until
he discovers that the urethral discharge is not cured by the
operation, and that the drop still obstinately obtrudes
itself.
Physical Characters.— The alterations of structure of
the mucous membrane in chronic urethritis need to be stud
ied during life by means of the bulbous bougie and the ure-
throscope, as well as by dissection after death, on account
of their variations in character, site, extent, and depth.
In some cases the only perceptible lesion is congestion
of the mucous membrane. This congestion is generally dif-
fused over a space of two or three inches, involving the
bulbous, membranous, and prostatic regions. It rarely in-
volves the whole length of the urethra. Sometimes the
membrane is congested in small patches from the balanic
region backward.
Most frequently, owing to excessive epithelial exfolia-
tion in the acute types and the consequent prolongation of
the stage of decline, another condition is observable, and
that is a granular state of the mucous membrane, designated
as caruncles and carnosities by writers of the sixteenth and
seventeenth centuries, and first demonstrated in the living
by Desormeaux in 1864. This granular state is in reality
an effort at repair. The denudation of the mucous mem-
brane is more complete in some regions of the urethra than
in others, notably in the bulbous portion of the canal, and
there is a constant emigration of leucocytes, some of which
become partly organized, forming the granulation tissue,
while most of them are cast away as pus. Unless modified
by treatment, the granular state continues indefinitely, and
beneath the granulations, in the meshes of the mucous
membrane, in the submucous connective tissue, and even in
the spongy substance, is an exudate which in lime becomes
incompletely organized, sclerosed, and shriveled, constituting
stricture. The exudate and granulation tissue may be dis-
tributed in multiple patches or may encircle the urethra.
Such is one of the modes of development of urethral strict-
ure from chronic urethritis, and this development is often
the work of five, ten, twenty, or thirty years. The supple-
ness of the urethra is impaired wherever there are granula-
tions with an underlying exudate. The bulbous bougie and
the urethroscope reveal both conditions.
Another way in which urethritis is perpetuated is when
a superacute urethritis has caused acute submucous ure-
thritis. In such a case the alteration of structure is much
more profound and rapid, sclerosis, shriveling, and strict-
ure occurring in a few months and exciting a constant
muco-purulent discharge which is liable to increase in
thickness and quantity after the slightest imprudence, even
to the simulation of acute urethritis.
A noteworthy circumstance is the frequent developmeal
of a very mild urethritis, with slight muco-purulent dis-
charge, from what is commonly the first stage of the acute
types. This form of urethritis has some of the characters
of chronic phlegmasia from the first, it is attended by phe-
nomena similar to those of chronic urethritis consequent
upon acute urethritis, and is as persistent. In these cases
there are the patches of granulation tissue, the submucous
exudate perhaps only in a very slight degree, and in point
of fact most of the lesions found in chronic urethritis that
arises from the acute types ; and stricture is one of the
sequehe of this form of chronic urethritis as much as it is
of the ordinary chronic type.
When unchecked, chronic urethritis causes alterations of
structure in the urethral mucous crypts and glands to the
extent of sometimes destroying them. It is liable also to
be propagated to the bulbo-urethral glands, to the prostate,
to the vesico-urethral region, and even to the testicles.
Long neglected, even the simplest form of chronic ure-
thritis almost inevitably leads to stricture of the canal or to
contracture of the vesical neck.
In the diagnosis of chronic urethritis it should be
remembered that all urethral discharges do not necessarily
indicate urethritis. Thus a clear glairy discharge emanates
from the urethral crypts without phlegmasic action, and
likewise an extremely viscid discharge comes from the
bulbo-urethral glands. A purulent discharge may come
from the vesico-urethral region, from the prostate, or from
the seminal vesicles. The true basis of the diagnosis of
chronic urethritis rests upon a complete history of the case,
gross and microscopical inspection of the discharge, and ex-
ploration of the urethra with the bulbous bougie or with
the urethroscope.
If a patient, applying for treatment on account of a per-
sistent urethral discharge, confess to one or two antecedent
attacks of acute urethritis, it is fair to assume his present
discharge to be the sequel of the acute urethritis, even if
this attack of acute urethritis date back a few months or
several years. But while this information helps, it is not
sufficient to indicate the particular form and site of the
existing chronic urethritis. The other aids to diagnosis,
consisting in the use of instruments of precision, are essen-
Feb. 13, 1892.]
GOULEY: DISEASES OF THE URINARY APPARATUS.
179
tial to accuracy-; The first of these aids to be used is the
bulbous bougie. A No. 12 (English) bulbous bougie is or-
dinarily of convenient size for the purpose. This instru-
ment is gently and slowly introduced into the urethra until
the patient experiences a sense of tenderness and perhaps
even of pain at a particular spot. The tender spot is gen-
erally a patch of granulation tissue covered with a layer of
pus. The bulb is then carried onward about half an inch
beyond the tender spot, where there may be neither tender-
ness nor pain, left in position for a minute, and slowly with-
drawn. If the base of the bulb is coated with a whitish
substance, this should at once be subjected to microscopical
examination. If it proves to be pus, the granular nature of
the tender spot may be considered as verified. In some
cases the granulation tissue bleeds freely on the slightest
provocation, and the bulb of the bougie is coated with
blood. During the introduction and withdrawal of the
bougie a delicate touch can discern a certain lack of sup-
pleness of the urethra, particularly where there are several
tender spots close together, or when a granular space with
an underlying exudate encircles the urethral mucous mem-
brane. This does well for urethritis anterior to the bulbo-
menibranous junction. If the examination is negative, all
the anterior part of the urethra may be washed, and a bulb-
ous bougie carried beyond the bulbo-membranous junction
into the prostatic region and withdrawn as before. A coat-
ing of pus upon the base of the bulb will indicate the site
of the granulations and source of the discharge, or, after
washing the anterior urethra, the patient is asked to urinate
into two separate glass vessels. If the first urine contains
pus and the second is free from pus, it may be inferred
that the pus has come from the membranous or prostatic
region. The urethroscope, however, brings to view the
granulations, their extent and their exact locality, or reveals
simply a congested state of the mucous membrane, diffused
or in patches.
When a stricture has already formed, there is almost
always behind this stricture a granular state of the mu-
cous membrane, which yields a more or less abundant
purulent discharge. This is perhaps what has led some ob-
servers to consider that a urethral discharge is the infallible
sign of stricture. In point of fact, the discharge had long
preceded the stricture and was one of the phenomena of
the pathic state that caused the stricture — i. e., granular
urethritis with an underlying exudate, the urine, partly
dammed, irritating the mucous membrane immediately be-
hind the stricture and thus perpetuating the discharge.
The cure of the stricture is followed by the disappearance
of the granulation tissue and of the consequent discharge.
To the at chronic urethritis rationally and success-
fully it is essential to distinguish the several chronic urethral
discharges, to ascertain the cause of the phlegmasia, its du-
ration, the kind of treatment to which it may already have
been subjected, and the physical condition, habits, and en-
vironment of each individual — in other words, to make a
correct diagnosis. The mere gleet of clear urethral mucus
requires no local treatment. It is particularly this gleet
that is so excessively treated and by so many different cruel
methods. The more it is treated the worse it becomes, and
finally the heroic treatment leads to an almost incurable
chronic purulent discharge. AYise hygienic management
and avoidance of certain factors in the causation of over-
secretion of mucus, such as sexual erethism, suffice to re-
store the urethral glands to their normal state.
The management of sufferers from chronic urethritis is
attended with many difficulties, partly owing to the moral
as well as the physical condition of the patient, partly in-
herent to the affection itself. Their treatment should there-
fore be moral, general, and local. Nothing will satisfy the
patient except the cessation of the discharge. To bring
this about is the chief indication, so far as the view of the
patient is concerned, but to the physician the indication is
not only to cure the local phlegmasia which gives rise to
the discharge, but to prevent the formation of stricture.
The character of the moral management has already been
hinted at in the beginning of this conference. In addition,
it may be said that the physician should gain the absolute
confidence and insure the co-operation of his patient, with-
out which all treatment would be in vain. He should dis-
suade him from concentrating his thoughts upon and from
continuing to magnify his infirmity, and, above all, should
break his habit of stripping, squeezing, and "milking" the
penis to bring to view the too tardy drop, for this alone is
sufficient to perpetuate the discharge which might other-
wise disappear even without local treatment.
The general treatment is directed to the improvement of
the physical condition of the patient, to place him in the
most favorable hygienic condition, to combat hyperlithuria,
and to strive to remove some of the causes tending to per-
petuate the phlegmasia. The use of balsamics in chronic
urethritis is apt to be worse than useless, for these drugs
almost invariably disturb digestion even in a short time.
An exception may be made in favor of the oil of gaultheria,
which sometimes acts as a very effective sterilizer of the
urine in chronic as well as in acute urethritis ; nevertheless
this agent should be used with prudence and in doses of
not more than five minims thrice daily. Another valuable
sterilizer of the urine is salol used in moderate doses. Al-
kaline mineral waters should be given sparingly and for not
more than eight or ten consecutive days.
The local treatment of chronic urethritis varies with the
site of the urethritis, the particular alteration of structure,
and the complications.
In case of simple chronic urethritis, in which there are
no granulations or submucous exudate, but only congest ion
of the mucous membrane, diffuse or in patches, particularly
when this congestion is limited to the "antebulbar" region,
mild astringent irrigations are indicated. It is wise, however,
to keep the patient under close observation for a week or
ten days, and during that time to make no local applications
whatever, for the general treatment may suffice to cure the
urethritis. If then the discharge persists, the urethra, for
the first five or six days, should be irrigated, only once
daily, with ten or twelve ounces of a solution of boric acid
or biborate of sodium, five grains to the ounce. Afterward
chloride of zinc should be substituted, but the zinc salt so-
lution should not exceed half a grain to the ounce. The
180
GOULEY: DISEASES OE THE URINARY APPARATUS.
[S. Y. Med. JonK.,
quantity of fluid used for each irrigation should be about
ten ounces. As a general rule, this form of chronic ure-
thritis yields rapidly to the irrigations, and in the course of
a few weeks is well.
In case of chronic cryptitis, the "antebulbar" irriga-
tions of boric acid and afterward of zinc chloride should he
made from before backward, so as to wash away from the
crypts the accumulated muco-pus.
Chronic urethritis with granulations demands a some-
what different treatment, although in the beginning the
irrigations with boric-acid solution should be used for
several days. If the granular urethritis be "antebulbar,"
the hest modifier that can be used is the nitrate of silver in
solution of half a grain to the ounce, one grain to the
ounce, and seldom increased to two grains to the ounce.
The amount of fluid should not be less than six ounces,
but should be used only once every four or five days.
In granular urethritis of the membranous and prostatic
regions, particularly in case of coexisting chronic gonecys-
titis, the strength of the nitrate-of-silver solution may,
with advantage, be increased to three, four, or even five
grains to the ounce, and three or four ounces only need be
used every four or five days. The bladder should contain
a few ounces of urine in order to insure the quick decom-
position of the silver salt. It is well known that when
fluid is thrown slowly and without undue force through a
catheter as far as the bulbo-membranous junction, it re-
turns and escapes at the meatus, but that when the catheter
is passed into the membranous region none of the fluid
escapes externally, but all of it enters the bladder. Mer-
cier pointed this out many years ago, and the experiences of
other physicians have confirmed the view. Two days after
each urethral irrigation a steel sound of moderate size
should be cautiously introduced as far as the bladder.
Too frequent catheterism or excessive dilatation only serves
to defeat the objects sought to be attained. The sound
should be carefully withdrawn in a minute's time, the pur-
poses of its introduction being to make pressure upon the
granulations, to slightly stretch the urethra at the seat of
disease, and to restore the suppleness of the canal.
There are cases of granular urethritis that obstinately
resist this treatment. These cases require direct applica-
tions to the granulation tissue, to accomplish which the use
of the urethroscope becomes necessary. The granulations
thus brought to view are penciled with a solution of nitrate
of silver (ten, twenty, or thirty grains to the ounce) every
four or five days until they disappear. Sulphate of copper
and other substances have been used for the purpose, but
are all inferior to the nitrate of silver.
Strong solutions are not well borne, are even mischiev-
ous, and therefore contra-indicated, in chronic urethritis
anterior to the bulbo-membranous junction, but are well
tolerated and effective when applied to the membranous
and prostatic regions, where may be used with advantage
the method of Guy on by the instillation of ten, twenty, or
thirty minims of nitrate-of-silver solution (ten, twenty, or
thirty grains to the ounce), to be in a minute washed into
the bladder by a current of water, and repeating the process
every three or four days. From Guyon's method good I
results have been obtained in otherwise intractable cases,
particularly those complicated with chronic prostatitis,
gonecystitis, or trachelocystitis.
Counter-irritation. — In certain cases of chronic urethri-
tis involving the perineal or prostatic, or both, regions of
the urethra, particularly those attended with dull pain and
a constant teasing sense of irritation in the parts, counter-
irritation of the perinaeuin by means of vesicating collodion
is often of much service, and should be used every three
or four days for several weeks. The vesicating collodion
should be applied with a camel's-hair brush on one side of
the perineal rhaphe, over a surface of half an inch by an inch
and a half, and the perin;eum covered with a layer of ab-
sorbent cotton, in order that the blistered skin may speedily
heal. In three days the blistering process is repeated on
the opposite side of the rhaphe, and so on every three or
four days until the desired effect is accomplished.
When chronic urethritis is kept up by stenosis of the mea-
tus urinarius, or of any other part of the urethral canal, it
can be cured only after the removal of the obstruction to
urination, in the first case by incision, in the second case by
dilatation, divulsion, or incision, according to the character
and particular site of the stricture.
In chronic urethritis due to urethral tuberculosis no treat-
ment other than the palliative is of any avail. The dis-
charge increases in quantity from day to day, in it swarm
the characteristic tubercle bacilli, and the patient soon suc-
cumbs to the inroads of general tuberculosis. A specimen
exhibited showed tuberculosis extending from the meatus
urinarius to the bulbo-urethral glands, spermatic canals,
seminal vesicles, prostate, bladder, peritonaeum, and right
ureter and kidney. The left kidney had undergone com-
pensatory enlargement and was not tuberculous. Both
testicles had been extirpated, on account of tuberculosis, six
months before the death of the patient. The specimen was
a particularly good illustration of ascending tuberculosis
of the urinary apparatus. There had been for several
weeks a thick urethral discharge, in which great numbers
of tubercle bacilli were detected. Several other specimens
were exhibited to illustrate descending tuberculosis of the
urinary apparatus. The disease, having begun in the lungs,
secondarily affected the kidneys, descended to the bladder
and urethra, and caused an obstinate purulent discharge.
Does Ether assist Digestion ? — '' The effect of ether on the digest-
ive processes in healthy subjects has been recently investigated," says
the Lancet, " by Dr. Gurieff, who gave thirty drops of sulphuric ether
to six healthy persons during dinner, which consisted of about half a
pint of soup, four ounces of meat, and sis ounces of bread. It was
found that the ether had tiie effect of stimulating the action of the gas-
trie glands, increasing the free hydrochloric acid in the gastric juice,
and causing the peristaltic movements of the stomach, together with its
power of absorption, to increase ; thus on the whole exercising a favor-
able effect upon the gastric digestion. The same result was obtained
w hen the ether was administered by means of hypodermic in jections.
It would appear, therefore, that the effects must be ascribed to a gen-
eral rather than to any merely local action on the mucous membrane of
the stomach. Dr. Gurieff is disposed to think that there is a stimula-
tion of the cephalic centers. This view is partly based on the observa-
tions of other Itus.-ian observers — Bekhtereff and Milosleveki, and Pav-
loff and Shumova Simanovskaya — on the dependence of the gastric
functions upon the central nervous system."
Feb. 13, 1892.] WOODWARD: SKIN-GRAFTING FOR DEFORMITY OF THE EYELIDS.
181
SKIN-GRAFTINO BY THE THIERSCH METHOD
FOR CICATRICIAL DEFORMITY OF THE EYELIDS.
By J. II. WOODWARD, M. D.,
BURMNOTON, VT.,
PHOFKHSOIi OF OPHTHALMOLOGY IN THE UNIVERSITY OF VERMONT.
Case I. Cicatricial L'vjophtludmvK. — In Nove uber, 189(1,
Jolm L., a laboring man, about thirty-five years of age, consulted
me at the Mary Fletcher Hospital for relief from the results of
an injury received several years earlier. He had been kicked
by a horse, and tl.c resulting lacerated wound of the left upper
eyelid had healed with deformity, owing to which he was not
able to close Ids eye, even by forced muscular effort.
1 found an irregular soar extending from the middle of the
free border of the lid in a vertical direction nearly to the eye-
brow, and involving the skin and muscular tissue. The ciliary
margin of the lid was deeply notched at the scar and the eye
remained permanently open I ordered the region of the left
eye to be thoroughly cleansed with soap and water and disin-
fected with 5oVi5- solution of the bichloride of mercury, the
conjunctival sac to be irrigated with a saturated solution of
boric acid, and the eye then to be covered with an antiseptic
dressing. His left shoulder, from which I purposed to take
the graft, was cleansed and disinfected and dressed in a similar
manner. These measures were repeated three times in the
twenty-four hours immediately preceding the operation.
Just prior to the adn inistration of the anaesthetic all instru-
ments, sponges, and dressings to be used in the case were
sterilized by superheated steam, and a one-per-cent. solution of
common salt was filtered and sterilized for use during the
operation for irrigating the wound and for moistening the dress-
ing after it. Ether was then administered, and the region of
the operation was again disinfected with the bichloride solution
and finally thoroughly washed with the saline solution. I
then made an incision nearly the entire length of the upper
eyelid at right angles to the scar and nearly one centimetre
from the ciliary margin, through the skin, and into the muscu-
lar tissue until I had penetrated deeper than the cicatrix. The
upper and lower lips of the wound Were dissected up until the
free border of the lid had returned to its normal curve, which
is convex below when the eyes are closed. The upper and lower
lids were then bound together with a single median suture.
Having checked all oozing from the wound, I shaved from the
previously disinfected shoulder a graft about three centimetres
long, one centimetre broad, and two millimetres thick. This
fitted the wound in the eyelid, to which it was immediately
transferred and gently pressed into its bed. Both wound and
graft had been thoroughly wetted with the sterilized one-per-
cent, saline solution. The dressing was protective sterilized
gauze moistened with the saline solution, and a bandage.
Every two hours, day and night, the dressing was moistened
with the saline solution.
On the second day the case was redressed with aseptic pre-
cautions, and the graft was found in good condition. There
was some muco-purulent discharge from the conjunctiva. Re-
dressed as before. The moist dressing was continued four or
five days, and at the end of a week the graft had united
firmly with the eyelid ; only a very narrow strip of the outer end
of it had perished. The result was complete relief of the
jfogophthalmus. The grafted tissue so closely resembled the
surrounding parts that one could distinguish it only by closely
scrutinizing the eyelid.
Ua»e II. Cicatricial Ectr opium. — George P., aged twenty-
two, an Adirondack guide, consulted me in October, 1891, for
deformity of his right lower eyelid, which was caused by a dog-
bite when he was four years old. The right lower lid was
everted and drawn downward by tbe cicatrix. The exposed
conjunctiva was inflamed and thickened by the prolonged ex-
posure. The inferior pnnctum lacrymale was drawn away
from the eyeball, and the resulting epiphora was a constant
annoyance to him. The cicatrix causing the deformity was ir-
regular; its chief traction was expended on a point about a cen-
timetre to the inner side of the median line of the lid.
The preliminary treatment, the aseptic management, and the
operation in this case were similar to those described above. In
this instance, however, the wound being larger and more irregu-
lar, I imbedded two grafts in it instead of one, for I did not
succeed in cutting a single graft of suitable shape and size to
fill the wound. The dressing was similar to that in the first
case. On the second day I redressed the case, and found that
the inner graft had perished. It was adherent to the'protective
and came away with the dressing, thus exposing one third of
the wound. A profuse muco-purulent discharge had been
poured out by the conjunctiva. The stitches uniting the upper
and lower lids had cut through and were removed. Redressed
as before. Two days later the wound was doing well. Nu-
merous small grafts were transplanted from the forearm to
the bed of the dead graft, which was thus completely covered.
Nearly all these small grafts lived. In a week the wound was
healed, the line of the ciliary margin of the lower lid was almost
perfectly restored to its normal curve, the punctum was in nor-
mal contact with tbe eyeball, and it was not easy to distinguish
the grafts from the normal integument.
The advantages of this method of handling- deformities
of the eyelids are too evident to require discussion. It is
not easy to do an aseptic operation in the region of the
eye ; it is perhaps impossible to secure perfect asepsis there.
Nevertheless, a sufficient approximation to the aseptic state
is attainable to warrant a successful termination of the
treatment. One of the features highly commendatory of
this surgical procedure in deformities about the face is that
the traces of the operation are practically invisible.
Sensory and Vaso-motor Disturbance in Facial Paralysis. — " Dr.
Frank! Bochwarfc, in an investigation into the conditions present in
twenty cases of facial paralysis, found that in three there were disturb-
ances of sensation and of the vaso-motor functions, in live of sensory
functions only, and in two of vaso-motor only . The sensibility was only
affected to a-very slight degree, and sometimes the mucous membrane
on the tongue and inside of the cheek was affected, and sometimes it
was not. Occasionally also taste was affected. These sensory phe-
nomena disappeared much earlier than the paralysis, but in one case in
which the paralysis persisted there was diminished sensibility even after
several years. The conclusion sought to be drawn from these facts is
that the facial nerve in man contain* some sensory and va«o-raotor
fibers ; but of course it would first have to be shown that the fibers of
the fifth nerve had not also suffered when the facial nerve became af-
fected."— Lana i.
A Gastrolith in Man. — " Dr Kooyker has reported in the ZeUschrift
fur klinhchr Medicin another case of gastric calculus — a condition
which, though common enough in animals, is so rare in man that so far
only seven eases have been reported. Dr. Kooyker's ease was that of
a man tifty-two years old, in whose lifetime it had heeii impossible to
make a positive diagnosis, though some neoplasm of the stomach was
suspected. The patient died from exhaustion. At the post-mortem ex-
amination a concretion was found in the stomach, almost entirely tilling
its cavity, which weighed eight hundred and eighty-live grammes and
was eighteen centimetres in length. The mieioscopie examination re-
sulted in finding starch, vegetable cells, chlorophyll, and vascular lulls,
while hair and other animal elements were entirely absent." — Lancet.
182
LEADING ARTICLES.
[N. Y. Med. Joub.,
THE
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by Edited by
D. Appi.kton & Co. Frank P. Foster, M. D
NEW YORK, SATURDAY, FEBRUARY 13, 1892.
AN UNWARRANTABLE ATTEMPT TO SECURE SPECIAL
LEGISLATION.
A committee of the Senate of the State of New York has
lately given its attention to a bill granting to such medical stu-
dents as entered upon their college'courses after the new medi-
cal law went into effect, but during the same year, exemption
from the requirement of passing the State examination. We
are informed that a thousand students have joined in the igno-
ble undertaking of getting this bill passed by the Legislature.
That number is a disgracefully large proportion of all the medi-
cal students in the State, and a still larger proportion of those
who may be supposed to be directly interested in the matter —
that is, of those who were matriculated within the time speci-
fied.
The senatorial committee seems to be unaccountably lenient
toward the promoters of this extraordinary bill, for we under-
stand that one of its members has asked a well-known physician
if he did not suppose thatj the ' students' motive was the out-
growth of their straitened circumstances, of their inability to
pay the State examination fee. Such guilelessness in the Legis-
lative mind is indeed refreshing. Nobody in the medical pro-
fession can have much doubt about their motive ; it is simply
that they find themselves confronted with a fence that they
think they can not leap over, and they are calling on the Legis-
lature to slip them under the rails.
There is, of course, no reason worth listening to why these
particular students should be exempted from a just legal re-
quirement. If they are exempted, it is difficult to imagine on
what grounds the Legislature can decline to accord the same
measure of favor to the following year's crop of students, and
so on indefinitely, thus practically nullifying a most wholesome
enactment. The pending bill is pernicious in the extreme, and
we hope that it will never get beyond the committee.
THE .ETIOLOGY OF CHANCROID.
When, nearly forty years ago, Bassereau and Clerc pointed
out clearly the distinction between the chancre and the chan-
croid, great efforts were made to establish the theory of the
existence of two distinct viruses, the syphilitic and the chan-
croidal. This idea of dualism was so simple and striking
that it gained quite general acceptance, and we find eminent
authors in Europe and in this country teaching the doctrine
that no amount of sexual excess, no degree of uncleanli-
ness, no irritation, traumatic or chemical, in short, nothing,
can produce chancroids except chancroids and chancroidal
buboes; or, as Fournier has put it, "if all the chancroid
patients in the world would avoid contact with others until
they got well, (he disease would cease from off the face of the
earth." There were those, however, who did not blindly ac-
cept this doctrine, and who could see nothing mysterious or
specific in the chancroid. Among this number were Dr. Bum-
stead and Dr. Taylor, of New York, whose investigations, both
experimental and clinical, proved beyond a doubt that ulcers
having all the features and peculiarities of chancroid could be
produced by many different varieties of pus, the chief essen-
tial being the activity of the ulcerative process in the sore from
which the pus was taken. It was natural to expect that mod-
ern bacteriological research would throw much light upon this
subject, but studies in this department have been disappointing,
and have only succeeded in establishing the fact that the chan-
croid is produced by pus rich in pyogenic microbes.
It is well known that most chancroids are contracted during
sexual intercourse, one of the persons concerned being already
affected with this form of ulceration ; but it is not so generally
known that chancroids may be found on the penis of a man,
and yet the woman with whom he cohabited be free from these
lesions. Such instances are by no means rare, as may be seen
by reference to a recent article on this subject by Dr. R. W.
Taylor in the Medical News for December 5, 1891. This author
cites a case in which a healthy young man, presenting no evi-
dences of syphilis or gonorrhoea, came to him with seven true
chancroids in the balano-preputial sulcus. He was positive
that the woman with whom he had cohabited was free from
any such trouble, and an examination of this woman showed
nothing but a deep and highly ulcerated fissure of the os uteri,
surrounded by an area of intense hyperaimia. Brownish, gelati-
nous pus escaped profusely from this ulceration. On inquiry,
it was learned that since this woman had had a child, seven
years before, she had had leucorrhoea most of the time, and that
four weeks before this examination she had been taken sick with
what was called peritonitis. She remained three weeks in bed,
and then, on getting up, indulged freely in sexual intercourse
with this man, at the same time drinking large quantities of
wine. The result was that he became affected with chancroids,
and she suffered greatly from pelvic pain.
Here, then, is a case in which, in consequence of an acute
attack of peritonitis, together with sexual excess, a discharge
from a subacute inflammation becomes converted into a more
active form of pus. The important clinical fact brought out by
this case is in direct accord with the results of inoculation ex-
periments which have been made by various observers with pus
from acne, ecthyma, impetigo, scabies, etc., in which lesions
were produced in no way distinguishable from chancroids.
The lesson taught by the case should be widely known, for it
is easy to see how a physician, ignorant of this fact, might
cruelly wrong innocent women.
Syphilitic women who are entirely free from specific lesions
of the genitals often have a purulent vaginal secretion which is
rich in pyogenic microbes, and which is capable of producing
chancroids in men; while, on the other hand, it is not unusual
for men to cohabit with impunity with women having an old
Feb. 13, 1802.1
LEADING ARTICLES.
183
and extinct syphilis and chronic chancroids. There are not a
few medical men who think that, because chancroid is classed
as a venereal disease, it must of necessity originate in sexual
contact, yet in many instances this supposition is not correct,
for, says Dr. Taylor, chancroids may originate in some subjects
dt1 novo. In other words, chancroids may develop in men who
have had no sexual intercourse whatever, as a result of some
diathetic condition or some contamination of herpetic vesicles,
chafes, abrasions, or fissures.
In the article referred to Dr. Taylor cites two striking exam-
plesof this clnss of chancroids. In the first case, a man, twenty-
nine years of age, of plethoric habit and seemingly in robust
health, presented himself with a typical chancroid of the inner
side of the prepuce. He insisted that he had not had any in-
tercourse for a month, and said that under like circumstances
he had had precisely similar ulcers, which had been pronounced
by eminent surgeons and sy philographers in America and Europe
as undoubtedly chancroids. The patient was kept under obser-
vation for a number of years, and it became evident that he
was a victim of a persistently recurring herpes progenitalis,
which at times would heal promptly, and at other times would
be transformed into unhealthy ulcers, which could not be dis-
tinguished from classical chancroids. The second case was
even more remarkable. A man, thirty years old, thin and
rather pale, had suffered for about ten years with frequent at-
tacks of herpes progenitalis. He had had severe attacks of
gonorrhoea when twenty-four and twenty-six years of age. He
had never had syphilis. These attacks of herpes began with a
smarting, burning pain ; the vesicles were situated on the skin
of the penis, on the inner surface of the prepuce, or near the
frenum and meatus urinarius. In the early attacks the vesicles
healed under simple treatment in about a week, but as years
went on he noticed that sometimes the vesicles assumed an un-
healthy, ulcerated appearance and were very rebellious to treat-
ment. Being a thoughtful and observant man, he soon con-
vinced himself that these attacks of herpes were never the
result of coitus, as sometimes the herpes would appear a few
days after coitus, and again it would appear after many weeks
of abstinence. Before he came under the author's observation,
in 1886, a crop of herpetic vesicles suddenly appeared in the
left fossa of the frenum, notwithstanding he had not had sexual
intercourse for three months. He had learned to be scrupu-
lously clean about his genitals, but, notwithstanding this, the
crop of vesicles rapidly developed into a larger ulcer, which
a surgeon pronounced to be an unmistakable chancroid and
stoutly maintained could only have been contracted in coitu.
After two weeks of careful treatment, chiefly with iodoform,
the ulcer healed, but not before two virulent buboes had ap-
peared. Following these buboes, a deep sloughing ulcer formed
in the left groin and a similar ulcer on the thigh, just below the
groin. It was at this time that he presented himself to Dr.
Taylor for treatment. The ulcers were thoroughly irrigated
with a five-per-cent. carbolic-acid solution, the parts were care-
fully dried, and the morbid surface was dusted with iodoform
and covered with gauze and a bandage. On the anterior sur-
face of the thigh there were three little ulcers, in all respects
like chancroids, and several hair follicles were the seat of a
deep hyperemia. According to the patient's statement, the
lesions upon the thigh were caused by a purulent discharge
from the buboes, as he had been unable to dress the ulcers
properly while traveling. These ulcers were treated in the
same way as the others, and all the lesions were healed in about
three weeks. In this case the possibility of a lymphatic infec-
tion from a lesion of the foot, leg, or buttocks was carefully
excluded, and infection from sexual intercourse was entirely
out of the question. During the following years recurring at-
tacks of herpes were experienced, in some of which the vesicles
were converted into destructive ulcers, and on two occasions,
as the result of a most rigid antiseptic treatment at the very
beginning, the vesicles were dried up and prompt healing was
secured. Again, in 1890, after abstinence from coitus for four
months, he was attacked with preputial herpes near the right
of the frenum. The vesicles developed into a typical chan-
croidal ulcer, and the ganglia in the right groin became swollen
and painful. The ulcer was treated with iodoform, and cold
was applied to the groin. The chancroid healed, but the gan-
glia went on to suppuration, and after free incision a deeply
ulcerated surface was left, which presented the typical appear-
ance of a virulent bubo.
It is important not to forget that simple inflammatory le-
sions of the genitals in syphilitics are often converted into typi-
cal chancroids or septic ulcers, undoubtedly as the result of
contamination with pyogenic microbes from some unknown
source. Pus taken from these chancroids is capable of produc-
ing, on inoculation, similar lesions for many generations. Clin-
ical observations seem to show that chancroids derived from
the pus of patients in whom the syphilitic diathesis is quite
active are commonly more active than those caused by the vari-
ous forms of simple pus. It is also well to remember that
lesions of continuity occurring about the genitals of old syphi-
litics, both men and women, are prone to assume the features
and characteristics of chancroids.
The tissues of the genitals of syphilitic women are also lia-
ble to the development of chancroids upon all lesions of con-
tinuity. Thus, in the case of a young woman who had been
syphilitic for a year, and, in consequence of a vulvar pruritus,
had produced an excoriation of the right nympha by scratch-
ing, a large and typical chancroid developed on this raw sur-
face, and a virulent bubo appeared a few days later. She had
absolutely refrained from coitus for a month previous to this
trouble.
It thus appears that what we call chancroid is the product
of many varieties of pus, derived from non-syphilitic and from
Syphilitic subjects, and that it is, therefore, in all cases, a septic
ulcer and in many instances simply an active form of wound
infection. From this it follows that Fournier's dictum,
already quoted, is utterly false, and that so long as pyogenic
microbes and i issue predisposition exist, chancroids will he
found upon the mucous membranes and integument of the
human race.
18+
MINOR PA RA OR A PHS. - ITEMS.
[N. Y. Med. Jouk.,
MINOR PARAGRAPHS.
THE TOXIC ACTION OF IMPURE CHLOROFORM.
It lias been an axiom for years that in the administration of
chloroform for anesthesia the purified drug only should he em-
ployed. This lias been founded in part upon observation and
in part upon a knowledge of the irritative effects of some <>f the
impurities in commercial chloroform. Professor Pictet's recent
method of refining chloroform, mentioned in the Joun, ,7 for
December 12th, gives a very pure chloroform and an impure
residue. Dr. Rene du Bois-Reymond has recently published in
the British Medical Journal the results of his experiments upon
the physiological action of tin- residue a- compared with that
of the purified drug, cardiography tracings being made of the
hearts of frogs placed under covered dishes with both liquids, and
manometric and respiratory tracings being made from rabbits
inhaling; the drugs through a tracheal cannula.
These experiments corroborated those already made on the
rfetioii of chloroform in general, but, on comparing the pure
with the impure drug, no difference was found in the shape of
the pulse waves or in the frequency of respiration. With the
residue, at the close of the experiments, the pulse rate was
higher than with pure chloroform : and when respiration
stopped, the blood pressure was higher after inhaling the pure
than the impure drug. Furthermore, the latter caused stoppage
of respiration much more quickly than the former. Pure chlo-
roform is much more volatile than the impure, and the purer
the drug the less the quantity required for anaesthesia and the
less risk of that respiratory failure which the Hyderabad Com-
mission concluded was the cause of death in chloroform admin-
istration.
WARMED ETHER AS AN ANAESTHETIC.
From the British Medical Journal for December 19th we
learn that a surgeon of Barcelona. Spain, has devised a plan for
administering ether in a warmed condition. Dr. Gine y Par.
tagas performed an operation in October, 1891, for osteoma of
the fibula, on a woman in the Hospital de la Santa Cruz, of the
city above named. This operation, which was reported in the
Independencia Medica, was the first one of magnitude to be car-
ried through under the new anaesthetic process. The ether was
administered by Dr. Diaz de Liafio, the designer of the appa-
ratus. The temperature at which the ether was kept was 87° F.
Insensibility was quickly induced and was maintained for fifty-
five minutes without accident. The ether was kept at 87° until
near the close, when it fell to 85°. The apparatus, which has
been called an " electro-thermo-etherizer " by its designer, has
since been used satisfactorily. In one case the administration
was prolonged for two hours and a half without ill effect. The
new method, it is maintained, will do away with some of the
disadvantages both of chloroform and of cold ether. A full de-
scription of the apparatus is promised to be published at an early
date.
THE KINOS COUNTY INSANE ASYLUM.
The Commissioners of Charities of Kings County have voted
to make a change in the supervision of the asylums at Flatbush
and St. Johnland, Dr. John A. Arnold, of the Flatbush Asy-
lum, will he temporarily superseded by Dr. Walter Fleming,
who is at present one of Dr. Arnold's assistants, and who will in
turn be replaced by a general medical superintendent to be ap-
pointed in accordance with the rules governing the State Com-
mission. The new appointee will he given general oversight of
all the hospitals for the insane poor. This action probably
terminates Dr. Arnold's long and useful career in the adjoining
county of Kin^s. We wish him a larger and more congenial
field, with a greater freedom from political interference and an-
noyance.
LARGE VITAL CAPACITY IN A NEZ PERCE INDIAN.
On the occasion of the recent visit to the Indian School at
Carlisle, Pennsylvani i, of a party of Xez Perces, the physician
of the school made a physicial examination of several of the
visitors. One of them, who was five feet and an inch in height,
and weighed one hundred and sixty pounds, was the possessor
of a clear chest expansion of five inches. When we remember
that a free expansibility of four inches is seldom possessed, ex-
cept as the result of special respiratory training, the lung ca-
pacity of this red man will be recognized as something remark-
able.
ITEMS, ETC.
Infectious Diseases in New York. — We are indebted to the Sanitary
Bureau of the Health Department for the following statement of cases
and deaths reported dining the two weeks ending February 9, 1892:
. DISEASES.
Week ending Feb. 2.
Week ending Feb. 9.
Cases.
D eaths.
Case*.
Otathe.
Typhoid fever ...
11
2
9
7
192
19
210
25
Cerebro-spinal meningitis
•1
1
2
1
Measles
137
12
132
13
Diphtheria
87
30
122
23
5
o
11
2
Erysipelas
0
II
0
0
0
0
0
0
ii
0
0
0
■ i
0
0
0
The Vereindeutscher Aerzte von Brooklyn. — The special order for
the meeting of Friday evening, the 12th inst., was a paper on Post-
partum Haemorrhage, by Dr. A. Ritter.
The Hospital for the Insane at Asbury, Iowa. — Dr. J. J. Brownson,
of Dubuque, has been appointed physician to the hospital.
The Conemaugh Valley Memorial Hospital was opened at Johns-
town, Pa., on Thursday, the 4th inst., with appropriate inaugural cere-
monies. Among the addresses was one by Dr. George W. Wagoner.
The Death of Dr. David Fleischman, of Albany, occurred on Janu-
ary 30th. The deceased was a graduate of the Albany Medical Col-
lege, of the class of 1881, and subsequently studied laryngology and
rbinology at the New York Post-graduate Medical School. He had de-
voted himself to these branches since 1883, and was highly esteemed
by the profession and the community.
The Death of Professor von Bruecke. — The Wit »> r klimschc WocJien-
schrift announces that Dr. Ernst W. Ritter von Briicke, emeritus pro-
fessor of physiology in the University of Vienna, died on the 7th of
January, at the age of seventy-two.
Army Intelligence. — Official List of Changes in the Stations and
Duties of Officers serving in the Medical Department, United Stata
Army, from January 24 to February 6, 1892 :
Bt RTON, Henry G., Captain and Assistant Surgeon, having been found
incapacitated for active service by an Army Retiring Board, is
granted leave of absence until further orders, on account of dis-
ability.
The order relating to Captain Aaron H. Appel and First Lieutenant
Julian M. Cabell, Assistant Surgeons, is suspended until further
orders.
Wright, Joseph P., Lieutenant-Colonel and Surgeon, is relieved from
duty as attending surgeon at the Military Prison, Fort Leavenworth,
Kansas, and will repair to San Francisco Cal., and assume the duties
of Acting Assistant Medical Purveyor, taking charge of the medical
purveying depot at that place, and relieving Lieutenant-Colonel
Feb. 13, 1892.]
ITEMS.— PROCEEDINGS OF SOCIETIES.
185
George M. Sternberg, Surgeon, who, upon being relieved, will pro-
ceed to Governor's Island, New York, and report in person to the
commanding general, Department of the East, for duty as attending
surgeon and examiner of recruits in New York city.
Snyder, Henry I)., First Lieutenant and Assistant Surgeon, now tem-
porarily serving at Fort Reno, Oklahoma Territory, is assigned to
duty at that post,
Dcnlop, Samuel R., First Lieutenant and Assistant Surgeon, is relieved
from duty at Fort Sill, Oklahoma Territory, and assigned to duty at
Fort Supply, Indian Territory, where he is now temporarily serving.
Brooke, John, Major and Surgeon, is granted leave of absence for
twenty-eight days.
Aprel, Aaron H., Captain and Assistant Surgeon, is granted leave of
absence for twenty-three days.
Naval Intelligence. — Official List of Change* in the Medical Corps
of the United States Navy for the three weeks ending February 6, 1892 :
Harwell, W. G., Surgeon. Detached from the Naval Hospital, Nor-
folk, and to wait orders.
Drake, N. H., Parsed Assistant Surgeon. Ordered to the Naval Hospi-
tal, Chelsea, Mass.
Pickrell, George McC, Passed Assistant Surgeon. Detached from the
Naval Hospital, Chelsea, and ordered to the Naval Hospital, Norfolk.
McCormick, A. M. D., Passed Assistant Surgeon. Detached from the Re-
ceiving-ship Minnesota and ordered to the U. S. Steamer Charleston.
Barber, George H., Assistant Surgeon. Detached from the U. S.
Steamer Charleston and ordered to the Receiving-ship Minnesota.
Cabell, A. G., Parsed Assistant Surgeon. Detached from the IT. S.
Steamer New ark and ordered to the I*. S. Steamer Kearsarge.
Stoughton. James, Assistant Surgeon. Detached from the Naval Hos-
pital, Norfolk, Va., and ordered to the Training-ship Portsmouth.
Guest, M. S., Assistant Surgeon. Detached from the Navy Yard, Nor-
folk, Va., and ordered to the Naval Hospital, Norfolk, Va.
Neilson, J. L., Surgeon. Detached from Training-ship Portsmouth,
and granted two months' leave of absence.
Marine-Hospital Service. — Official List of the Changes of Stations
and Duties of Medical Officers of the United States Marine- Hospital
Service for the four weeks ending January 16, 1892 :
Irwin, Fairfax, Surgeon. Granted leave of absence for seven days.
January 13, 1892.
Carter, H. R.. Passed Assistant Surgeon. To proceed to Cincinnati,
Ohio, and assume command of the service. January 8, 1892.
Brooks, S. D., Passed Assistant Surgeon. To inspect unserviceable
property at Marine Hospital, Detroit, Michigan. December 23,
1891.
Williams, L. L., Passed Assistant Surgeon. Granted leave of absence
for twenty days. January 12 and 13, 1892.
Pettus, W. J., Passed Assistant Surgeon. To proceed to Buffalo, N.
Y., and assume command of the service. December 21, 1891.
Magruder, G. M., Passed Assistant Surgeon. Relieved from duty at
Washington, D. C. ; ordered to Marine Hospital, New Orleans, La.
January 8, 1892.
Perry, T. B., Passed Assistant Surgeon. To proceed to Cape Charles
Quarantine for temporary duty. January 13, 1892.
Death.
Long, W. H., Surgeon. Died at Cincinnati, Ohio, January 5, 1892.
Society Meetings for the Coming Week :
Monday, February 15th: New York County Medical Association ; New
York Academy of Medicine (Section in Ophthalmology and Otology);
Hartford, Conn., Medical Society; Chicago Medical Society.
Tuesday, February 16th : New York Academy of Medicine (Section in
General Medicine); New York Obstetrical Society (private) ; Ogdens-
burgh Medical Association ; Medical Societies of the Counties of
Kings and Westchester (White Plains), N. Y. ; Baltimore Medical
'Association.
UTednesday, February 17th : Northwestern Medical and Surgical Soci-
ety of New York (private); Harlem Medical Association of the City
of New Yoik; Medico legal Society ; New York Academy of Medi.
cine (Section in Public Health and Hygiene); New Jersey Academy
of Medicine (Newark).
Thursday, February ISih : New York Academy of Medicine ; Brooklyn
Surgical Society ; New Bedford, Mass , Society for Medical Improve-
ment (private).
Friday, February 19th: New York Academy of Medicine (Section in
Oithopa?dic Surgery) ; Baltimore Clinical Society ; Chicago Gynae-
cological Society.
Saturday, February 20th : Clinical Society <>f the New York Post-
graduate Medical School and Hospital.
Answers to Correspondents :
No. 371. — We think that pneumonia can not be said to be caused
by the use of alcohol, but it is of frequent occurrence in the subjects of
alcoholism, and, like most diseases, is more fatal in them than in
others. We are not aware that pneumonia in alcoholic subjects has
features distinctive enough to warrant the term alcoholic pneumonia.
jproceeoings of Societies.
MEDICAL SOCIETY OF THE STATE OF NEW YORK.
Eighty-sixth Annual Meeting, held at Albany on Tuesday,
Wednesday, and Thursday, February 2, 3, and 4, 1892.
The President, Dr. A. Walter Suiter, of Herkimer, in the
Chair.
A Pathological Review of Diphtheria, with Special Ref-
erence to a New Method of Treatment, based upon Three
Years' Practical Experience, was the title of a paper by Dr.
F. E. Martindale, of Port Richmond. The history and aetiolo-
gy of the disease were discussed at some length, and the fatality
so common in rural districts was ascribed to imperfect ventila-
tion in the houses, to dampness, and to the presence of an abun-
dance of bacilli, which probably originated in vegetables stored
in cellars. The author's method of treatment consisted in rais-
ing the temperature of the sick-room to 104° F., and saturating
the atmosphere with the vapor of tar and turpentine, which
were mixed in equal portions and const mtly vaporized by the
action of heat during the progress of the disease. Twenty-
three patients had been treated in this way, and all but one had
recovered, and that one had not been seen until the disease was
beyond cure.
Dr. S. Barucii, of New York, approved of the method which
had been advocated, but did not look upon it as a new one. It
had been used by others, and he had used it himself eight or
ten years before.
Asepsis and Antisepsis in Obstetrical Practice.— Dr.
George Seymour, of Utica, read a paper in which he advocated
the precautions which modern midwifery insisted upon, includ-
ing the free use of carbolic acid, sublimate, and creolin.
Dr. Andrew F. Currier, of New York, believed that the
essence of successful treatment in obstetric practice was clean-
liness. Antiseptics were not indicated in normal cases. Vim.
sual precautions, aside from cleanliness, though possible in hos-
pitals, were often impossible or impracticable in the duellings
of the poor.
The Treatment of Endometritis. — Dr. Ralph Waldo, of
New York, read a paper thus entitled. This disease, he said,
had many phases, and was in many cases most difficult to cure.
One of the most useful means of treatment was drainage. The
idea of drainage of the uterus was not new. The words of Sims
were quoted, describing the value of this means of treatment
in terms which would apply to methods in vogue tit the present
186
PROCEEDINGS OF SOCIETIES.
[N. Y. Med. Jour.,
time. Intra uterine douches of hot water were also an efficient
means of treatment, which were to be used in conjunction with
suitable means for drainage, whether such means were gauze,
glass, or rubber. The application of escharotics to the interior
of the uterus was attended with no little danger. Stenosis and
cicatrization after such treatment were often a source of much
trouble.
Dr. Currier believed that drainage was one of the most im-
portant means of treatment in the hands of the gynaecologist.
He also insisted upon the great importance of the intra-uterine
tampon in the treatment of endometritis, as well as in numerous
other pathological conditions of the uterus, not only furnishing,
as it did, a most efficient means of drainage, but also serving as a
stimulant to the uterine muscular tissue.
Dr. W. B. Chase, of Brooklyn, agreed with the reader of
the paper in reference to the dangerous character of escharotics
in the treatment of endometritis, lie was a firm believer in
the curette and in dilatation as suitable means of treatment.
Dr. Hayd, of Buffalo, referred to the danger of exciting
tubal disease by the use of violent means of treatment. He
agreed with the previous speakers in regard to the danger of
escharotics and the essential value of drainage, especially when
the gauze tampon was used.
Dr. Seymour believed that in numerous instances an oopho-
ritis or salpingitis was caused by the freedom with which the
uterus was invaded in the treatment of endometritis. He was
disposed to attach great importance to the use of tonics, suita-
ble diet, and exercise as means of treatment, believing that
the endometritis was frequently only a manifestation of a de-
praved general condition.
Dr. R. B. Talbot, of New York, thought that dilatation
was a valuable measure if properly applied. He preferred
gradual dilatation with bougies and sounds to the use of power-
ful expanding instruments. He had seen no accidents resulting
from dilatation, as he was in the habit of using it.
Open Incision for Talipes Varo-equinus.— Dr. A. M.
Phelps, of New Y7ork, read a paper thus entitled. This opera-
tion had been first performed by him in 1879, and he had been
able to present to the society the histories and photographs of
some of his earliest cases. The cures effected by his method
had been permanent, and the children who had been operated
upon bad growrn up with useful and shapely limbs. Be was the
more pleased to make this report inasmuch as there had been
much skepticism as to the value of his operation. All the soft
parts were divided in his incision, which began at the internal
malleolus and extended a third the distance across the foot.
Osteotomy should not be done in these cases, as a primary
operation for a permanent cure was less likely to result, and
even a fatal result had occurred in a few cases. The equinus
was to be overcome by subcutaneous division of the tendo
A chillis, and this should be done prior to the incision for the
relief of the varus. A series of 161 operations upon 93 patients
was reported, in which there had been but ten relapses. In
only 17 cases had he found it necessary to perform linear oste-
otomy.
Dr. Willy Meyer, of New York, narrated cases which had
come under his observation. The treatment of these cases
should be begun almost at birth. Some of them could be cor-
rected by pressure and traction, but, if such measures failed,
Phelps's operation was indicated.
Dr. Herman Mynter, of Buffalo, believed that operative
measures frequently became necessary in consequence of the
carelessness of mothers in following out the directions of the
surgeon when milder measures had been resorted to. Such an
operation as was under discussion frequently obviated the ne-
cessity of amputation.
Dr. Phelps said that a failure might result if the incision
was not extensive enough, and he believed that surgeons some-
times erred in this particular. His formula was to make the in-
cision before performing a bone operation, and to avoid the
latter if possible.
Mineral Springs in the Treatment of Disease.— Dr.
Charles C. Ransom, of New York, read a paper which was a
plea for the. more careful study and classification of the mineral
springs of this country, and in particular a study of the sulphur
waters of Richfield Springs, N. Y., and their application to the
relief of various constitutional disorders.
Amputation of the Vaginal Portion of the Cervix Uteri
in Cases of Suspected Carcinoma.— Dr. Cuerieb read a paper
thus entitled. ( I'o be published.)
The Mental Derangements observed in Multiple Neuri-
tis, especially that of Alcoholic Origin.— Dr. E. D. Fishm
of New York, read a paper thus entitled. The symptoms of
this disease, as gjven by Starr, were briefly described. Espe-
cially important as a symptom was the loss of knowledge of
time.and place during the illness. The patient was conscious
of experience which occurred until his illness began, but from
that period until his recovery all was a blank to him. The dis-
turbance of function was most manifest in the upper extremi-
ties, and was derived from lesions of the association fibers of
the brain. The disease might continue for months, improve-
ment in the peripheral nerves and mental condition taking
place, and recovery resulting eventually. The disease occurred
not only in those who had long been addicted to alcoholic ex-
cesses, but in moderate drinkers as well.
Two Successful Cases of the Conservative Caesarean Sec-
tion.— Dr. Charles Jewett, of Brooklyn, reported the follow-
ing cases: Case I. — An English woman, thirty-two years of
age, four feet six inches in height, was in fair health with the
exception of a chronic nephritis. The pelvis was kyphotic, and
the inlet slightly contracted ; the outlet two inches and three
quarters in the pubo-coccygeal, and two inches and a quarter in
the bisischial diameter. She was admitted into the Long Island
College Hospital after being several hours in labor. The os ex-
ternum was dilated to the size of a half-dollar and the mem-
branes had ruptured. The operation was done on December 2d.
The pulse was 90. A large, thin- walled rubber tube was used
as a cervical constrictor. The placental seat was under the uter-
ine incision. A hand was passed over the left edge of the pla-
centa and through the membranes. The head was extraced
with difficulty and only after relaxing the grasp of the con-
strictor. The umbilical cord was clamped at two points with
catch-forceps and cut between them. The child was alive and
respiration was promptly established. There was no eventra-
tion of the uterus. The placenta and membranes were separated
by the hand, and the uterine cavity was left undisturbed. The
uterus was closed with twelve deep silk sutures and a symperi.
toneal suture of catgut. Hardly any handling and no special
cleansing of the peritonaeum took place. The abdomen was
closed with ten silk sutures. The loss of blood was no greater
than in ordinary labor. The tonicity of the uterine muscles was
apparently unimpaired by the cervical ligature. A good recov-
ery was made, with no sign of sepsis. The abdominal sutures
were removed on the tenth day. Uterine involution was some-
what tardy.
Case II. — A German immigrant, twenty years of age, had
for a long time been subject to hysterical paroxysms, occasion-
ally ending in convulsions and semi-coma. She was in bad con-
dition from inanition, and was the subject of a slight broncho-
pneumonia at the time of the operation and also of syphilis in
the second stage. A most remarkable feature of this case was
the temperature record. The thermometer several times regis-
Feb. 13, 1892.]
PROCEEDINGS
OF SOCIETIES.
187
tered 107° F., and onco 110°. At the beginning of the opera-
tion her temperature was 108'6°. This woman was of slender
I figure and four feet six inches and a half in height, and her pel-
vis was extremely flattened. The true conjugate was two inches
and a half, and the pubo-occygeal and bisischial diameters were
each two inches and a quarter. She fell into labor shortly after
the sixth month of gestation. The operation was done about
ten hours after the first pains. The waters had drained away,
but the cervix would barely admit the examining finger. The
i section was complicated with troublesome protrusion of intes-
tines, owing (o tympanites. There "was nearly a complete es-
cape of the liquor amnii, with placenta prajvia Caesareana. A
large, thin- walled rubber tube was used as a uterine ligature as
IBi the previous case. The placenta was separated as before.
The child was alive and breathing, but not viable. The uterus
was lifted out of the abdomen. The membranes were separated
with difficulty. The uterus was closed with ten deep sutures in
fourteen minutes from the beginning of the operation. The de-
cidna was not included in the sutures. Symperitoneal sutures
of silk were used. No flushing and little cleansing of the peri-
tonaeum were employed. The abdominal incision was closed
with ten silk sutures. The temperature at the close of the op-
eration was 98'6°, and the pulse 90, lower than at the begin-
' ning. There was some abdominal distention on the second day,
which was promptly and permanently relieved by free evacua-
tions of the bowels with salines. The temperature soon resumed
\ its customary oscillations, but there was no bad symptom at-
tributable to the abdominal section and the patient made a sat-
isfactory recovery.
The writer mentioned as the most important points in the
technique of Cajsarean section asepsis, the secure closure of the
uterine wound by the typical Sanger suture with silk, and the
' avoidance of all scrubbing and use of antiseptics of any kind in
the aseptic uterine cavity and irrigation or much sponging of
the peritonaeum. The resort to saline cathartics soon after the
first expulson of flatus he considered a valuable measure. The
best time for operation, in his opinion, was an appointed time
• immediately before labor. The simplicity of the technique and
the comparatively favorable condition of the patient in timely
operations, he thought, entitled us to expect results in Cesarean
delivery quite equal to or better than the best records of lapa-
1 rotomy in disease.
Compound Fractures and their Treatment was the title
r of a paper by Dr. Herman Mynter, of Buffalo. For many
years the mortality in European hospitals in connection with
compound fractures had been very great. It was Volkmann who
instituted a radical change in the treatment of such injuries, and
in 1877 he was able to report seventy-five cases, in some of which
aniputation was performed on the second day after the injury,
! all of them resulting favorably. His treatment consisted in
thorough cleansing of the wound, with the removal of all dirt
and dead or hopelessly bruised tissue, irrigation, and drainage.
In fact, it was the application of antiseptic methods of treat-
ment. The principle upon which the author treated such eases
i was that of converting a contused and lacerated wound, with its
dirt, splinters of bone and crushed tissue, into a simple incised
wound, all tissues being removed which were likely to undergo
necrosis, and the wound thoroughly cleansed, even it it was
' originally only a punctured wound, and then closed like any
other simple incised wound. No drainage-tubes were used and
I no silver wire. The limb was immobilized after closure of the
wound, and the subsequent course after such treatment had in
his experience been an aseptic one. The plaster dressing wn>
retained from four to six weeks, and he was now treating many
cases successfully in this manner for which in former years am-
putation would have been considered necessary.
Dr. Lewis S. Pilcher, of Brooklyn, remarked that compound
fractures, above ali injuries, showed the advantages of antiseptic
surgery. He thought that the chapters upon this subject were
being rewritten. The directions of former years were to be, in
most respects, discarded. The results obtained by the reader of
the paper were ideal — better than could ever be expected by
the profession at large. He believed that the danger in such
cast's lay not in the treatment received in the hospital, but in
the first dressing made by the ambulance surgeon. This lat-
ter subject was one which heretofore had been too much over-
looked
Dr. J. H. Packard, of Philadelphia, referred to the occa-
sional overlooking of punctured wounds in compound fractures
because they were thought to be of minor importance. They
were not of minor importance, and frequently signified a disor-
ganized condition of the tissues. Such wounds should therefore
be laid open and thoroughly cleansed, the general principle
being to get at the bottom of all cavities. He objected to the
use of plaster for the first dressing, preferring the ordinary anti-
septic dressing with splints of felt or binders' board. A plaster
dressing applied when the limb was ssvollen would be inefficient
when the swelling had disappeared. He believed that all sur-
geons should aim at ideal results, such as had been obtained by
the reader.
Dr. Hayd was familiar with the work of the reader of the
paper and corroborated his statements in regard to the excel-
lence of the method employed. It was an advance upon Volk-
mann's method in that drainage-tubes had been found unneces-
sary. The plaster dressing had not justified the objections re-
ferred to by the previous speaker in the cases which he had
observed.
Dr. Mynter emphasized his point of converting a contused
into an incised wound, and also tbe possibility of obtaining
healing, even in extensive wounds, without pus. The plaster
dressing was placed outside a thin antiseptic, dressing. He did
not think hospitals were so much at fault as surgeons when
healing did not take place. If a surgeon was thoroughly clean,
cases such as those which were under discussion could be suc-
cessfully treated even in very dirty hospitals. He did not think
one should expect too much from ambulance surgeons, who were
not men of experience in their work. The temporary dressing
made by them should be removed as soon as possible, and not
allowed to remain for hours as a matter of convenience to the
surgeon.
Intravenous Saline Infusion for the Relief of Shock and
Acute Ansemia. — Dr. Pilchee read a paper thus entitled. The
subject was not a new one. The object of the proposed meas-
ure was to restore the circulation to full volume as soon as pos-
sible after the occurrence of shock or the loss of blood. Blood
was not absolutely necessary to effect this end. There were
three classes of cases in which the method was indicated : (1)
those in which shock was the predominating influence, (2) those
in which haemorrhage and shock were combined, (8) those in
which haemorrhage was the predominating influence. In a con-
dition of shock the blood pressure was observed to fall, vitality
w as lowered, and, it this state continued, syncope would result.
Such a result should be anticipated by laying bare ami opening
the median basilic vein, and injecting not less than eight ounces
of a weak saline solution. This quantity might not be sufficient
and might be increased to a quart, or even two quarts, as in a
case which was narrated by the reader. In any case it would
be necessary to continue the injection until the volume and
force of the pulse were measurably augmented by the rapid dif-
fusion of the fluid. The operation was a simple one, the instru-
ments required being a glass tip for introduction into the vein,
a piece of rubber tubing attached to the glass tip, and a funnel
188
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[N. Y. Mkd. Jol-b.,
attached to the distal end of the tuhe. The funnel must have
sufficient elevation to give the requisite degree of force to the
fluid in entering the vessel.
(To be continued.)
NEW YORK ACADEMY OF MEDICINE.
SECTION IX ORTHOPEDIC SURGERY.
Meeting of December 18, 1891.
Dr. Samuel Ketch in the Chair.
Congenital Absence of a Portion of both Lower Ex-
tremities.— Dr. John Ridlon presented a hoy, ten years old,
who had been brought by Dr. Manning to the last meeting of
the Hospital Graduates' Club. There was an entire absence of
all the parts below the condyles of the femur, and just posterior
to the extremity of each of these stumps was a fleshy mass,
which probably represented the undeveloped digits. Tiie boy
could walk quite well on these stumps, and at present was wear-
ing artificial limbs, but, as these caused pain, he had presenter!
the hoy with the hope that some suggestions might be offered
as to the best way of treating the case. It was questionable
whether an artificial leg with a joint at the knee could be ap-
plied to limbs of this length, and hence the question of amputa-
tion might properly be considered. Personally, he was in favor
of applying artificial legs, without any knee joint, directly to the
stumps without operative procedures.
Dr. W. R. Townsend thought that the fleshy masses would
interfere with the proper application of these artificial limbs, and
hence favored removing them.
Dr J. E. Kelly thought that the fleshy masses were un-
doubtedly the remains of the undeveloped lower portions of the
limb. He thought their position the normal one in utcro. He
had seen within the last few months a somewhat similar ampu-
tation in the upper extremity, with rudimentary digits which
had been capable of movement.
Dr. Halsted Myers, on -examination, found a slightly mov-
able bony mass between the condyles of the left femur, proba-
bly a poorly developed patella. He thought the case one of
non-development, not amputation.
Congenital Deformities of the Upper and Lower Ex-
tremities.— Dr. Myers presented a case and asked the opinion
of the Section as to the value of operative procedures for the
relief of the constrictions caused by amniotic bands.
Dr. Kelly thought that the phalanges of the great toes were
perfect in tins case, but that the digits had been suppressed, and
development had taken place beneath the skin.
Tne Chairman referred to a child he Lad seen in which there
had evidently been an attempt at amputation in utero. There
was a deep constriction just above each ankle, more marked,
however, on one side. The mother of this child, quite early in
pregnancy, had been tripped by a cord which some boys had
tied across the street, and it was thought that this maternal im-
pression was responsible for the deformity. The child was able
to walk with the aid of ordinary ankle supports.
Dr. Townsend did not favor operating upon these constrict-
ing bands, for the cicatrix would cause farther contraction.
The Anatomy of the Foot, with Exhibition of a New
Club-foot Shoe. — The postponed discussion on Dr. J. E. Kelly's
paper was opened by Dr. Royal Whitman, who said that the
author had spoken of removing a wedge-shaped {Tece from the
cuneiform bones, but as these bones were quite small, their di-
mensions varying from half an inch to an inch, it was evident that
a cuneiform osteotomy on such bones would be impracticable.
The calcaneum could, of course, be treated in this manner by
cutting to a considerable depth, but such an operation was to-
tally unnecessary. When one recalled the fact that the astrag-
alus was poised on the os calcis in unstable equilibrium, there
seemed to be no reason for increasing this instability. Such op-
erations might be allowable if it were true, as had been stated
before in the Section, that the radical cure of flat-foot was im-
possible, and that all that could be hoped for was relief. He
had seen more than 300 cases of Hat-foot, and he believed that a
radical cure without operation was not only possible but easy.
Dr. A. B. Judson said that the mechanical toy constructed
by Dr. Kelly admirably illustrated the fact that human locomo-
tion resembled the action of a wheel in motion, in which the
legs were the spokes and the feet were the felloes, as pointed
out by Dr. Holmes. That ordinary locomotion was a continual
falling and a continual recovery was seen in the gait of a child
learning to walk, and in the titnbation of a drunken man, whose
body inclined in a given direction and would fall if the legs and
feet failed to make a timely movement forward to prevent a fall.
He said that Dr. Kelly's apparatus took advantage of the weight
of the body for the correction of the varus. It was well known
that varus corrected to a certain point and held there was fur-
ther corrected by the weight of the body applied in successive
blows, as the child ran about. On the other band, if the varus
was reduced only to a point on the wrong side of the line be-
tween deformity and symmetry, each foot-fall was a blow in-
ci easing the varus. Dr. Cook, of Hartford, had shown a varus
shoe at Washington last summer which had had attached to the
sole a flat piece of steel extending outward a few inches to en-
able the weight of the body to act in a favorable manner on the
deformity. He had seen a horse treated for some affection which
made it desirable to prevent extension of the foot by the appli-
cation of a horseshoe having a long posterior prolongation!
The veterinary surgeon could attach his apparatus with absolute
firmness to the foot, but in our patients the foot was apt to
turn over inside of the shoe. As a rule, the weight of the body
could be made more effective by the use of an apparatus having
an upright extending up the leg, and a steel foot piece in which
the foot was prevented from rolling by a strip of adhesive
plaster.
Dr. R. II. Sayre said that this succession of falls during the
act of locomotion was well shown in instantaneous photographs
of athletes running. The shoe exhibited by the author was
doubtless intended for the treatment of club-foot in the later
stages, when it was possible for the foot to be placed flat on the
ground in a fairly good position. Before this stage the shoe
could not be easily adapted to the crooked foot. The usefulness
of this "snow shoe" was not so much on account of its shape
as of the fact that there was a long lever on the outer portion
of the foot which prevented the child from standing on this outer
portion. In connection with this shoe, he had intended to exhibit
a shoe which one of his patients had devised for his own U9e.
His shoe had been made with the sole sloping outward for some
distance, thus answering the same purpose as the snow-shoe.
This patient had bad adhesions and contracted tendons following
infantile paralysis, so that the weight of the body bad been un-
able to do more than prevent an increase of the deformity. The
foot had only been brought straight by subcutaneous tenotomy
and the use of very strong force applied by means of Bradford's
instrument.
The Chairman said that many instances were recorded in
which this principle of utilizing the weight of the body had been
embodied in various kinds of apparatus. In some cases of equi-
nus the patients had been allowed to walk without apparatus
with the idea of utilizing this factor.
A Consideration of some of the Affections of Tendon
Sheaths and Bursae, and their Relations to Injuries and
Diseases of the Joints. — Dr. Royal Whitman read a paper with
Feb. 13, 1892.]
PROCEEDINGS
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189
! this title. He briefly described tlie structure and anatomical
relations of bursa) and tendon sheaths, their diseases, and their
appropriate treatment, calling attention to the tact that chronic
disease of tendon sheaths was usually tuberculous in character,
for which early removal was the only remedy. The relation of
the tendon sheaths to the ankle and wrist joints, and their lia-
bility to injury in sprains and fractures, explained the symptoms
I — weakness, local pain, and limitation of normal motion — often
persisting after such injuries. The importance of local massage
and stimulation in the early stage, in order to prevent the for-
mation of adhesions alter secondary inflammation of tendon
sheaths, was urged. In chronic and neglected sprains a careful
examination should be made, and, if adhesions or contractions
were present, treatment should be directed to a recovery of the
normal range of motion. This result might often be accom-
plished by a forcible overstretching under anaesthesia, followed
by massage and support. By such treatment patients disabled for
many months might, be relieved quickly and permanently. In
, conclusion, attention was called to the importance of slight in-
juries in childhood, which might be the starting-point of tuber-
culous disease, the diagnostic value of chronicity, and the neces-
sity of careful observation and early treatment in suspicious
i cases.
Dr. Judson said that he had seen a case of tumor of the
, semi-membranosus similar to the one shown in the model. The
child had been about six years old, and, under a purely expect-
ant treatment, the tumor had disappeared in the course of a few
months, leaving no deformity or disability.
Dr. Townsend said that he had seen many of the cases re-
, ferred to by the author, and he had been struck with the many
and varied diagnoses which had been made upon them before
they came to the dispensary. The diagnosis in the early stages
was often difficult, especially when there was only a meager and
often misleading history such as accompanied most dispensary
: cases. The importance of the diagnosis could not be too strong-
i ly emphasized, particularly as upon it depended a correct prog-
nosis.
Dr. C. A. Powers said that he inferred from the author's re-
marks on injuries at the lower end of the radius that he recom-
mended confining the flexor and extensor tendons of the fingers
in the treatment of Colles'3 fracture. He saw a large number of
I these cases with functional disability following this method of
, treatment, and he therefore preferred to use the long anterior
splint for the first five or six days, and then to shorten both the
anterior and posterior splint to the first row of the carpus, di-
recting the patient to make very active use of the fingers. Four
or five days after this he expected him to be able to shut the
fingers well down into the palm.
Dr. Kelly said that in Dublin, the home and birthplace of
Golles's fracture, the keel-shaped splint, which avoided injurious
pressure on the thenar and hypothenar eminences was almost
universally employed. The mode of development of the bursa'
found on various points exposed to pressure was difficult to un-
derstand, unless we remembered that the peritonaeum, which
was the great areolar interspace of the body, had had a similar
development from the connective-tissue structures. He was
glad that the author agreed with him as to the position of the
foot — viz., slight adduction with the foot at right angles to the
leg. This slight adduction produced what he called " artificial
talipes varus."
The Chairman said that lie inferred from what the author
said that he considered these bursal tumors of tubercular origin,
il' wished to dissent from this opinion, for many of them w ere
benign and the result of injury.
Dr. Whitman explained that he had spoken of slow, chronic
enlargement of the sheaths of the tendons of the wrist and band
as tubercular. The deep-seated bursas were favorably located
for tubercular inflammation, and accordingly when they under-
went chronic enlargement he preferred to treat them radically.
He had only incidentally referred to the treatment of Colles's
fracture. He did not consider the confinement of the fingers
with vigorous massage and local stimulation the same as the
confinement treatment which had been criticised during the dis-
cussion.
An Improved Adjustable School Desk and Chair.— Mr.
E. E. Hicks exhibited a chair and desk which he had devised,
and to which reference had been made in the recent discussion
on the subject of the relation of faulty attitudes to lateral curva-
ture of the spine. The desk and seat admitted of an independent
vertical adjustment of four inches, which was manipulated by
means of a key. The slope of the desk could also be varied to
suit individual requirements. The desks and seats could be
folded so as to occupy very little space, thus facilitating clean-
ing the school-room and allowing room for gymnastics. The
seat and desk had a common base of support; a child using the
desk, therefore, occupied the seat joined to the desk next be-
hind. This improved desk cost only about fifty cents more than
those now found in the market.
Dr. R. H. Sayre thought this desk was a decided improve-
ment on the usual style.
The Chairman thought that it might be desirable for a child
already suffering from lateral curvature, but he did not believe
that faulty attitudes at school were the cause of rotary lateral
curvature.
Tubercular Disease of the Vertebrae in its Early Stages.
— Dr. R. H. Sayre presented the second, third, and fourth lum-
bar vertebrae of a patient, showing a very early stage of tuber-
cular disease. There was a cheesy mass in the third lumbar
vertebra w hich had not yet broken down and ulcerated through
into the cartilage. The points of junction between the second
and third, and the third and fourth vertebra? were apparently
normal. There was an extravasation of blood into the vertebra?.
The history of the patient from whom these specimens were
taken was quite interesting. A child suffering for some time
from chills and high temperature had begun to have a peculiar
posture and mode of locomotion and to suffer from abdominal
pains. This had led to a diagnosis of spinal disease, but in a
consultation with an orthopaedic surgeon this opinion had not
been confirmed, the latter believing that the child was suffering
from malaria. The symptoms not subsiding under the adminis-
tration of quinine, the child had been brought to Dr. L. A.
Sayre, who had concurred in the diagnosis of disease of the
spine. At this time there had been some psoas contraction on
the right side, with spinal rigidity and very slight pains. It
could hardly be said that there had been a kyphosis ; the lumbar
spine had been straight instead of concave. The child had been
placed in a wire cuirass. About a month later he had suddenly
shown a temperature of 104°, with vomiting, photophobia,
phonophobia, stiffness of the neck, and a rapid pulse Be bad
then been seen by the speaker, who had found an abdominal
enlargement near the left side of the umbilicus, which could be
separated by percussion from the spleen. It bad been quite
freely movable. Small doses of bichloride of mercury had been
administered, and in a few days the temperature had fallen to
100° and- bad remained at this point, and the other meningeal
symptoms bad disappeared. There had been no colic indicating
tubercular peritonitis. The child bad become then even more
anaemic than before, and the abdominal swelling had increased
in size. It. had seemed hardly possible that the mass could be a
psoas abscess pointing in such an unusual position. Alter some
time the mass had become larger and bad moved toward the
posterior surface of the abdomen. In consultation with Dr. W.
190
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[N. Y. Med. Jour.,
T. Bull, it had been decided to be inadvisable to operate. The
child had died six days ago, and for a few days before death
there had been slight jaundice. The post-mortem examination
hud .shown that the abdominal tumor was formed by a tuber-
cular mass which united the intestines into one large mass.
There were no small miliary tubercles scattered over the perito-
naeum. One little band pressed upon the gall-bladder, and so
accounted for the jaundice. The kidneys were firmly bound
down with adhesions, and the left one was very large and
waxy and its pelvis was much dilated. There was a large quan-
tity of Huid in both pleural cavities, and there were cheesy
nodules at the apices of the lungs. The heart was enormously
thickened; the brain was not examined.
The Chairman thought that the symptoms described were
more like those of an acute non-tubercular meningitis, as in the
initial stage of the tubercular variety a high temperature was
unusual, and the pulse was ordinarily slow or intermittent.
Then, again, the subsidence of the symptoms was not in accord-
ance with such a diagnosis.
Dr. Kelly called attention to the fact that in the early and
late stages of tubercular meningitis the pulse was rapid, while
in the intermediate stage it was slow.
Dr. Ridlon said that he inferred from the remark of the
chairman that he shared in the general feeling in the profes-
sion that if a child survived, it was proof that the meningitis
was not tubercular, and vice rersa. lie desired to express dis-
sent from this opinion. Eight or nine years ago he had treated
a boy who had suffered from a form of meningitis which sev-
eral eminent consultants had considered to be tubercular; and
they had an opportunity of seeing the patient a good many times.
The patient was still alive, but he did not believe this proved
that the diagnosis was incorrect.
The Chairman said that he had never seen one undoubted
c ise of tubercular meningitis end in recovery, although he be-
lieved there were a few such cases on record.
Dr. H. W. Berg was not aware that there was any symptom,
either subjective or objective, which would enable one to make
a diagnosis between simple and tubercular meningitis. He
thought that where there was a high temperature at the begin-
ning of a meningitis, it was due to a series of eclamptic seizures
which, by paralyzing the beat center of the body, allowed of a
sudden rise of temperature.
Dr. Townsend had had an opportunity of seeing a consider-
able number of cases of tubercular meningitis, almost all of
which had been proved by autopsy to be tubercular, and he
could not recall any case where there was an extremely high
temperature at the beginning.
Dr. R. H. Sayre said that he had looked upon the meningitis
as tubercular, because of the very general tubercular infection.
The child had looked as if it would die within a few days after
the onset of these meningeal symptoms, and he had been much
surprised when the acute symptoms had subsided so rapidly.
The high temperature might have been due to the abdominal
lesinns. The extent of the abdominal lesions had been remark-
able, as they bad been younger than the disease in the spine.
AME R I C A N L A R YNC 0 LOG I C A L A SSOOI A TION.
Thirteenth Annual Congress, held at Washington, on Tuesday,
Wednesday, and Thursday, September 22. 23, and 24, 1891.
The President, Dr. W. ('. Glasgow, of St. Louis, in the Chair.
The Troublesome Symptoms caused by Enlargement of
the Epiglottis, and the Advisability of reducing the Size
of this Cartilage by Operative Measures. —Dr. C. 0. Rioe, of
New York, read a paper on this subject. (To he published.)
Dr. Mulhall: Did I understand Dr. Rice to state that he
had seen cases of uncomplicated, non-syphilitic, non-malignant,
non-tubercular, non-traumatic primary enlargement of the epi-
glottis?
Dr. Rice : Yes, I have.
Dr. Mulhall: Are they not uncommon?
Dr. Rice: I think they are.
Dr. Mulhall: I have asked this question because it is to me
a novel fact that there can be a case of pure, uncomplicated,
simple chondritis in any part of the body. I can understand
enlargement of the epiglottis from surrounding catarrhal or
other inflammation, which is the usual cause. I recall the case
of a lady in St. Louis who had an unyielding, irritable cough.
She went abroad a year ago and consulted a prominent laryn-
gologist, who pronounced the cause of her cough to be a dis-
torted and enlarged epiglottis, and he galvano-cauterized it.
Following this there was much irritation of the epiglottis and
swelling, with more cough. This lady died a week ago with
pulmonary tuberculosis. She told me that the prominent laryn-
gologist did not examine her lungs once. I can understand a
large, pendulous epiglottis as a result of irritation ; but I can
not understand a primary non-specific enlargement of the epi-
glottis. It is new pathology to me.
Dr. S. 0. Vander Poel: I wish to emphasize the remarks
of Dr. Rice regarding the unfavorable results following the gal-
vano-cautery in cases of this kind. The use of the curette or
sharp spoon has given me much more satisfaction. The patho-
logical condition described by Dr. Rice, the hypertrophy of the
cartilaginous elements. I am not familiar with, but I have seen
enlargement, with more or less inflammation and hypertrophy,
of the epiglottis in connection with enlargement of the tonsils.
Dr. Jarvis : I was much interested in Dr. Rice's remarks
upon hypertrophy of the epiglottis, lie explains a condition
new to me — something 1 have never seen. The signs of con-
gestion and enlargement from inflammation we are familiar with,
but primary hypertrophy of the cartilage of the epiglottis is
new. You may perhaps remember a somewhat similar condi-
tion, which was referred to in connection with our discussion
of the enlargement of the saeptum narium at a former meeting.
I then held that there might be an enlargement of this cartilage
due to increase of cartilage cells, which could only be demon-
strated by the microscope ; and, upon making further investiga-
tion, discovered that inflammatory changes in the submucous
tissue directly above the cartilage could be easily demonstrated.
I think that, in all probability, in the enlarged epiglottis of Dr.
Rice a similar condition will be found to exist. Change of form
of the epiglottis may result from distortion and congestion. That
we may have disturbance of function from these causes I am
satisfied. I recall the case of a clergyman who came to me with
a cough and difficult phouation. I found a swollen epiglot-
tis, and applied cocaine in the manner recommended by Dr.
Rice, and the patient experienced so much relief that he was
enabled to resume his duties in the pulpit. There may he no
direct, advantage gained from the use of the galvano-cautery,
but we must acknowledge that the psychical effect produced is
often very great, whether this agent be applied to the hyper-
trophied epiglottis or to the tip of the nose. I believe it may
have given relief from cough, but think it merely acted through
the medium of the patient's mind. A much better substitute
is to train patients to exercise their will, and in this way over-
come the tendency to cough.
Dr. Wagner: About ten years ago I read a paper before
this society in which I reported a case of removal of the en-
tire epiglottis for carcinoma by a subhyoidean incision, the first
case on record. Before performing the operation, I considered
the several methods, and came to the conclusion that removal
Fell. 13, 18U2.]
PROCEEDINGS OF SOCIETIES.
191
by the mouth of the entire epiglottis was impracticable. The
patient experienced no ill effects after the operation, except a
peculiar cough. A similar effect had been observed by an ex-
perimental physiologist at Harvard University in a number of
cats upon which he had performed the operation. I have never
seen a case of ordinary catarrhal inflammation of the cartilage,
as described by Dr. Rice.
Dr. Rice: I certainly think that these cases of enlarged epi-
glottis are exhibitions of a chondritis, and can not see why we
may not have cartilaginous inflammation and enlargement of
the epiglottis as well as of the septal cartilage. I am at a loss
to know why the gentlemen have not observed these enlarged
epiglottides. In many cases I have found enlargement of the
lingual tonsil to be the cause of the irritation and hypertrophy
of the epiglottis, but not always, for in some cases the enlarge-
ment seems to be congenital. 1 do not believe that enlargement
of the epiglottis is an unusual clinical condition, and this condi-
tion is almost as great a source of irritation in the larynx as is
a small foreign body. That enlargement of the epiglottis and
its contact with neighboring tissues produces distressing symp-
toms and demands appropriate treatment, I am sure must be
admitted. Medicinal applications seem to be inadequate to re-
duce the size of the epiglott is.
The Result of Treatment of the Upper Air-passages in
producing Permanent Relief in Asthma.— Dr. F. H. Bos
worth, of New York, read a paper with this title as the open-
ing of a discussion on the subject. (To be published.)
Dr. Beverley Robinson : Mr. President, I merely desire to
take up this subject again in order to affirm the opinions which
I have endeavored to place before this association at previous
meetings and before other societies, and which I have expressed
in some of the medical periodicals of the day. I am glad, if I
interpreted Dr. Bosworth's paper correctly, to learn that he has
somewhat modified the views winch he maintained several years
ago. It is certainly remarkable for him to say that other con-
ditions than those present in the nose take a prominent part in
causing an outbreak of asthma. Certainly none of us take ex-
ception to his statement that he had by his treatment given re-
lief to a certain number of cases. We merely do not accept the
assertion that all cases of asthma arise in the nose ; that, in ef-
fect Providence has appointed that all cases of this kind should
fall into the hands of the rhinologist and laryngologist, and that
all cases of pure asthma should go to the specialist and to him
alone. In a paper which I read before the Cliinatological As-
sociation in 1889 I endeavored to prove, and believe I did prove,
that Dr. Bosworth's views were wrong from a broad general
standpoint ; that they were those of a specialist. I think that
if Dr. Bosworth had followed up his cases he would have found
a certain amount of the old trouble recurring at intervals. I am
firmly of the belief that where there are frequently changes
in the peripheral nerve fibers or central nervous system, a per-
manent cure is rare. Local conditions of the nose may at
times justify an operation for removal of a source of irrita-
tion, hut I wish to put myself upon record against the view that
obstruction of the nasal chamber, or the effect of inflammation,
is the usual cause of asthmatic attacks. I am opposed to such
a limited view of the disease. While we may occasionally re-
move the source of a certain amount of irritation by the treat-
ment of the nose, we do not remove the disease ; relief may fol-
low just as it sometimes follows the application of a blister be-
tween the shoulders. The relief may persist for a certain length
of time, but after a while the condition producing the attack will
return and the old disease reappear.
Dr. Roe: In all cases of asthma caused by disease of the
nasal passages we should distinguish between those in which
the asthma is dependent directly upon diseased conditions in the
nasal passages and those in which there is associated disease of
other portions of the upper respiratory tract which have resulted
from disease in the nasal passages and which often become inde-
pendent centers of irritation in the production of asthma. As
regards the astiology of asthma, I believe that asthma proper is
always dependent upon a diseased condition of the bronchial
mucous membrane, and it is by reason of this abnormal condi-
tion of the bronchial mucous membrane that diseases in the up-
per air-passages so readily produce turgescence and swelling of
the bronchial mucous membrane, as was first pointed out by
Weber. I think that in those cases reported by Dr. Bosworth,
where the attacks recurred, it was because he overlooked the
diseased conditions in other portions of the respiratory tract
after he had removed the disease in the nose. In this manner
it is readily explained why in some cases asthma dependent upon
nasal polyps will be readily cured by the removal of the polyps,
while in other and quite similar cases the removal of the polyps
will have but little or no effect in arresting the asthma.
Dr. Wagner: In a brochure, published about ten years ago,
on Habitual Mouth-breathing, I reported a case of nasal polypi
which greatly obstructed the nasal respiratory passages. After
removal by operation the patient had relief from asthma, from
which he had long suffered. But I have seen since then so many
cases of asthma with, so far as I could judge, perfectly healthy
nares, and, on the other hand, so many cases of nasal polypi, de-
viation of the septum, hypertrophied mucous membrane, exos-
toses, etc., with no symptoms of asthma, that I have long since
ceased to look upon the nose as a factor in this affection, or to
recognize any connection between asthma and nasal disorders.
In regard to patients being benefited by removal to great
altitudes, I have seen many that experienced no relief by the
change. I might refer to one, a New York physician, a sufferer
from asthma, who went through the usual course of painful local
treatment of his nose ; not experiencing relief, he tried change
of climate — to the South, thence to the West Indies, thence to
Colorado Springs, thence to New Mexico, and finally to the sea
level in southern California, where he not only found relief, but
has quite recovered.
Dr. Shurly : I think that the ground has been pretty well
covered in the discussion. I remember very well the paper that
Dr. Bosworth read before the Cliinatological Association, some
years ago, in which he gave his opinions on the causes of asthma
and its treatment. I remember that the same points were
brought out in the discussion then that have just been consid-
ered. Since many cases of disease of the nose occur without
asthma, and rice versa, we are still held to the old conclusions
or doctrine that two causes must co-exist to produce asthma:
Firstly, a point of irritation, which may he in any part of the
body ; and, secondly, a peculiar predisposition of the nervous
system of the individual. Such treatment as Dr. Bosworth pro-
poses is necessary in a certain number of cases ; but the physi-
cian who neglects to treat the nervous element would not do
his whole duty to the patient. In any case, if it is associated
with a hypertrophic enlargement which gives rise to irritation,
this should be removed. In a paper which I wrote sonic years
ago I recorded the results of some experiments upon dogs in
relation to this subject, one of which was that, by irritating the
peripheral nerves of the respiratory tract with an electric cur-
rent, symptoms were produced resembling asthma. This does
not invalidate the view that asthma may be due in some cases
to vascular excitement, or congestion, in certain parts of the
body, because the physical conditions may be about the same. I
regret to say that in many cases the pathology and aetiology can
not be made out, and such I recommend to go to a more suita-
ble climate ; it may be St. Paul, or southern California, or
Macinnac, if it is possible for them to go.
192
PROCEEDINGS
OE SOCIETIES.
[N. Y. Med. Jouk.,
Dr. Glasgow : We must remember that in the surgical treat-
ment of asthma there is a psychical factor; as an attack can
often be broken by a powerful emotion, t lie application of the
electrical cautery has a similar effect. The method of Duclos
at the beginning of the century was based upon this, the effect
being brought about by the application of aqua ammonia to the
pharynx. I read a paper before this society upon the effect of
applications to the larynx in breaking up a paroxysm. I called
attention to the use of carbolic acid and the insufflation of cer-
tain powders into the larynx, and showed that this was immedi-
ately followed by a cessation of the attack of asthma. I have
also seen an attack relieved by simply cleaning the nostrils, by
the removal of a polypus, and even by spraying the cavities
with a simple alkaline wash. One case made a profound im-
pression upon me. I applied a strong solution of carbolic acid
to the larynx during the height of the attack, and the man has
never had an attack of asthma since, and that was three years
ago. The statement of Duclos, together with my own experi-
ence, has made me believe that the results in some of our
patients are largely due to the powerful psychical impression.
Like all nervous affections, asthma is erratic in its course and
appearance. The asthmatic habit is stronger in some than in
others, and the same methods of repression will not be equally
successful in all cases. The habit is unquestionably sometimes
kept up by points of irritation in various parts of the body, and
relief of this irritation is necessary before permanent relief can
be obtained.
Dr. Mulham, : I think that we are arguing away from (un-
original standpoint. What Dr. Bosworth w as referring to was
simple nervous asthma. My objection to the statistics presented
is that they are not properly studied. When Mi-. Hutchinson,
of London, recorded a case, he took the address and visited the
patient afterward to learn the results of treatment. In Dr.
Bosworth's list there are a number in w hich the result is not
given, because the patient failed to come back to him. This in-
validates his percentage of cures. 1 remember when Dr. Daly
read his paper on galvano-eautery in the treatment of hay-fever,
I was impressed by it, and during the next season I treated
twelve cases in this way. I took the address as well as the
name of each patient, and subsequently I called upon them and
found that, while they were surprisingly relieved, they were not
cured. That nasal disease is one of the causes of nervous asth-
ma I can not deny, but that it is the sole cause of the disease is
simply absurd. Patients with nasal polypi are many of them
free from asthma or the tw o diseases may coexist. The patho-
logical irritation may start from the nasal mucous membrane,
and cause reflex contraction and symptoms in parts of the body
other than the bronchi. In one case that I recall there was a
difficulty in passing urine, a spasmodic stricture, which was im-
mediately relieved by the removal of nasal polypi. This patient
had what might be called "vesical asthma."
I agree with Dr. Bosworth in his statement that some cases
of bronchial asthma are cured by the removal of disorder from
the nose, such, for example, as hypertrophic rhinitis. In two
cases that I recall where there was associated enlargement of
the anterior end of the middle turbinated bones I have the
record; one was done five years ago and the other three years
ago. I took the patients' addresses and have verified the result
in each case ;is being complete and lasting successes. The posi-
tion I take with patients is this : I tell them that I have been
able to find nothing wrong in the body except this disease in
the nose, and by its removal the asthma may be cured. I by
no means promise that it will cure the asthma; it may do so
and in many cases will do so, but I can not promise that it will
in any particular case.
Dr. Ingai.s: From my own experience and what I have
learned from others, I am satisfied that in a large percentage of
cases operations on the nose, however complete, fail to relieve
asthma. I have seen three cases in which there was a peculiar
and interesting connection between nasal polypi and asthma.
In all of the three where polypi were confined to one naris, the
patient alleged that the asthma was also confined to the same
side.
Dr. Robinson : I wish to call attention to cases o' asthma of
malarial origin, and would state in the first place that I am to
read before the Climatologies] Association a paper on The Gen-
eral cermix Local Treatment of Catarrhal Inflammations of the
Upper Aii' Tract, in which these cases are reported. They came
under my observation with symptoms of asthma some years
since. I have now reason to believe that in these instances ex-
amination of the blood would show the presence of the liajma-
tozoon malaria?. There is not invariably in such cases enlarge-
ment of the spleen or other physical signs of malarial poisoning.
I have proceeded upon the conviction established by symptom!
to show the connection between the respiratory disorder and
blood-poisoning. By acting in this manner, I have been able
also to note that treatment directed to the condition of the
blood was followed by relief from the asthma. In cases of dif-
ferent order where some nasal source of irritation was present
the Iliematozoon miliaria; was not found.
One other point I would like to mention. A very valu-
able essay w as read by M. Noel Gueneau de Mussy some years
ago upon the effects of enlargement of the bronchial glands in
causing asthmatic attacks in children, and physical examination
has proved to me the correctness of this statement. Why may
not such a condition be sometimes present in cases of asthma in
adults? One reason why the iodide of potassium has such
remarkable value in some of these cases may be explained by
the presence of hypertrophied lymphatic ganglia. I think that
in those cases where there are hypertrophies of the nose, opera-
tion does good by giving freer respiration and relieving conges-
tion.
Dr. Bosworth: I seem to have been exceedingly unfortu-
nate in my choice of words, else I should not have been so mis-
understood. The real subject of my paper has been largely
passed by in the discussion. Dr. Mackenzie has come to the
conclusion that I affirm that I can cure emphysema. I made
no reference to this affection. I did not say that all cases of
asthma were caused by nose diseases. That would be a gross
misstatement ; nobody believes it. To state that because hyper-
trophic rhinitis does not always cause asthma it never causes
asthma, that because nasal polypi do not always cause asthma
they never cause it, scarcely rises to the dignity of discussion.
The old view is that asthma is caused by spasm of the bron-
chial muscles. I do not believe that the bronchial muscles have
anything to do with it. I believe that the vaso-motor theory of
"Weber is the correct one; and if any gentleman here would do
me the favor to read the paper which I prepared three years ago
I think that he would agree with me. I hold that there are
three causes of asthma, as I stated in my paper. This does not
conflict with the views of Hyde Salter and others. W'ith regard
to the cases where there is enlargement of the heart or disease
of the liver or kidneys, I say that these are conditions which
aggravate and keep up the disease. I did not say that the nose
was the only cause, and that its treatment was the only treat-
ment ; but I will say that in nineteen out of twenty cases, if we
pay attention to the nose and remove any disorder existing here,
we shall do better by our patient than if we simply rely upon
iodide of potassium and routine treatment with the usual reme-
dies for asthma.
Dr. Jonathan Weight, of Brooklyn, read a paper on this
subject. (See vol. liv, page 711.)
Feb. 13, 1892.]
BOOK NOTICES.
193
Dr. MuxhaliT: I did not hear all of Dr. Wright's paper, but
1 agree with his conclusion. In my specimen and report pre-
sented last year I took occasion to state that I doubted very
much the propriety of Hopmann's statement that he had found
so many cases of true papilloma. I removed such a growth,
just before 1 left home, attached to the columua. It resembled
a bunch of grapes, was pedunculated, and completely blocked
the nostril. I found upon examination that it w as a true pap-
illary fibroma — the only case I have ever seen. I wondered
why 1 had never seen any before when Hopmann had seen so
many, but Dr. Wright has probably furnished the true expla-
nation.
Dr. Shukly: I was very much interested in this truly
valuable paper we have just heard read; it is valuable for its
Investigations in the fields of histology and pathological anat-
omy. In these papillary growths we have another illustration
of the law of evolution and the analogy between the animal
and vegetable world. This process of budding, so prominently
belonging to vegetable growth, is nevertheless destined in a
few years to be accepted in explanation of the growth of tu-
mors, a vegetable process manifested, as it were, by animal
tissues.
Dr. J. Solis-Cohen : I believe that macroscopically a distinc-
tion may be made in many cases between papillary and other
tumors in the contrast between the size of the growth at its
base and at its attachment, the former being pedunculated. I
think something of this kind was what led Hopmann astray.
I remember that Dr. Jarvis some some years ago pointed out
this contraction at the point of attachment of papillomata, and
I think that this led to the invention of the snare.
Dr. Jarvis: I had something to say upon this point last
year. The only case of true papilloma that ever came to my
notice I reported at that time. I have seen a number of cases,
in both public and private practice, such as Hopmann describes,
but I recall one case of true papilloma, and this was at the mar-
gin of the vestibule at its junction with the skin. I have also
seen that condition of the turbinated bone alluded to by Dr. Solis-
Cohen which Hopmann evidently mistook for a true papilloma.
In the nostril proper I have never seen an instance of independ-
ent papilloma, but I have seen them in connection with other
growths, such as mucous polypi, and think that they may easily
be overlooked. I regard these as secondary to the polypi, and as
not requiring special treatment. As remarked by Dr. Solis-
Cohen, it is of more interest to ns and to those in general prac-
tice to establish points of diagnosis upon macroscopic distinc-
tions rather than microscopic. I pointed out in a former com-
munication that chromic acid afforded a special means for dis-
tinguishing papillary from other growths. In papilloma the
application of chromic acid to the base of the growth creates a
peculiar eschar.
Dr. Mackknzie : At our meeting a year ago I said that true
papilloma of the nans was rare, having myself seen only two cases.
It is more common anteriorly than in the posterior nares. It is
probable that Hopmann has mistaken for papilloma those papil-
lary vegetations characteristic of the transition stage from hy-
pertrophic to atrophic rhinitis. It is not unusual for patients
to expel these masses spontaneously, thereby gaining relief from
previous nasal obstruction. As a matter ot fact, however, this
process of detachment and expulsion is degenerative, and the
final condition of atrophy is worse than that which preceded.
Dr. Weight : There is very little to be said in closing the
discussion. I think that Hopmann was not so much led astray in
his diagnosis as be was wrong in his nomenclature ; he knew
what they were, but called them by an objectionable name. If
this is permitted, it introduces confusion into laryngological
literature. I was not aware that he had recanted in a more re-
cent publication, as I have not followed up the subject very
closely. I must take exception to the statement of Dr. Jarvis
that it is not very important to make a microscopical diagnosis
between these tumors and others which resemble them. I think
it very important.
Dr. Jarvis : I meant from a therapeutical point of view.
Dr. J. Sous-Cofien : If the word papilloma is to be rejected,
perhaps some title such as " dendritic vegetations " would be a
good substitute.
Dr. Wrigiit : I think it would be better to abandon the term
papilloma altogether:
( To be continued.)
I^ooh llotices.
A Practical Treatise on the Diseases of the Ear, including a
Sketch of Aural Anatomy and Physiology. By D. B. St.
John Roosa, M. D., LL. D,, Professor of Diseases of the Eye
and Ear in the Newr York Post-graduate Medical School and
President of the Faculty, etc. Seventh Revised Edition.
New York: William Wood & Co., 1891. Pp. xxii-741.
Many physicians will greet this work as an old and well-
tried friend, reliable and trustworthy. It has changed very
little since its last appearance, though some additions have been
made, mainly in the portion devoted to middle-ear diseases.
It is a work which is not only valuable to the specialist, but
also peculiarly adapted to the needs of the general practitioner
who is situated at a distance from a specialist and must either
let aural diseases work their disastrous results upon his patients
or learn to treat them himself. To the physician wTho prefers
to do the former, suggestions are useless, but to him who desires
the latter, this work is to be strongly recommended as a safe
and conservative guide.
Cookery for the Diabetic. By W. H. and Mrs. Poole, with a
Preface by Dr. Pavy. London and New York : Longmans,
Green, & Co., 1891. Pp. vi-64.
This little book will lift a load from the mind of every phy-
sician who has a serious-case of diabetes to manage. He knows
how soon apparently slight restrictions in diet become irksome
and how often articles of themselves harmless are rendered in-
jurious by the cooking. He has felt the need of formulas by
which his patients' diet might be rendered not only harmless
but palatable. A list of prohibited and permissible articles is
not sufficient, but it is all that is usually given. This book is a
recipe-book designed not for the physician's library, but to be
sent to the cook in the kitchen. The receipts are evidently prac-
tical and, having the sanction of Dr. Pavy, may be relied upon
as harmless. Some are original ; others are modifications of
well-known receipts, while some are simply changed by the use
of saccharin instead of sugar.
BOOKS, ETC., RECEIVED.
Atlas of Clinical Medicine. By Byrom Bratnwell, M. D., F. R. C. P
Edin., F. R. S. Edin., Assistant Physician to the Edinburgh Royal In-
firmary. Vol. I. Part III. Edinburgh: T. & A. Constable, 1891.
Pp. 9V to 140.
The Principles of Bacteriology : a Practical Manual for Students
and Physicians. By A. ('. Abbott, M. First Af>istant, Laboratory
of Hygiene, University of Pennsylvania, Philadelphia. With Illustra-
tions. Philadelphia: Lea Brothers & Co., 1892. Pp. viii-18 to 263.
The Diseases of the Mouth in Children (Non-surgical). By F. Porch-
194:
heiraer, M. D., Professor of Physiology and Clinical Diseases of Chil-
dren, Medical College of Ohio, etc. Philadelphia: .1. B. Lippineott
Company, 1892. Pp. vi-8 to 199. [Price, $1.25.]
The Complete Medical Pocket-Formulary and Physician's Vade-
Mecmn : containing upward of 2,500 Prescriptions, collected from the
Practice of Physicians and Surgeons of Experience, American and
Foreign, arranged for Ready Reference under an Alphabetical List of
Diseases ; also a Special List of New Drugs, with their Dosage, Solu-
bilities, and Therapeutical Applications; together with a Table of
Formula? for Suppositories; a Table of Formula; for Hypodermic Medi-
cation ; a List of Drugs for inhalation ; a Table of Poisons with their
Antidotes; a Posological Table; a Lis*, of rn compatibles ; a Table of
Metric Equivalents ; a Brief Account of External Antipyretics, Disin-
fectants, Medicil Thermometry, the Urinary Tests; and much other
Useful Information. Collated for the Use of Practitioners by J. C.
Wilson, A. M., M. D., Physician to the German Hospital, Philadelphia.
Philadelphia: .1. B. Lippincott Company, 1892. Pp. x-11 to 261.
[Price, $2.]
Diseases of the Bladder and Prostate. By Hal. ('. Wyman, M. Sc.,
M. D., Professor of Surgery in the Michigan College of Medicine and
Surgery, Detroit, Detroit: George S. Davis, 1891. [The Physicians'
Leisure Library.] [Price, 25 cents.]
Stricture of the Rectum : a Study of One Hundred and Thirty-eight
Cases. Second Edition, enlarged. By Charles B. Kelsey, M. D., etc.
Four Congenital Tumors of the Head and Spine, all submitted to
Operation. (Clinical Lecture delivered at the .Jefferson Medical College
Hospital.) By W. W. Keen, M. D. [Reprinted from International
Clinics.]
Jacksonian Epilepsy; Trephining; Removal of Small Tumor, and
Excision of Cortex. By Charles K. Mills, M. D., and W. W. Keen, M. D.
[Reprinted from the American Journal of the Medical Sciences.']
Considerations upon Medical Hemorrhage surgically treated ; with
a Successful Case, by a New Technique, of Saline Infusion for Severe
Haemorrhage. By Robert H. M. Dawbarn, M. D.
Remarks Introductory to a Discussion on Acute Diffuse Peritonitis.
By A. L. Carroll, M. D. [Reprinted from the Transactions of the Kew
York Slate Medical Association.]
Medical Ethics gone to Seed. By James H. Bell, M. D., Philadel-
phia. [Reprinted from the Medical News.]
Dental Infirmary Patients. The Use and Abuse of Dental Charity.
By Richard Grady, M. D., D. D. S., Baltimore. [Reprinted from the
Journal o f the American Medical Association.]
Microscopical Diagnosis of Tuberculosis. By Paul Paquin, M. D.,
Battle Creek, Mich.
The Situation and Climate of Asheville, N. C. By H. Longstreet
Taylor, A. M., M. D., Asheville, N. C. [Reprinted from the Lancet-
Clinic]
The Results of the Shurly-Gibbes Treatment of Tuberculosis at
Asheville, N. C. By H. Longstreet Taylor, A. M., M. D., Asheville, N. C.
[Reprinted from the Therapeutic Gazette.]
What can be done in Cerebral Surgery. Remarks based chieflv
upon Personal Experience in Twenty-three Cases. By E. Lanphear,
M. D., Kansas City, Mo.
A Clinical Study of One Hundred and Forty-two Cases of Heart Dis-
ease in Children. By Floyd M. Crandall, M. D. | Reprinted from the
Archives of Pwdialrics.]
Tenth Annual Report of the Hospital for Women and Children,
Newark, N. J., December, 1891.
De la chloroformisation a doses faibles et continues. Par le Dr.
Marcel Baudouin. [Extrait de la Gazette des hdpitaux ]
Transactions of the American Gynaecological Society. Volume
XVI, for the Year 1891.
Kemp & Co.'s Prescribers' Pharmacopoeia, A Synopsis of the more
Recent Remedies, Official and Unofficial, with a Therapeutic Index and
a Resume of the B. P. Additions, 1890. By a Member of the Pharma-
ceutical Society of Great Britain. Second Edition. Bombay: Kemp
& Co., Ld., 1891. Pp. xi to 429.
Thirty-sixth Annual Report of the Executive Committee of the Hart-
ford Hospital. Presented to the Directors at their Annual Meeting,
December 16, 1891.
[N. Y. Med. Joan.,
Ilcto #nbcntions, etc.
A NEW HYPODERMIC-SYRINGE NEEDLE.
By W. J. P. Kingslky, M. D.,
ROME, N. T.
Fob many years I have used the common form of hypodermic
needle very extensively. During this time I have always been greatly
inconvenienced by the tendency of the channel to clog easily. This is
not only very annoying, but occasionally of serious importance in an
urgent case. Within the past year it occurred to me that a needle
with a conical channel, having the smallest opening attached to the
syringe, could not clog. Several months ago Messrs. George Tiemann
& Co., of New York, made a few needles according to my design.
None of these have ever clogged, although thoroughly tested, and they
have proved so satisfactory in every way that I desire to give the pro-
fession the benefit of this improvement. Fig. 1 shows the regular
size. Fig. 2 shows an enlarged view, which will be more easily under-
stood.
Itl i s c c 1 1 a n n .
The Vernacular Medicine and Surgery of Japan. — Dr. Benjamin
Howard contributes the following article to the Lancet for January
16th:
In aptitude, adaptation, and enterprise the Japanese have shown a
decided superiority over all other nationalities of the Orient. These
qualities, added to great delicacy of manipulation, have made them in
art conspicuous throughout the world. It is but natural to expect,
therefore, that they should be found to have arrived at something, both
in medicine and surgery, which the nations of the West might find to
be an acquisition. The earlier Japanese medicine dates back to the
"Shindai," or divine age, many centuries before Christ. The Chinese,
as early as 218 b. c, found their way among the Japanese doctors with
medical books dating back, it is alleged, to 2737 b. c, and the influence
of Chinese medicine upon Japanese medicine has continued to beacon-
trolling one up to the recent introduction of European medicine now in
vogue. As it is difficult to disentangle that past which is of Chinese
origin, I include in the vernacular medicine and surgery of Japan all
which pertained to its general practice, say, forty years ago, and which
still pertains to the practice of about 30,000 out of the 41,000 physi-
cians now practicing throughout the empire. Of the 30,000 of the old
vernacular school, one of thtm is still on the list of the Court physicians
and maintains a high reputation.
The impression throughout Europe that colored papers, exorcisms,
etc., are the basis of Chinese and Japanese medicine is erroneous. I
have myself seen nearly 2,000 books by these people, covering most of
the departments of medicine, but among which matt ria meuica occu-
pies altogether the leading place. In these books are the doctrines of
the successive schools, strikingly like some of those which in past cent-
uries existed among our own ancestors. The successive medical col-
leges have always had a professor of astrology, but the solid fact re-
mains that the materia medica has included among its several hundred
remedies a large number of those used by ourselves, and these are not
only vegetable, but animal and mineral, in the latter class mercury
being prominent. Surgery became a separate branch as long since as
the seventh or eighth century. Tube acupuncture needles, so compara-
tively new with us, have been in use here since a. d. 1688. Centuries
ago one of their authors wrote : "When medicines are ineffectual as
well as acupuncture and the cautery, the abdomen and back may be
opened, the stomach and intestines be washed, etc." A narcotic mixt-
ure employed on such occasions contained Datura alba, aconitum, etc.
EG OK NOTICES.— NEW INVENTIONS.- MISCELLANY.
Fell. 13, 1892.]
MISCELLANY.
195
As the history of medicine in Japan once included so much which
seems sulistanli.il, Tliiive inquired with much care among practitioners
of the old or vernacular school — all of whom were in practice before
1 8 "7 * > — hoping to discover something in their practice now which would
be a veritable addition to the medical resources of our European
brethren. 1 am sorry tu have to say that the result of my search has
not met uiy anticipations. As far as 1 have been able to discover, the
vernacular practice of Japan to-day, over the entire length and breadth
of the empire which I have traversed, is entirely empirical. Rhachitis
being unknown, and the life led by the women being so much more
natural than in Europe, obstetrics may scarcely be said to be needed,
I and certainly does not exist.
Syphilis, which came here from China in 1630, is treated in a man-
ner which is the same in principle as the treatment I have seen prac-
ticed in Nubia, where the patient, for several hours at a time, buries
all the parts of his body except his head in the hot sands of the desert.
In tliis excessively volcanic country the various hot springs which
abound, and some of which are exceptionally hot, are the sovereign
remedy. In these baths, some of which are fully exposed to public
view, whole families, entirely nude, pass a large part of the time during
their visit to the particular spa. In several cases I have not seen, but
I have been told by the patients, of results from them which certainly
seem remarkably good. In acupuncture, which, as I have said, has
been practiced by the Japanese for many centuries, they exhibit very
delicate manipulation. For six seng (3d.) one of the blind practition
ers of this art will, without pain, insinuate a long needle into your
stomach, intestines, arms, legs — almost any part except the eye and
the brain. The conditions for which it is held in particularly high es-
teem are flatulence and colic; next, perhaps, in order for neuralgia and
rheumatism of the joints. From my own experience I can say it is
almost absolutely painless. The points to be penetrated are not en-
tirely arbitrary, but are determined by astrological indications. It is a
noticeable experience to see one of these poor blind men take from the
' folds of his "kimono," or robe, a case of beautifully bright long
needles of gold, steel, or silver, and with the nonchalance of the Ori-
ental, and without the slightest pause in his conversation, to see him
burying his needles two, four, or six inches in various parts of your
• person in a way which would astonish a European professor of sur-
gery. I mention this practice only as a pretty display of manual dex-
terity, not as a practice to be imitated. There is one medical proced-
ure, however, in which the Japanese can teach us something in every
particular. I refer to their manner of practicing massage. For rea-
sons sufficiently apparent, the number of blind in Japan, as in all
Eastern countries, is enormous. Every blind boy or girl is expected
to join the one guild, which is exclusively their own, and be an "am-
mah." With their small hands and supple limbs they give to massage
a variety and a delicacy not approached even in India. To what ex-
tent anatomy enters into their training I do not know, but no duly
qualified surgeon could seem to be more intimately acquainted with
the formation of the joints and the course of the nerves as a guide to
manipulation. As to percussion, they obtain it by a semi-rotation of
the hand with a velocity so great as to make the movement almost in-
visible. The deeper structures external to the joints they get at with
the olecranon ptocess of the naked elbow, which, by an equally rapid
movement of the forearm, reaches every interstice with a force regu-
lated with the greatest delicacy. For the muscles of the back, as in
lumbago, the "ammah" frequently use their feet, with which they are
■ almost as dexterous as with their hands. When great force is desired
this is very efficient. Plain rubbing, which is the principal part of
massage in Europe, would be beneath their dignity. Nearly every one
• of their various manipulations includes some delicate niameuvre which
| excites one's surprise and admiration. So common is massage in Japan
} that on arriving at a hotel — next to the tea, which is always immedi-
ately brought — the ''ammah" is the individual who will surely appear.
For the superficial or general massage at such time the tariff price is
six seng (or 3d.); but a European is expected to pay twoor three times
as much as that, unless he can talk Japanese, in which ease lie generally
floes not. I have had massage in Sweden, which I thought perfection;
1 have had it in Turkey, which I thought otherwise; I have had it in
India, and found it in most instances too rough and indiscriminate;
but with a good "animal." or masseur in Japan I have had but one
regret, which is that my friends at home could not share my ad-
vantage.
Another lesson we might learn f rom the Japanese with probable
advantage is the more general use of the moxa. For almost any pain
whatsoever, if persistent and if at all deep seated, the remedy through-
out the country is the moxa. Whereas with ourselves the moxa is,
even with a surgeon, a very unusual remedy, its use here is one of the
female accomplishment- in almost every household. A cone of cotton-
wool previously saturated with a decoction of the Artemisia vulgaris
latifolia is placed upon the part concerned, and, being lighted, is allowed
to slowly smolder to ashes. It leaves a superficial eschar, which
seems to heal without special attention. The performance is often
seen going on in passing a house, a woman operating on a man, woman,
or child, and dressing the patient's hair, perhaps, at the same time. I
have therefore inferred the procedure is much less painful than might
be supposed. The sore is clean, exactly the size wished, and must
often be a very useful counter-irritant. In the public baths I have
counted on men, women, and children as many as thirty or fortv dis-
colored spots from this cause, a row being commonly seen on either
side the spine, and many other marks on the limbs, especially in the
vicinity of the joints. To get the same amount of counter-irritation,
we should certainly disable the patient from any active occupation and
compel a good deal of inconvenient dressing, all of which, if the
counter-irritation was to be maintained, would require repetition. In
hygienic matters the Japanese have everywhere a habit which also may
have a lesson for us. In their nightly bath and morning wash the
water is never cold, never warm, but always as hot as it can be borne.
To foreigners this habit seems very surprising, but the most inveterate
Englishman, if he stays in the country long enough, abandons his cold
tub in its favor. The cold-taking which it is suspected must fol-
low it is found not to occur if the water has been hot enough. This
heat is maintained by a little furnace beneath the bath. In the bath
the bather or bathers take a prolonged soaking, the washing proper
being done on the bath-room floor; then follows a second and final
soaking, drying with towel, and a lounge in bathing wrapper. This
habit seems to promote softness and suppleness of the skin, and by
persons inclined to rheumatism is soon found to be altogether prefer-
able to the cold bath in every particular. The poorest of the Japanese
hear of a cold bath with amazement, and would be sure the man who
used it must be a barbarian. With respect to the superiority of the
hot bath over the cold, I have come to find that in my own case cer-
tainly the Japanese are right.
The Paper Ice-bag. — From a pocket handkerchief to an umbrella it
is difficult to say what is not made out of paper, and everything made
out of paper is comparatively cheap. The ice-bag is a very favorite
remedy, both in private and hospital practice. The ice is generally
applied in bags suspended so that the patient may get the cold from it
without its weight coming upon the affected part. These pretty little
bags are always made of thin paper. They are much cheaper than
the oil silk used by ourselves in that, whether they become broken or not,
they can be frequently renewed, and this, in a large hospital with sur-
gical cases, is an important consideration. The texture is softer, it
adapts itself better to the parts to which it is applied, and in a private
patient one of these paper ice-bags will easily last in constant use for
several days. They would be a valuable acquisition in English hospi-
tals. I inclose one of them that the editors of the Lancet ma) form
their own opinion of it.
It will be observed that the only things I have thought w orth recom-
mending are rather outside than inside the lines of strict medicine and
surgery. It would seem that the decline in medicine must have Icon
as great as the decline in the prevailing religions; hence the alacrity
with which the foreign systems of both were seized by this hungry peo-
ple as soon as presented. The Japanese massage, then, the Japanese
bath, and the Japanese paper ice-bags are things which might certainly
be regarded in Europe as useful acquisitions.
The late Sir Morell Mackenzie. — Dr. Arthur Q, Root, ■ >!' Albany,
writes as follows :
Again has the messenger of death called from among our ranks a
196
MISCELLANY.
|N. V. Med. Jock,
noble leader. A bright star has ceased to shine in its earthly firma-
ment. Again a voice which has bespoken words of instruction, of
sympathy, and encouragement to so many has been hushed. Seldom
has the medical profession throughout the world had such cause to
mourn, seldom have we felt a loss as deeply as we now feel in the death
of Sir Morcll Mackenzie.
A man of great originality, he has given to the profession and world
at large much that shall perpetuate liis memory.
A man of a strong personality, possessing a sensitive and a sympa-
thetic nature, throughout his life, the nobility, the power for good, the
almost divinity of the profession of which he was a representative, was
always uppermost in his mind. Few men at fifty-eight can look back
upon a life so full, so rounded, and so complete. Proudly and unfalter-
ingly might such a spirit enter the shadows, for for such there is a
light beyond. Happy is he of whom it can be said that those who
knew him best loved him most.
As one who has known the value of that close relationship, as one
who has felt the ennobling influence of that untiring devotion to duty,
I feel most keenly the loss which has come to us. Grandly he lived,
triumphantly he passed away, and deep within the hearts of thousands
remains a loving memory.
The Necessity of Pure Drinking-water. — It is evident that the ne-
cessity of using absolutely pure drinking-water can not become too
strongly impressed on the public mind, but water in that condition is
provided by very few communities. Hence the public are availing
themselves of bottled natural mineral waters to a great extent, espe-
cially Apollinaris, which is of recognized purity, for its long-continued
and world-wide use attests its merit. Where such waters can not be
obtained, the ordinary drinking-water, if the least suspicion attaches to
it, should be boiled before using. Precautions should be taken at all
times of the year. It is often thought that in early spring, when riv-
ers are swollen by melting snow, river water is purer and safer than in
summer or fall. Recent experiments, however, have shown that the
number of bacteria in the water supply increases greatly while the
snows are melting on the uplands. Ice also is known to be a frequent
source of poisoning; hence, while the water that is used may be pure,
the ice that is put into it often renders it noxious.
The Physician and the Painter. — The New York' Times quotes the
following from the Pall Mall Gazette :
Here is a good story of a doctor and a painter's wife. The doctor's
name does not appear, but the painter was Meissonier. Mine. Meis-
sonier sent for the family physician in a great hurry. He came, think-
ing some illness had overtaken the artist. But it was not the artist ;
it was only a lap-dog. He pocketed his pride and attended the patient,
who soon recovered. At the end of the year the bill came in, but
there was no item for attendance on a dog. Mme. Meissonier noticed
the omission and told the doctor to charge. He would not charge ; he
said he could not charge ; he was not a vet. He was very glad to be
kind to the dog, etc. The lady insisted. Well, said the doctor, the
hinges of my garden gate are rusty ; ask M. Meissonier to bring his
brush and paint them for me.
The German Medical Congress. — The Eleventh Congress for Inter-
nal Medicine will be held in Leipsic, on the 20th, 21st, 22d, and 23d of
April, under the presidency of Professor Curschmann. The programme
announces reports on Grave Anaemic Conditions, by Dr. Biermer, of
Breslau, and Dr. Ehrlich, of Berlin ; and on Chronic Hepatitis, by Dr.
Rosenstein, of Leyden, and Dr. Stadelmann, of Dorpat ; and the follow-
ing papers : On the Causes of Immunity f rom Infectious Diseases, and
on their Treatment, by Dr. Emmerich, of Munich : On Uraemia, by Dr.
Peiper, of Greifswald ; On the Results of Suggestive Therapeutics, by
Dr. Binswanger, of Kreuzlingen-Constanz ; On the Consequences of the
Excision of Large Portions of the Spinal Cord (a Report of Observa-
tions on Dogs by Dr. Goltz and Dr. Ewald), by Dr. Goltz, of Strass-
burg ; On the -'Etiology of Chronic Heart Diseases, by Dr. Schott, of
Nauheira ; On so-called Hepatic Colic and False Gall-stones, by Dr.
Futbringer, of Berlin ; The Treatment of Alcoholism, by Dr. Vucetic,
of Mitrovitz ; Further Contributions on Diabetes Mellitus after Re-
moval of the Pancreas, by Dr. Minkowski, of Strassburg; On the Treat-
ment of Carcinoma, by Dr. Adamkiewicz, of Cracow ; The Various
Forms of Pneumonia, by Dr. FinkLr, of Bonn ; On the Secondary
Changes in the Circulatory Organs in Renal Inadequacy, by Dr. Israel
of Berlin; On the Therapeutic Value of the Transfusion of Blood in
Man, by Dr. Landois, of Greifswald; On the Pathology of the Bilharzia
Disease, by Dr. Riitimeyer, of Basel-Richen ; On Hemorrhagic Infarcts
of the Lungs, by Dr. Grawitz, of Greifswald ; On the Cure of Tubercu-
losis and on the Biology of the Tubercle Bacillus, by Dr. Klebs, of
Zurich ; Investigations of the Causes of Immunity, and of Recovery,
especially in Pneumonia, by Dr. G. Klemperer, of Berlin, and Dr. F.
Klemperer, of Strassburg; On Immunity from Infectious Diseases, by
Dr. Buchner, of Munich; On Subcutaneous Transfusion of Blood, by Dr.
von Ziemssen, of Munich ; On the Ratio of the Danger of Infection to
its Actual Occurrence in Tuberculosis, by Dr. Wolfi, of Reiboldsgriin •
On Intestinal Disinfection, by Dr. Stern, of Breslau ; Observations on
Diabetes Mellitus, by Dr. Leo, of Bonn ; and On Circulatory Disturb-
ances in the Kidneys, by Dr. Schreiber, of Kiinigsberg. Dr. von Jaksch,
of Prague, Dr. Ebstein, of Gotlingen, Dr. Gerhardt, of Berlin, Dr. Gep-
pert. of Bonn, and Dr. Loffler, of Greifswald, are announced to read
papers the titles of which are not given.
To Contributors and Correspondents. — The attention of all who purjme
favoring us with communications is respectfully called to the fallow.
ing:
Authors of articles intended for publication under the head of " original
contributions " are respectfully informed that, in accepting such arti-
cles, we always do so with the understanding that the following condi-
tions are to be observed: (1) when a manuscript is sent to this jour-
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of the fact at the lime the article is sent to ns ; (2) accepted articles
are subject to the cus'omary rules of editorial revision, and will be
published as promptly as our other engagements will admit of — we
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new conditions can be considered after tlie manuscript has been put
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articles which, although they may be creditable to their authors, are
not suitable for publication in this journal, cither because they are
too long, or are loaded with tabular matter or prolix histories of
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Secretaries of medical societies will confer a favor by keeping us in-
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ings will be inserted when they are received in time.
Newspapers ami other publications containing matter which the fierson
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dressed to the publishers.
THE NEW YORK MEDICAL JOURNAL, February 20, 1892.
(Original Communications.
WHAT CAN WE EXPECT FROM THE
SURGICAL TREATMENT OF EPILEPSY?*
By B. SACHS, M. D.,
PROFESSOR OP MENTAL AND NERVOUS DISEASES IN THE NEW YORK POLYCLINIC.
The treatment of so grave a disorder as epilepsy is a
subject which may well claim the attention of all medical
men. The disease is a veritable scourge that leaves its in-
delible mark upon the victim, often attacking him at an
early age, unfitting him for the serious work of life and
blighting all the hopes dependent upon him. In view of the
importance of the subject, it need not surprise us that the
subject has come up for discussion so frequently before our
learned societies ; and no apology is needed, I believe, for
continuing before this Academy a discussion which was con-
ducted most ably only a few weeks ago before the American
Surgical and Neurological Associations at Washington.
The brilliant achievements of American and European
surgeons have given us the utmost confidence in the possi-
bilities of cerebral surgery, and, with the increasing knowl-
edge of neurologists in localizing accurately the site of dis-
i ease in the brain, there would seem to be no good reason
why the results of cerebral surgery should not equal those
in abdominal surgery. But, unfortunately for the patient
and for us, the complicated structure of the brain makes
cerebral disease a very different affair from disease in or
around the abdominal viscera. Sufficient allowance is not,
as a rule, made for this difference, whence it follows that in
the case of the surgical treatment of epilepsy much has been
expected and but little has been realized. It seems wise to
me, therefore, before we allow our hopes undue scope, that
! we should stop to inquire what we can expect from the sur-
gical treatment of epilepsy.
To those who have not acquainted themselves with the
literature of the subject a simple answer may occur. They
may say : " Take the recorded cases, note the results, and
make your inferences " ; but in the case of the surgical
treatment of epilepsy statistics are useless. A few success-
ful cases have been reported, and even these with undue
haste. Von Bergman n f and the latest author, Sahli, J have
given up the attempt to tabulate the results of operations
upon epileptic patients. I started out on the same path a
few months ago, but soon found it would be love's labors
lost. In this matter of the cure of epilepsy after operation
the memory of medical men is not as reliable as it fortu-
nately is with regard to most other diseases. A distin-
guished surgeon stated recently before one association that
; he knew of a case of traumatic epilepsy in which the cure
* The opening paper in a discussion on the medical and surgical
treatment of epilepsy, held before the New York Academy of Medicine,
October 15, 1891.
t Von Bergmann. Die chirurghche Behandlung von Hirnkrank-
keiten. Berlin, 1889.
% Sahli. Volkmann's Samrnl. klin. Vortr., Vortr. No. 28. N. F.,
1891.
was of ten years' duration, and before another society, a
few days later, that the longest cure that he knew of was of
three years' duration. But what of the innumerable fail-
ures ? They have not been reported with the same candor
and promptness with which most men have heralded their
short-lived successes. And if the attacks are inhibited for
a number of weeks or months, is even this temporary suc-
cess to be put to the credit of the operation ? As long ago
as 1875 Maclaren* insisted that epileptics were improved by
any operation whether it be for cancer of the pelvic organs,
for joint disease, or what not ; and it is as likely as not that
some of the supposed cures after ovariotomies may be ac-
counted for in this way, though I am not willing to go to
the extreme to which Dr. White, f of Philadelphia, has re-
cently gone, in putting the improvement following trephin-
ing for traumatic epilepsy in the same category with the
" curative effects of operations per se" simply because no
gross organic changes were found in the organ so exposed.
I propose to answer the question embodied in the title
of this paper by presenting to you the views I am forced to
hold regarding the nature of the disorder which we attempt
to cure, and by giving you the results of my own experience
in the surgical treatment of epilepsy — an experience that I
owe chiefly to the kind offices of Dr. Gerster and Dr.
Wyeth, with whom I have been associated in fourteen cases
of cerebral operation, ten of which were done for the relief
of epilepsy.
Let me remind you that epilepsy is a symptom, not a
disease ; that it is often merely one of a number of symp-
toms pointing to organic disease of the brain — to tumor,
haemorrhage, abscess, or widespread meningitis and scle-
rosis. In other cases it is a direct or remote effect of trau-
matic injuries to the skull or brain. In addition to these
we have cases of genuine epilepsy, so called. Some one has
suggested that it would be better to call them cases of
epilepsy from unknown cause, and our modesty should, I
think, incline us to this latter view. For one, I find that
I see relatively fewer cases of genuine epilepsy than 1 did
in former years. On closer examination I have not infre-
quently found that the epilepsy had taken its start from a
long-forgotten injury or accident ; that it was in its earlier
days associated with paralysis, the paralysis having left but
the slightest traces, while the epilepsy has remained dis-
tinctly enough. Nor is it to be supposed that a true epi-
lepsy— I do not mean single convulsive seizures — is a func-
tional disease. In our ignorance we may call it so, bul with
the improved methods of examining cortical tissue I am
confident that we shall before long be able to demonstrate
its anatomical substratum. Two French authors have been
leading the way in this inquiry. Marie, \ who goes to the
extreme of denying hereditary epilepsy, claims that children
may be born epileptics, but they have not been conceived
as such. By which he implies that, as in the case of con-
genital cerebral palsies, some slight lesion has been estab-
* Maclaren. Edinh. Mid. Journal, January, 1875.
f White. The Supposed Curative Effect of Operations per H. An-
nals of Surgery, August and September, 1891.
% Marie. I'rogrex mid., 1887, No. 44.
198
SACHS: THE SURGICAL TREATMENT OF EPILEPSY.
[N. Y. Med. Joub.,
lished during the intra-uterine period ; that this lesion may
be lost sight of, but the secondary degeneration following
upon it is the cause of this supposed hereditary epilepsy.
Fere * has furnished strong evidence in favor of this view.
He induced Chaslin f to examine five brains taken from epi-
leptic subjects; in all of these brains the most careful mi-
croscopical examination revealed an increase of neuroglia
tissue with the formation of small fibrils emanating from
the spider cells of the neuroglia. Chaslin infers that this
is a sort of gliomatous sclerosis, and that this sclerosis is to
be found in epileptic brains of entirely normal macro-
scopical appearance.
I have led you into this discussion of the anatomy of
so-called genuine epilepsy in order to have you associate
in your minds the idea of secondary sclerosis of the cor-
tex with epilepsy. This secondary sclerosis is the pivot
upon which the entire question turns. I repeat that in
cases of idiopathic epilepsy the initial causal lesion has not
yet been determined ; idiopathic cases have by common
consent not been considered proper cases for operation ;
but we have learned to operate in cases of localized epilepsy
— Jacksonian epilepsy — due to focal disease, whether of
traumatic origin or not, and in these cases the focus of
disease is present, and so is the secondary sclerosis. If
years pass by before death ensues, the focal disease may be
beyond recognition, but the secondary sclerosis can be and
has been recognized. Tn early childhood the cortex suffers
focal injuries which might well be called traumatic, if they
were due to an external force ; but, whatever the cause may
have been, we have a meningeal haemorrhage often enough ;
the clot resting upon the cortex may be absorbed, but it has
given rise to a local change which extends by degrees until
it finally leads to secondary changes in tha form of a lobar
sclerosis. Paralysis and epilepsy are the chief symp-
toms of this condition. Instead of a meningeal haemor-
rhage due to difficulty during labor, imagine a traumatic
haemorrhage ; disregard the a;tiological differences and the
two accidents will result in the same processes.
Let us push the argument one step further. Every one
is familiar with the fact that the convulsive seizure of a
localized type is due to an irritative lesion of the motor or
sensory centers. The most familiar cases of localized epi-
lepsy are those due to discharging lesions in the motor areas.
It is well known, too, that convulsive movements of a thumb
or an arm point to a discharging lesion in the center or cen-
ters representing these parts. Those parts only are capable
of a discharging lesion which are not actually destroyed;
if destroyed, we have absolute paralysis and not localized
convulsive seizures. Does the diseased area contain within
itself the irritating power, or is this irritation conveyed to
it from other parts ? As a tumor grows n^ar a center, it
irritates that center and causes convulsive seizures ; as soon
as it has displaced or destroyed the center, the formerly
convulsed part becomes paralyzed. The injuries and morbid
processes with which we are here concerned rarely lead to
the destruction of a center ; it is capable of discharging,
* F6r6. Les epilepsies et la? epilepiiques, I'm id, 1890.
f Chaslin. Remains, med., 1889.
and the irritation it needs seems to me to be supplied by
that secondary sclerosis of which it — the focal injury — lias
been the prime cause. Is there any clinical evidence that the
secondary sclerosis plays this part ? I shall be very much
mistaken if it does not explain the very curious fact that in
traumatic injuries and in the cortical diseases of early child-
hood the epilepsy does not, as a rule, develop for months
and even years after the focal lesion has been established.
It takes months, and even years, until a large amount of
sclerosis is established. It is fortunate that focal injuries
are not invariably followed by sclerosis ; why it should de-
velop in some cases and not in others it is difficult to say ;
the severity of the lesion is not the sole determining factor.
Some may maintain that, while this reasoning may apply
to epilepsy following organic diseases, the sclerosis has not
been actually demonstrated in cases of traumatic injuries.
The fault is with the investigator. Bergmann* reports the
case of a man who had received a gunshot wound of the
left parietal bone in 1870 ; he was operated upon and bone
was removed. Two years later he had the first epileptic at-
tack. These attacks continued for fourteen years ; then
Bergmann trephined over the scar. The patient did well for
one month ; after that he fell into the status epilepticus, in
which he died. The author assures us that the wound had
healed perfectly, and that the cortex and dura were en-
tirely normal — macroscopicallv. it may be — but no micro-
scopical examination was made. Inasmuch as some of the
cases to be operated upon hereafter may die, it will be well
to make a most careful histological examination of the
cortex in such cases.
Returning to the practical bearing of these pathological
studies, we infer that we have an initial focal lesion and a
condition of secondary sclerosis to deal with. It is our
plain duty, therefore, to prevent the development of sec-
ondary scleiosis if possible, or, if it has been developed, to
neutralize its effects. The first part of our task is by far
the more difficult. Not knowing as yet the exact condi-
tions under which this sclerosis is developed, we can
scarcely be expected to meet these conditions ; but we can
attempt to diminish the initial lesion and, if possible, to re-
move it. This is equivalent to a plea for early operations
in traumatic and organic cases. How can we neutralize the
effects of a well-established sclerosis ? Shall we say by ex-
cising the diseased area ? The method is rational enough,
since we can not rid the brain of the sclerosis.
This method of excision has been applied by Horsley,f
Keen, \ Bergmann, and others. The results have been
satisfactory in some cases, disappointing in others. In
spite of the removal of the center, the sclerosis has exerted
its power through other channels, through other irritable
centers. If the diseased center is the only irritable area,
the result will probably be a good one; but we have no
means of predicting whether or not this will be the case.
And to make matters worse, excision of a center means loss
of function. You may not cure the epilepsy, but you are
* Lor. rit., p. 160, second edition,
f Brit. Med. Journal, April, 1887.
% Keen. Am. Jour, of the Med. Sciences, October and November,
1888.
Feb. 20, 1892.J
SACES: THE SURGICAL TREATMENT OF EPILEPSY.
199
very apt to paralyze the convulsed part ; but this function
of the excised part is very apt to be assumed by other parts
! of the brain, particularly in young persons, and among
older persons the patient, if left to make his choice, will
prefer a local paralysis to a severe epilepsy.
The practical conclusions to be drawn from the forego-
ing are these :
1. In a given case of traumatic or organic lesion, operate
as early as possible, to prevent the development of second-
ary sclerosis.
■2. If you have not operated at the outset, the onset of
epilepsy is a warning that secondary sclerosis has been es-
tablished ; by operation at this time you may avoid an in-
crease of the trouble.
3. Excision of the diseased area is the only rational
operation ; if all other centers are not in an irritable condi-
tion, the operation may be thoroughly successful.
But if we can not easily cure epilepsy, we may improve
the patient's condition by diminishing the number of at-
tacks. What we can accomplish I propose to discuss in
the second part of this paper. I refrain purposely from en-
tering upon the subject of operative interference in cases of
tumor or abscess of the brain, as the advisability of operat-
I ing is governed by motives other than the cure of the epi-
lepsy. Traumatic epilepsies will attract us fiist, and next I
wish to enlist your interest in certain forms of epilepsy as-
sociated with infantile cerebral palsies. These latter dis-
eases have been so generally overlooked that the epilepsy
constituting one of the symptoms has rarely been recognized
as a special form.
Traumatic cases call for immediate surgical interfer-
ence. Whenever the skull has sustained a severe or even a
| moderate injury, a surgeon or the attending physician
should do an exploratory operation to make sure that there
is no depression of bone. As trepanation is not a very
dangerous operation, it would be better to do this than to
have the slightest doubt. I was pleased to note that Dr.
Agnew* insisted strongly on this point in his recent paper
at Washington. Together with Dr. Wyeth, I had the
privilege of seeing, only a few weeks ago, a robust individ-
ual who had sustained a fracture of the skull by falling
from his wagon ; he was picked up in an unconscious con-
dition, and, with the exception of an occasional lucid mo-
ment, remained in a condition of stupor up to the time of
the operation. There was no paralysis and no focal symp-
tom of any sort. Yet during the exploratory examination
a large fracture was found which extended well back from
the coronal to the lambdoidal sutures, and running: for a
part of its course along the sagittal suture. A trephine
opening was made to see whether there was any splintering
, of the inner table, or whether the dura had been lacerated.
\ As far as we could see, no severe injury had been inflicted ;
and the good, but slow, recovery which the patient has
made may possibly have come about in this special case
without any operation. Yet these are the very cases which
so often develop epilepsy from pressure of depressed bone ;
and it seems to me fully as important that the surgeon
* Agnew. University Med. Mcujaziae, 1891.
should operate early to determine whether there is a de-
pression as that he should defer operation until epileptic
symptoms appear which may place the case beyond the
possibility of surgical relief.
After the epilepsy following traumatic injury of the
skull or of the brain has been developed, there is still hope
that the epilepsy may, in a few instances, be inhibited by
surgical methods. For ages past trepanation has been the
classical operation in these cases. Wherever depressed
bone presses upon any part of the cortex, or an old scar acts
as a source of irritation, the removal of such bone or scar is
clearly indicated ; in many cases improvement, if not a
cure, of the condition follows. We must seek an explana-
tion, however, for the improvement which follows trepana-
tion in many cases of traumatic epilepsy of long standing
in which there is no old scar and no marked depression of
bone. We will not explain this on the theory that any or
every operation helps ; we know, however, that adhesions
between the brain and its coverings are apt to be formed,
and that traumatic cysts are very frequent. The trephine
opening may therefore relieve the increased pressure due
to these morbid conditions. It will be well to enlarge the
trephine opening and to make it as ample as the conditions
will permit. To show you how much or how little may be
accomplished by mere trepanation, allow me to present the
very condensed histories of a few cases of traumatic epi-
lepsy. The full histories I hope to publish in due course
of time, in conjunction with the surgeons who have done
the operations.
Case I. — Boy, nged sixteen years, from Madison, Wisconsin ;
no hereditary history. At the age of eighteen months fell out of
a first-story window ; since that time epileptic attacks of great
severity, with occasional intervals of freedom from attacks.
These generally begin in the right arm and extend to the leg
and face; often they become general. Loss of consciousness in
all attacks. I referred him to Dr. Gerster. Operated upon Febru-
ary 23, 1891. The skull was trephined over the arm area, which
was proved to have been exposed by the electric test; the tre-
phine opening extended so as to expose the greater part of arm
and leg centers. Attacks set in two days after the operation
and have continued with old-time severity. Result, no improve-
ment. The father would not consent to a second operation.
Case II — Young man, aged twenty years; works on his
father's farm in New Jersey. At the age of twelve years was
pushed backward over the pole of a wagon, striking, according
to account, on the back of his head ; was unconscious for a few
minutes, but went to work. A week later the first general epi-
leptic attacks ; these attack.- had recurred at varying intervals
for two or three years. For the past three years the boy had
attacks of typical Jacksonian epilepsy, in which the muscles
about the right half of the mouth only were convulsed. I bad
occasion to see several such attacks. These minor attacks would
occur many times a day. This series would be interrupted by
an occasional severer attack of localized convulsions, ending
up in general convulsions, loss of consciousness, etc. The
boy, who is a fairly bright lad, desired the operation. This
was done February 13, 1891, by Dr. (ierster. As demon-
strated by the faradaic stimulation over the exposed area,
the trephine opening had been laid exactly over the center
representing, according to Ilorsley,* the upper face and angle
* Ilorsley. Am. Jour, of the Med. Scieneex, 1887, vol. i.
200
SACHS: TEE SURGICAL TREATMENT OF EPILEPSY.
[N. Y. Med. Jopk.,
■of the mouth. Adhesions were found under the button of hone
which was removed. Good recovery, hut attacks set in within
a week after operation, and in these attacks the eyelids were
convulsed, showing a slight extension of the focal lesion. A
few weeks later the attacks were as of old in every respect.
" No improvement whatever," so the hoy reported to me eight
months after the operation.
Somewhat better success has followed upon operation in two
<sases of sensory epilepsy of traumatic origin : as they are rare
forms of epilepsy, 1 wish to refer to them briefly in this con-
nection.
Case III. — J. D., aged eight years. When seven months old
fell upon the left side of the head ; at eleven months began to
have epileptic convulsions ; (switchings usually began in the right
arm and leg, and the mouth would be drawn to the left side.
After the age of Ave years these attacks disappeared. Since
last March the boy has had similar attacks; but with the onset
of these attacks it was noticed that the ear began to discharge.
The convulsive attacks were regularly preceded by aura?, in
which he would either perceive a very foul odor or else imagine
a steam-car close upon him. lie would close the window to
keep out the noise, and at once fall into a convulsion. The at-
tacks would be more frequent whenever the discharge from the
ear ceased. About one such attack occurred every week before
operation.
The mastoid region was not painful, but everything pointed
to mastoid trouble, and hence I sent him to Dr. Gerster for
operation. On August 14th Dr. Gerster chiseled through the
mastoid process into the middle ear and removed several se-
questra; no pus. The wound healed quickly. The boy has
had but one attack in two months, and is far less irritable and
brighter than before.* It is interesting to note that with the
onset of this ear trouble the old epileptic tendency due to trau-
matism had been revived.
Case IV. — A man, aged thirty years, of alcoholic habits, at
the age of ten years was struck by a stone on the back and side
of the head. Four years later he began to have general epilep-
tic convulsions. These continued regularly ; every two weeks
he would have two or three attacks in a single day. Patient
has become stupid and irritable; has left lateral hemianopsia.
Operation, July 24th, by Dr. Gerster. Removal of occipital scar ;
external plate found to be depressed; this was removed with
chisel. After dura was exposed and adhesions were cut away, the
opening in the occipital bone was enlarged to the size of a silver
dollar. The wound did well. Sixteen days after operation
three epileptic attacks occurred ; they were followed by transi-
tory delusious of persecution, from which he soon recovered.
He was discharged on August loth, and had no attack until Oc-
tober 1st, after taking a large amount of liquor for the relief of
pain. The result may be designated as a marked improvement.
The hemianopsia has remained unaltered.
This is an epileps^y starting from one of the sensory areas of
the brain, but whether the patient actually had a visual aura he
is too stupid to slate.
Our own experience in this matter is not unlike that of
other physicians. Horsley, Bergmann, Park, Keen, and
others have not fared much better.
In the search after better methods, Horsley's sugges-
tion, in case of focal lesion to remove the entire diseased
center, met witli general favor. With the aid of our pres-
ent methods of determining centers, and particularly if we
* A second operation was done about two months later, since
which time the boy has been free from attacks.
allow the result of faradaic stimulation of an exposed area
to be our chief guide, we can very accurately determine the
extent of the area to be removed, and I have satisfied my-
self that this can be done before the dura is opened. But,
as I have intimated before, even the excision of diseased
centers is not an unmixed good. First of all, it often fails.
Attacks have returned after such operation in the cases of
Bergmann, Park,* and Keen. In one of Park's cases the
contents of the cyst were emptied, but the cyst was not
removed. Horsley's first case has been the only very posi-
tive success, no attacks having occurred for twenty-two
months after operation. f
Rational as this method seems to be, there are reasons
for its failure. The entire center may not have been re-
moved ; the paralysis of the convulsed part has been thought
by Keen and others to be proof of the fact that the entire
center has been removed. Then, again, if an arm center
has been the actual focus of disease, the neighboring face
or leg center may, in the course of years, have attained a
sufficient degree of irritability to become the discharging
center, and, furthermore, the existing sclerosis will help to
advance this or other centers to the dignity of a discharg-
ing center, if they have not already acquired this unfortu-
nate function.
Another serious feature of this excision operation, and
indeed of all cerebral operations, is the possibility that
the operation itself may lead to the formation of cicatricial
tissue in or around the cortex, which may do more damage
than the initial lesion. Yet, from what I have seen of the
condition of brains years after an operation, I believe this
danger from new cicatricial tissue to be quite slight.
Granting the entire success of the operation in ques-
tion, you have at best in many cases substituted a paralysis
for an epilepsy. In the case of an arm or face center, most
patients would consent, and prefer the paralysis to their epi-
leptic seizures. Few would care to have their leg centers
excised, and to wait until some vicarious center may give
them power to walk ; and I doubt whether in Case IV,
which 1 reported above, the patient or my own conscience
would have permitted me to remove one visual center. Ex-
cision of a center, while it promises relief in a few well-
selected cases, is not so much of a divine inspiration as it
appears to some to be. Let us prevent traumatic epilepsy
as far as in our power lies ; it will be easier to prevent it
than to cure it.
I consider it my duty to call your attention to the epi-
lepsy associated with the cerebral palsies of children. In
a paper J published last year it was shown that forty-four per
cent, of all cases of infantile cerebral palsies develop epi-
lepsy, and I have stated that there could be but little doubt
that, of all cases of ordinary epilepsy, a very fair propor-
tion were developed in connection with infantile palsies.
This view has been accepted by later writers. I have seen
at least half a dozen cases of epilepsy within the past year
'* Park. X. Y. Med. Jour., November, 1888.
t 1 can not find any later reference to this case. Other cases have
been reported, but before a sufficient period of time had elapsed.
\ Sachs and Peterson. Journal of Nervous and Mental Disease, May,
1890.
Feb. 20, 1892.]
SACHS: ThE SURGICAL TREATMENT OF EPILEPSY.
201
which were supposed to be cases of idiopathic epilepsy, but
which, when examined carefully, revealed the traces of an
old hemiplegia. Nor are the pathological conditions un-
derlying these palsies properly recognized.
One case of Horslcy's, a boy four years of age, with
right hemiplegia, who had as many as thirteen or fourteen
attacks per day, is a case in point. Dr. William A. Ham-
mond * some time ago reported the case of a girl of twenty,
afflicted with an old hemiplegia, in whose brain he found a
large cvst which was evidently the leavings of a former
haemorrhage, and Case V of Dr. Keen's f latest paper is not
merely a case of defective development, but one of infantile
cerebral hemiplegia with epilepsy and idiocy. I would not
call attention to this class of cases if we did not find among
them the only cases of non-traumatic epilepsy which de-
mand surgical interference.
These palsies come on either in the intrauterine period
or early in life. The initial lesion in the acquired cases is
generally a haemorrhage, thrombosis, or embolism, and this
focus of disease leads in many cases with rather surprising
rapidity to the development of secondary sclerosis through?
out the cortex. In fully ninety-five per cent, of all these
cases the lesion is in or upon the cortex. The lesion — a
haemorrhage or softening, say — is very apt to be strictly
limited to one or more areas. It need not, therefore, sur-
prise us that typical Jacksonian epilepsy is found in some
of these cases, or that we find scars and cysts and sclerosis
just as we do in the traumatic cases.
The three cases of this class which I shall refer to were
operated upon during the past year — two of them by Dr.
Wyeth and one by Dr. Gerster. The histories are briefly
as follows :
Case V. — L. C, male, aged six years. Onset of disease at
the age of five years with right hemiplegia and convulsions of a
Jaksonian type which have been repeated every week since,
: finally increasing to as many as rive daily ; athetoid movements
, of right hand ; is irritable and bad-tempered. Operation was
done December 29, 1890. A large opening was made in the skull
over the motor arm area of left hemisphere and enlarged from
this; adhesions to skull broken up. No attacks for six weeks
after operation, and none for several months after leaving the
hospital. I have not heard from the boy in fully three months.
Case VI. — A girl, aged sixteen, who has had right hemi-
plegia and epilepsy since early childhood ; epileptic attacks very
frequent and affecting paralyzed part exclusively. Dr. Wyeth
operated upon the girl in the Polyclinic Hospital, exposing, by
the method which I must leave to him to explain, the entire left
motor area. In this area 1 determined by the use of the fara-
^ daic current the exact arm center. The dura was opened in
semicircular fashion, but, as the entire area seemed normal, we
did not at the time excise any part of it. The dura was closed,
and the wound healed nicely ; she was free from attacks for at
least five months.
Case VII has been by far the most interesting.^ I was asked
by Dr. Wyeth to see A. II. G., aged thirty-two, who had applied
to him for the relief of his epilepsy. The history showed that
the epilepsy had been developed at the age of two years, and
* Hammond. N. Y. Med. Journal, August, 1890.
f Keen. Am. Jour, of the Med. Sci., September, 1891.
t This case has been referred to in the author's paper on the Pa-
thology of Infantile Cerebral Palsies, this journal, May 2, 1891.
that with the epilepsy a complete left hemiplegia appeared. On
examining the patient this hemiplegia was evident enough, and
this, taken in conjunction with the history of unilateral attacks,
led me to look for a focal lesion — a haemorrhage probably —
which, from the nature of the attacks, I thought likely to be
most marked in the arm center. Dr. Wyeth trephined over this
site, enlarged the opening, cut open the dura, and then exposed
the discoloration and thickening of the pia which was adherent
to the cortex beneath. A number of incisions were made into
the cortex at this point, breaking up old adhesions, and lessen-
ing the increased tension at this point. The patient did well
after the operation. On the second day the paretic arm was
paralyzed, but alter the lapse of a few days it was no worse than
before the operation, while the epileptic convulsions, which had
appeared at least once a week before the operation, did not occur
until six months after the operation. The further course of this
epilepsy will have to show whether any permanent impiove-
tnent has been gained.
Simple trepanation seems to be more successful in these
epilepsies associated with infantile cerebral palsies than in
the traumatic forms, probably because of the still greater
frequency of cysts in these diseases than in the traumatic
epilepsies. The early recognition of these troubles is of
great importance ; and the question naturally arises whether
we can diagnosticate the lesion with sufficient accuracy to
encourage the surgeon to operate at an early day before sec-
ondary degeneration is established. I believe this will be
possible in many cases, but the disease sets in frequently at
a very tender age at which cerebral operations are but poor-
ly tolerated ; moreover, the epilepsy, although a probable
sequel, is still a remote contingency ; the paralysis repre-
sents the reality, and parents will be most apt to tell the
physician to care for the present only, more particularly if
looking to the future means a possible increase of the pa-
ralysis. As soon as epileptic symptoms appear, the paraly-
sis has the value of a focal symptom ; the centers should be
exposed, and if not removed, they should at least be treated
in accordance with the special indications of the case. In
children, excision of a center is a less serious affair than in
the adult, for in the former other parts of the cortex are ca-
pable to a greater degree of assuming the functions of the
destroyed part. I am confident that, if these cases of in-
fantile cerebral palsies are more generally recognized, and
if we succeed in checking the tendency to epilepsy in them,
the total number of epileptics will be noticeably diminished.
If the surgical treatment of epilepsy be of any value at all,
it is in view of the foregoing not to be restricted to the
traumatic forms, but let it be applied also to those epilep-
sies which are associated with the cerebral palsies of child-
hood.
In conclusion, I would say that, under favorable condi-
tions and by the methods described in this paper, the sur-
geon may be able to cure a few cases of epilepsy. He will
be able to improve many, but surgeons and neurologists
should in future make an earnest effort to prevent epilepsy.
Ichthyol in Small-pox. — "A solution of ichthyol, live or ten per
cent., has recently been used with much success as a local application
in small-pox, in the pustular stage of the eruption. The solution being
painted over the pustules two to four times a day was found to hasten
the drying up, check extensive suppuration, and prevent pitting." —
British mid ('olo)iiid Drui/ijist.
202
LESZYNSKY: HEMIPLEGIA FROM CEREBRAL HEMORRHAGE. [N. Y. Med. Jocr.,
THE MANAGEMENT AND CARE OF
PATIENTS WITH HEMIPLEGIA RESULTING
FROM CEREBRAL HAEMORRHAGE.*
By WILLIAM M. LESZYNSKY, M. D.,
LECTURER ON MENTAL AND NERVOUS DISEASES
AT THS NEW YORK POST-GRADUATE MEDICAL SCHOOL, ETC.
In discussing this subject, we must accept the term
" hemiplegia " (paralysis of one side of the body) as indi-
cating the predominant clinical manifestation of a disease,
and not descriptive of the pathological process itself. In
other words, to speak of hemiplegia as a disease would be
at variance with our knowledge of its pathology and in op-
position to the modern principles of nomenclature. In the
vast majority of instances it is symptomatic of the rupture
of an intracranial blood-vessel. This condition, which oc-
curs suddenly and places the individual hors de combat, is
essentially due to disease of the arterial system. It is mere-
ly supererogatory for me to mention that hemiplegia may
result from other causes, such as cerebral embolism or throm-
bosis, or meningeal haemorrhage, or from a tumor involving
the intracranial portion of the motor tract, or from a uni-
lateral lesion in the upper cervical portion of the spinal cord.
I shall therefore confine my remarks to hemiplegia in the
adult as a result of cerebral haemorrhage.
The haemorrhage is far more apt to occur in or near one
of the corpora striata than in any other part of the brain.
The point of selection is most frequently one of the len-
ticulo-striate arteries which has developed miliary aneu-
rysms. All trustworthy observers are agreed that morbid
changes in the arterial walls precede their rupture, although
there are differences of opinion as to the character of such
changes.
The extremities which are affected are always those on
the side opposite to the lesion in the brain. This depends
on the anatomical fact, so well known to you all, that the
motor columns decussate in the anterior pyramids of the
medulla. Thus, any unilateral affection of the nervous cen-
ters situated above the decussation of the pyramids, if it
causes paralysis at all, invariably causes paralysis of the op-
posite side. Those movements which are performed in har-
mony by the two sides of the face or body remain unim-
paired in hemiplegia.
Hemiplegia from a lesion of one side of the brain is not
necessarily so complete as to present a maximum loss of
power. Not infrequently the face escapes entirely.
Sometimes the leg can be moved perfectly, while the arm
is completely paralyzed. Power is usually regained in the
leg earlier than in the arm. A comprehensive and practical
knowledge of general medicine is a sine qua non in the man-
agement of these cases. Its rational treatment presupposes
a familiarity with its pathology. Obviously it is beyond
the scope of this paper to enter at length into a technical
and exhaustive description of cerebral haemorrhage in its va-
rious phases.
Cerebral haemorrhage is relatively frequent after the for-
tieth year and becomes more common as age advances. The
* Read before the Practitioners' Club, of Newark, New Jersey,
January 4, 1892.
belief that it is of more common occurrence in men with
short, thick necks and florid faces than in those who are of
a different build is a popular fallacy. There is no such
thing as an apoplectic constitution. Some families exhibit
a predisposition to cerebral h;emorrhage. Hence it has
been assumed that the disease is hereditary. It is only an
indirect result of the inherited tendency to arterial degen-
eration.
Most writers speak of prodromic symptoms, and men-
tion the following as premonitory signs of cerebral haemor-
rhage : Headache, vertigo, tinnitus, or numbness in the hand
or foot ; facial paresis, coming on suddenly without spasm,
and usually disappearing within a few hours or a few days.
There may be loss of speech with this facial paresis, but
more often defect of speech only. All of these symptoms
are likely to arise where arterial degeneration exists, and
may be due to local circulatory disturbances resulting either
from gradual narrowing of the lumen of the vessel, or from
thrombosis or embolism — or possibly from minute haem-
orrhages ; thus producing on the one hand a transient cir-
cumscribed anaemia, and on the other cerebral softening.
They may appear separately or variously combined, and
although all of them may occur without being followed by
an apoplectic attack, yet, in the old and middle-aged, espe-
cially when the arteries are degenerated, they should be re-
garded as warnings. The rupture has been known to occur
without any precursory symptoms whatsoever.
Among the exciting causes of the attack may be men-
tioned excessive emotions, cold baths, and indulgence in
stimulants, provided that the vessels are in the diseased
condition, which seems to be a necessary antecedent of
haemorrhage ; temporary obstruction to the return of
venous blood from the brain, in such actions as coughing,
sneezing, laughing, or straining at stool. It has been
claimed that its direct effect must be small.
A number of instances have occurred under my obser-
vation, and no doubt many of you have seen similar cases,
where the patient has been found in the closet either para-
lyzed or dead from cerebral haemorrhage, undoubtedly as a
result of straining at stool.
Cerebral hajmorrhage sometimes occurs first while the
individual is making some violent effort or subjecting his
vascular system to an excess of pressure. Sudden exposure
to cold may increase the arterial tension by inducing ex-
tensive contraction of the cutaneous vessels. Cerebral
haemorrhage has also been known to occur during sleep,
when the pressure in the cerebral vessels is supposed to be
particularly low. I have often thought that possibly a
change in the pressure might have been occasioned by an
exciting dream.
Hemiplegia may occur suddenly without loss of con-
sciousness. Then the recognition of the paralysis is sim-
ple both for the patient and the physician. During coma
the diagnosis is frequently attended with difficulty owing
to the general and complete muscular relaxation. The
stertorous breathing and the concomitant facial paralysis
are quite characteristic. In case the coma is only partial
and the muscular resistance is feeble or lost upon one side,
the diagnosis is clear.
Feb. 20, 18V2.J
LESZYNSKY: HEMIPLEGIA FROM CEREBRAL HEMORRHAGE.
203
While the patient remains unconscious the prognosis
is doubtful, as we are unable to determine the extent of the
haemorrhage. He may die comatose from shock, asthenia,
or some complication.
Should consciousness be restored and the vital signs be
maintained, the prognosis as to recovery from the paralysis
depends upon a number of factors. Recovery from hemi-
plegia will occur from any kind of lesion, if it be a small
one. If the patient begins to move the arm next day he is
likely to get well altogether. We can not infer so much
from early recovery of the leg, as this is very often not
completely paralyzed at the outset, and we know that it
frequently recovers when the arm remains much paralyzed.
When rigidity of the limbs takes place no further improve-
ment will follow. In this connection it will be of interest
to call attention to some of the clinical signs of hemiplegia
which heretofore have not been observed nor their value
recognized.* Corresponding to the well-known fact that
in the facial paralysis accompanying hemiplegia the orbital
portion of the nerve is usually unaffected, a similar phe-
nomenon may be observed in the upper extremity in the
fibers of the spinal accessory nerve. This nerve divides
into two branches — one supplying the sterno-cleido-mastoid
muscle, and the other the trapezius. As a rule, the branch
to the sterno-cleido-mastoid escapes, while that supplying
the trapezius is paralyzed. The latter paralysis manifests
itself in the drooping of the shoulder while at rest. The
paralysis in the lower extremity, which is usually neither
complete nor permanent, also shows several characteristic
peculiarities, which explains the fact that walking is still
possible even in severe cases.
In such patients, while in the supine position, one can
demonstrate that active elevation of the extended leg to a
certain height can still be accomplished, although feebly.
The dorsal flexion of the ankle joint is nearly or completely
abolished, but plantar flexion can be performed with con-
siderable force. In the prone position the flexors of the
knee joint are nearly or completely paralyzed, while the ex-
tensors show a well-marked or almost normal strength.
Therefore in hemiplegia the muscles which are especially im-
portant in locomotion are the ones that are the least affected.
During the early stage the clothing should be carefully
removed, and all jarring of the head or body should be
avoided. A ligature about the extremities close to the
trunk will prove serviceable in diminishing the volume of
blood in the internal organs, thus relieving the intravascular
pressure and hastening the formation of the clot. This
procedure is most likely to prove efficacious where the symp-
toms are indicative of a large haemorrhage, or in those cases
where there is an apparent tendency to an extension of the
haemorrhage.
Absolute rest in bed should be enjoined, no matter
whether the attack be very mild or severe in character.
In case unconsciousness is present and lasts more than a
few hours, the bladder should be relieved by the catheter.
If there is reason to believe that there is an accumulation
of faeces, five or ten grains of calomel or two drops of cro-
* Wernicke. Berlin, klin. Wochemchrift, 1889, No. 45.
ton oil should be placed on the tongue, or an enema may
be given. Whenever there is serious difficulty in swallow-
ing, the administration of food by the mouth should be
forbidden, on account, of the danger of its entrance into
the larynx. A day or two without much nourishment will
do very little harm. If it is thought desirable, rectal ali-
mentation may be resorted to. Further details in the man-
agement of this stage will suggest themselves according to
indications.
There is neither clinical nor experimental evidence to
prove that we possess any drugs whose administration will
hasten the absorption of the extravasated blood or relieve
the patient of his paralysis. As we can not remove the clot
or directly hasten its absorption, let us ascertain what we
can do for our patient. Before he is able to leave the bed
much can be done by careful management and close atten-
tion to details to prevent unnecessary complications.
A good nurse or an intelligent attendant will prove quite
an acquisition. Bed-sores over the sacrum and over the
heels are not essential features of the malady, but are usu-
ally the result of carelessness and neglect.
The position of the patient must be frequently changed,
and, either by a water-bed or by various mechanical devices,
the points that are subjected to pressure must be protected.
In addition to these measures, it has been my custom to
use a mixture containing two drachms of the oxide of zinc
to the ounce of alcohol. The skin that shows any redness
is painted daily with this preparation. As the alcohol
evaporates, a thin coating of zinc remains on the surface.
In rare cases the formation over the buttocks of a so-called
bed-sore, which is due to trophic changes, may occur, de-
spite the most careful vigilance. A few days after the at-
tack, all joints of the paralyzed limbs should be daily sub-
jected to gentle passive motion, in order to prevent the de-
velopment of ankylosis. This is more likely to occur in
the shoulder joint, and may also be classified among the
avoidable complications. Electricity, in the form of the
induced current, should not be used until from four to six
weeks after the onset of the attack. The strength of the
current applied to the paralyzed limbs should be just suffi-
cient to produce slight but evident muscular contractions.
The applications are to be made every alternate day, the
entire seance lasting from ten to fifteen minutes. Faradiza-
tion keejis up the nutrition of the paralyzed muscles and
improves the condition of the peripheral circulation. The
same may, however, be accomplished by suitable massage.
In view of the clinical fact that the extensors in the up-
per extremity and the flexors in the lower extremity are
the muscles usually paralyzed, our electrical or manual
manipulation should be directed in greater part to these
groups of muscles. These applications will be of service
while we are waiting for compensatory restitution of func-
tion. They prove useful as an artificial exercise.
In the presence of contracture which generally develops
later, much can occasionally be accomplished by the use of
galvanism applied to the brain and the peripheral nervesr.
The anode is placed over the parietal eminence on the same
side as the lesion, and the cathode over the trunks of the
nerves which supply the rigid muscles. The current is
204
CURRIER: ORIGIN AND RESTRICTION OF TUBERCULOSIS. [N. Y. Med. Jouh.,
gradually increased by the use of a rheostat, until the pa-
tient receives from three to six milliamperes, the seance last-
ing from three to five minutes. Any sudden interruption
in the circuit, either by removal of electrodes or by rapid
increase or diminution of the current strength, should be
carefully avoided, or sudden vertigo and other unpleasant
symptoms may supervene. We must constantly bear in
mind that central nerve fibers that have been torn across or
broken up in any part of their course do not undergo re-
generation, and that motility can not be restored in those
parts which receive no motor impulses. We must not,
therefore, delude ourselves in the belief that we can cure a
hemiplegia. The most potent remedy that we possess is a
combination of the "essence of patience" and the "tinct-
ure of time."
A partial restoration of function will take place in spite
of all methods of medication instituted with the object of
curing the paralysis. Here is where the vis medicatrix
naturae comes to our aid. Hence our efforts must be con-
centrated with a view to the prevention of another attack.
This constitutes the most important element in the rational
management of these cases. Nature can not be trusted in
•this instance.
It may be asked, Upon what grounds are we enabled to
infer a predisposition to cerebral hasmorrhage ?
1. From the history of a previous attack.
2. From the constitutional state which induces arterial
deganeration — i. e., senility, chronic nephritis, rheumatism,
gout, syphilis, lead-poisoning, etc., often accompanied by
cardiac hypertrophy.
3. From the presence of arterial degeneration itself, as
manifested in the radial and temporal arteries by their
rigidity and tortuosity. These evidences of degeneration
are extremely suggestive, but are not proof positive of a
similar condition of the cerebral blood-vessels. As a matter
of fact, a number of cases are on record where post-mortem
examination and careful microscopical investigation have
shown normal cerebral vessels coexisting with degenerated
temporal and radial arteries. On the other hand, the pres-
ence of retinal hemorrhages furnishes an indication of con-
siderable value. They are significant, inasmuch as they
point to a state in which cerebral haemorrhage is likely to
occur. Some recent writer has referred to a varicose con-
dition of the sublingual vessels as being one of the signs of
arterial degeneration that is highly suggestive of a similar
state in the brain. I have been unable to confirm this state-
ment.
4. From the presence of high arterial tension, as deter-
mined by the radial pulse.
These are questions which demand immediate investiga-
tion. In all cases of cerebral haemorrhage the condition of
the arteries (statical, as atheroma ; dynamical, as degrees
of tension) is a matter of first importance. Too much stress
can not be laid upon this point. We should never fail to
examine the urine and satisfy ourselves as to the integrity
of the heart and kidneys. In fact, every organ in the body
should be examined.
Granting that the cause of the arterial degeneration is
to a great extent irremediable, let us devote our attention
to the avoidance of exciting causes of the rupture. Even
patient should be repeatedly impressed with the possible
danger to which he exposes himself while straining at stool.
He must be taught to avoid all additional causes that have
been previously enumerated. Sneezing or coughing should
be controlled or modified. Anything that is likely to pro-
duce a sudden increase of arterial tension should be scrupu-
lously avoided.
In conjunction with the foregoing, the general plan of
treatment which will be found appropriate in most cases
would be to regulate the diet to suit the individual case ; to
reduce the quantity of nitrogenized food (if it had been used
in excess) ; to keep the bowels free ; to diminish high arterial
tension by the use of salines or mercurials, or nitroglycer-
in, the nitrites, etc. ; to administer antisyphilitic remedies
when necessary. There is no proof that the use of strych-
nine, hypophosphites, or other so-called " nerve remedies "
directly influences the paralysis. They should be restricted
to those cases in which they are indicated for improving
the general health.
I have thus briefly outlined what seems to me to be the
proper method to be adopted in the management of an un-
fortunate class of cases that taxes the resources of the phy-
sician to the utmost.
Much of our success in averting another attack will de-
pend upon the co-operation, self-denial, and self-control of
our patient.
61 East Seventy-fifth Street.
ORIGIN AND RESTRICTION OF TUBERCULOSIS*
By CHARLES G. CURRIER, M. D.
From an enormous number of experiments upon animals
and from somewhat fewer than a hundred reported cases of
accidental inoculation upon human beings, it is regarded as
proved that the bacilli of tuberculosis, which are exceed-
ingly numerous in the sputa and other excretions from foci
of the disease, tend to cause tuberculosis whenever these
characteristic germs in a highly vitalized form enter the
system in sufficiently large numbers.
Primary affections of the lungs by these bacilli are
oftener observed in autopsies than primary tubercular dis-
ease of any other part of the body. It has, further, been
observed that cases of lung tuberculosis have arisen among
some of the animals and human beings that have happened
to be exposed to breathing in air containing among its dust
particles those produced by the drying and pulverizing of
tuberculous sputa. The fact that fatal tuberculosis resulted
in such cases caused the extensive adoption of the general-
izations enounced by Cornet ; and, by the zeal of neophytes,
the theory became almost universal that all the cases of tu-
berculosis that occurred were due to the inhalation of dried
sputum, and that the " heredity " and " predisposition " of
former years were obsolete and obstructive terms. Hold-
ing that the inhalation of the harmful bacillus was the sole
* Read in a discussion at the New York Academy of Medicine,
January 21, 1892.
Feb. 20, 1892.]
CURRIER: ORIGIN AND RESTRICTION OF TUBERCULOSIS.
205
important factor, although he appears to be modifying his
views as with the years more complete and careful observa-
tions bring facts in refutation, Cornet even declares that
" we daily are able to see that even the most robust people,
apparently in the best of health, become the victims of the
tubercle-bacilli infection."
Summarizing the observations made in two hundred and
twenty-one autopsies of tuberculous cases, Grawitz, formerly
Virchow's assistant, reported one hundred and fifty-two cases
as primary in the lungs, nine as primary in the digestive tract,
three arising from external wounds, and the original entrance
of the infection was doubtful in the other cases. [Deutsch.
militararztl. Zeitschr., 1889, Heft 10, Ref.) Then some of
the many cases where animals were experimentally fed with
tuberculous meat and milk resulted in intestinal infection.
But such facts had been observed years before the charac-
teristic bacilli were recognized. Leudet [Gaz. hebdom.,
1890, No. 9), reviewing many cases among married people
in the better circles of society, states (like Brehmer and
many others) that it is exceedingly rare for tubercular in-
fection to pass from one spouse to the other. Schwarz and
numerous others adduce the facts of long and extensive
hospital experiences to show that hospital attendants are
not so prone to the affection as Cornet assumed, and Ilaupt
[Med. Revue, 1890, No. 1), gathering the statistics of two
hundred and seventy-five female nurses encountering tuber-
culosis in a general experience, found that during twelve
years only two of these nurses had manifested the symp-
toms of the disease. In this country, comprehensive inves-
tigations of nursing statistics made with similar care are
not at hand. We, who have seen many cases in the homes
of the poor before any care was paid to adequate disinfec-
tion, can not, so far as I learn, recall much evidence of the
disease being communicated from one to another of those
living in the unhealthy abodes of our lowest classes.
But, aside from the lack of positive evidence to prove
the extremist views, there are further facts to negative or
modify the postulates. Thus Prausnitz [Archiv f. Hygiene,
1891, p. 192) reports negative results when inoculating ani-
mals with dust taken from the floor of railway compart-
ments in through trains carrying consumptives for many
hours on the long journey through Bavaria. Kustermann
[Munch, med. Wock., Nov. 10, 1891, p. 796) reports wholly
negative results from collecting dust from the walls and
floors of the Munich prison hospital, and then inoculating
this dust into animals.
Happily the element of contagion, even if existing on
the clothes, the skin, and in all the secretions, soon loses its
vitality under the conditions most prevalent. Koch has
said that when exposed to daylight and the oxygen of the
air, the tubercle bacilli present in dust form are liable to
die in from a few hours to a few days.
Although the temptation is ever present to use a " royal
road " for learning about the origin of the disease and, by
assuming the inhalation theory as explaining all cases, to
consider other explanations as unwarranted, it must be in-
sisted that the inhalation theory accounts for only a portion
of the cases, and that, after all, heredity seems a very potent
source, as evidenced by the common-sense experience of
clinicians and statistical observers, as well as by bacteriolo-
gists of the highest standing, such as Professor Baum-
garten (see Deutsche med. Wochenschrift, Oct. 13, 1891)
and others, who are thoroughly conversant with the exten-
sive literature of the subject and acquainted with all the
progress and changes of the decade. An infant seems quite
as liable to inhale the bacteria of exsiccated sputum as an
adult is, and then to develop tuberculosis of the lungs if
the inhalation theory is adequate to account for all cases ;
but we have the clinical fact presented us that the lungs do
not develop tuberculosis in infants as often as in adult life,
yet the glands, bones, and joints are relatively very often
affected without any evidence that the infection arose pri-
marily in the subject through inhalation of bacteria. These
considerations, together with the occurrence of cases of
foetal tuberculosis (Birch-Hirschfeld and Rindfleisch, Mun-
chener med. Wochenschrift, 1890, p. 768), and the demon-
strations, by comparative biologists, of the presence of bac-
teria in ova, as well as the established fact that " struct-
urally healthy testicles of tuberculous subjects can have
bacilli detectable in their spermatozoa " — all of these con-
siderations warrant the conclusion that tuberculosis may be
inherited. That is, the most potent factor in the causation
of tuberculosis can, in foetal cases, be conveyed from a
parent or parents immediately to the unborn child.
To explain later developments, whether manifested in
the lungs, or in the bones, joints, glands, or elsewhere, the
assumption of heredity seems more adequate than the in-
halation theory, particularly because in childhood the lung
manifestations are decidedly in the minority, even if we do
not include the considerable percentage (twelve) of latent
tuberculosis reported by Bollinger and others who have
made numerous autopsies of children.
Even lung tuberculosis in adults is explicable in many
cases by this modernized doctrine of heredity quite as well
as by the inhalation theory. We know so very little of
the life history of the tubercle bacillus under such condi-
tions of nutrition and environment as these parasites find
in various organs of the human body, that we are quite
unable to fix any limit as the time beyond which they can
not remain in a state of latency, endowed with a capacity
for resuming their most virulent activity. Atmospheric,
telluric, and other external influences which are not yet
fully understood, together with internal conditions that are
as yet beyond our complete comprehension, may, so to
speak, arouse the bacilli from this latency, and they then
may develop with varying rapidity and harmfulness. Under
circumstances that foster the vitality of these micro-organ-
isms, serious and progressive disease may result. With
other factors at work, the morbid manifestation may be
very slight. Whatever the extent of the morbid process,
the pernicious activity of the bacilli may be followed by
their more or less total destruction if the disease be ar-
rested, or they may again become dormant. Those that
chance to be in a less suitable region, as in the muscles,
develop less readily than when in a more favorable organ,
as, for instance, in the lung.
It is probable that in the earliest period of life the
great formative and vital energy of the body-cells offers a
206
SHAFFER: MECHANICAL TREATMENT IN POTTS DISEASE. [N. Y. Med. 3ovk+
high degree of obstacle to the activity of the tubercle ba-
cilli, which survive, if at all, usually in a latent state, unless
exceptionally virulent or exceedingly numerous. If from
any cause the system weakens and thus loses its power to
restrain the destructive activity, the disease process ensues
with its varying phases.
Since, then, the inhalation theory explains the origin of
only a portion of the cases of tuberculosis, we must base
our hygienic warnings upon the broadest understanding and
further recognize that the terrible disease arises also from
other sources than from sputa ; yet we should keep con-
stantly in mind the probable danger of infection coming
from dried sputa and from other excretions.
The zeal of research in this field has led to reports that
the harmful bacilli are detectable even in the sweat and on
the clothing of " consumptives," and, even if what Mattei
and Spillheim have said in this connection does not prove to
be verified by further tests, we should admit the probabil-
ity that scientifically prosecuted cleanliness is a valuable
safeguard against the extension of the scourge.
In view of the part that heredity plays in the propagation
of tuberculosis, we must, in combating the disease, direct un-
remitting attention toward increasing the sum total of the
vital forces of the patient, and all climatological, pharma-
co-dynamic, and other means should be employed which
give the system added power to resist or destroy the para-
sites. Not the least important aid to the patient is the
maintenance of a high degree of vitality before the bacilli
have been enabled to make sufficient inroad to become de-
tectable through the usual physical and other symptoms.
Our duty, then, is to remain both conservative and pro-
gressive, to utilize the valuable truths evolved from the tire-
less laboratory researches of the present, and yet to respect
the unquestionable facts established by clinical observers.
The methods by which to prevent the passage of the
infection of tuberculosis from the lungs of one person to
the lungs of another have been indicated by the various
commissions and health officials here and in the cities of
Europe. Scientific cleanliness is the beginning and the end
of all effectual means. Heat is apparently the most reli-
able disinfectant. The germ-destroying value of fresh air
does not seem to be appreciated as generally as it should be.
In order to influence the masses, sanitary instructions
for the restriction of tuberculosis should be very brief, al-
though detailed explanations of the facts, the methods, and
the reasons for these may be given at length.
For the guidance of the many, then, we may formulate
the knowledge of to-day in this regard as follows :
Keep clean. Avoid unclean places and avoid unclean
and diseased people.
Do not spit on the floor or on the ground, and do not
allow others to do so.
Expectorated matter loses its harmfulness when burned.
Clothing and other articles used by "consumptives"
can be sterilized by exposure to the heat of boiling water
for at least fifteen minutes.
It is safest to use milk, water, and other foods only
after they have been well cooked.
Abundant fresh air is a valuable purifier.
ON THE BENIGN COURSE OF
ABSCESS IN POTT'S DISEASE
UNDER EFFICIENT MECHANICAL TREATMENT*
By NEWTON M. SHAFFER, M. D.,
ATTENDING SURGEON IN CHARGE OF
TOE NEW YORK OUTIIOP.'EDIC DISPENSARY AND HOSPITAL.
My early medical education was received under the
direction of one of the most conservative medical men I
have ever met — viz., the late Dr. James Knight, the founder
of the New York Society for the Relief of the Ruptured
and Crippled. Some of the present members of the Ameri-
can Orthopaedic Association also received their first ortho-
paedic training under the same auspices, and with them I
can recall the feeling of criticism — not to say ridicule — with
which we regarded Dr. Knight's treatment of " cold " ab-
scesses in Pott's disease and in hip-joint disease. Those of
our number who passed several years under his preceptor-
ship have had, since we left the institution, ample oppor-
tunities to compare his method with the various operative
methods ; and I think it is a safe thing to say that we are
not, even at this date, entirely in accord upon the question
of the treatment of chronic tubercular abscess of the spine
or major joints.
My own experience has been a varied one. "When I left
the institution I felt that I had escaped from an unwarrant-
able restraint, and, with the enthusiasm of my years, I went
to the opposite extreme and fell into the error of accepting
Sayre's adaptation of the old proverb, " An empty house is
better than a bad tenant," a saying, I am assured, that has
done much harm as applied to tubercular abscess in chronic
articular disease. Experience has taught me that if a quali-
fication could be added to Sayre's dictum, it would express
the real state of the case. And this qualification is, " when
one can be sure that the tenant will behave well under evic-
tion, or that the tenant will not damage the whole house
before he leaves."
I feel that surgeons generally stand as a unit on the
subject of the surgical treatment of acute abscess ; and if
the chronic abscess in tubercular disease resembled the acute
abscess in its more important particulars, we should not hear
the animated discussion that always follows the introduction
of the question of the treatment of abscesses arising from
tubercular joint disease. And I think it is correct to assume
that we are all too apt to regard " abscess " in its generic
sense rather than in its pathological sense — that we are too
apt to regard a fluctuating tumor, containing the products
of a chronic, infectious disease, as a something to be got
rid of at almost any cost — ignoring the fact that the con-
tents of a tubercular abscess differ in many important re-
spects from the contents of an abscess due to an acute, non-
tubercular lesion. How many of us would hesitate about
the propriety of opening a well-marked acute perityphlitic
abscess ? How many of us would deliberately open a
chronic intrapelvic abscess due to an active and progress-
ive tubercular disease of the dorso-lumbar spine ?
The conservatism of Dr. Knight amounted practically to
* Revised remarks delivered at the fifth annual meeting of the
American Orthopaedic Association.
Feb. 20, 1892. J
SHAFFER: MECHANICAL TREATMENT IN POTT'S DISEASE.
207
a surgical nihilism. The extremists who would open every
tubercular abscess connected with an actively diseased spine
or joint are, I think, as much in error as those who ignore
the indications which point to surgical interference. Un-
fortunately, with all our discussions on this subject, we
have no statistics to demonstrate either the weakness or the
strength of either position ; but I feel safe in stating that
more recoveries occur under the plan of non-interference
than under the one which indiscriminately applies the knife
to every chronic articular abscess.
My own results — after I adopted the plan of opening
every chronic abscess — were not so satisfactory as those
which followed non-interference. It is true that at that
time the antiseptic method of Lister was not available, and
the tubercular bacillus had not been discovered by Koch.
After the antiseptic method was introduced I followed it
very closely, but still I found my results in chronic abscess
of joint disease were not satisfactory. It seemed to me that
in opening a tubercular abscess from Pott's disease, for ex-
ample, we were treating a " symptom " rather than the dis-
ease ; that we were tapping a reservoir, and paying but little
attention to its source ; and that we were in too much haste
to give exit to the so-called " pus," which kept on flowing
from the source, notwithstanding our external antiseptic
dressings. It seemed that high temperature would fre-
quently develop, notwithstanding the gauze and protective
and irrigation and drainage, and that repair, as a rule, was
delayed rather than promoted by our efforts to find a short
route to recovery.
After an experience among many cases and many meth-
ods, I came gradually to adopt a course which appeared to
me to have a rational foundation. I attempted to insure as
perfect a mechanical protection as possible to the diseased
joint or spine and to maintain the general health in every
available way, hoping that the actual disease might cease
hefore the abscess opened (and this proved to be the case
on many occasions), or to await the occurrence of either
severe local or important general symptoms, due to the ab-
scess itself, before I resorted to incision, etc. After I
adopted this plan, I found to my surprise that many ab-
scesses entirely disappeared ; that some became quiescent
or encysted ; that few, if any, gave rise to trouble ; that
those which opened spontaneously almost uniformly did
well ; and that my results were more satisfactory and more
permanent.
My experience is that tubercular abscesses in Pott's dis-
ease, as well as in the abscesses of the chronic tubercular
lesions of the major articulations, pursue a very benign
course under efficient mechanical protection to the diseased
articulation, and that we too often resort to the use of the
knife. If the disease is cured, then the abscess becomes a
local affair and we may treat it as such, though it then usu-
ally disappears spontaneously.
Among the many cases I could submit to illustrate this
position 1 cite the following :
Master S. W., aged eight years, consulted me on March 4,
1887, bringing a letter of introduction from Dr. Weir Mitchell.
The patient h:ul Pott's disease of the spine, involving the elev-
enth and twellth dorsal vertebras. There was a slight kyphosis,
which had evidently been progressing for over a year, but which
had been unnoticed until it was discovered by Dr. Mitchell. The
patient was pale and thin and in a generally bad condition, but
gave a good hereditary history. The prominent feature of his
case was the presence of three large abscesses — one in the pel-
vic cavity, another in the gluteal region, and a third on the in-
ner aspect of the thigh — all on the left side. Fluctuation could
be detected between the femoral and pelvic abscesses. The
gluteal abscess seemed not to be connected with the others.
Both the gluteal and femoral abscesses were very large, the for-
mer being especially prominent, while the latter increased the
circumference of the thigh three inches over the measurement
of the thigh of the unaffected side. The pelvic abscess extend-
ed nearly to the free border of the ribs. The patient had only
a slight rise of temperature, the daily evening temperature aver-
aging 99-C°, the morning temperature averaging 98-2°, for a
period of over a month during which the record was kept.
The analysis of the urine showed nothing abnormal, and all the
vital organs were in good condition.
An antero-posterior support (a modified Taylor's) was care-
fully adjusted, though at first it seemed difficult, on account
of the gluteal abscess, which was so large and extended
so high up that it interfered with the hip band of the appara-
tus. Special provision being made for this, the apparatus was
adjusted and the patient was closely watched. He went to
his home in May after ten weeks of careful treatment, dur-
ing which there was a very perceptible decrease in the size
of all the abscesses, and in July, ]889, they had wholly dis-
appeared. Careful attention was paid during treatment to
the general health and to the climatic surroundings of the
patient. He did not spend one day in bed on account of
his spinal disease during the entire treatment. I saw the
patient during the present summer (1891), and he is well and
strong and as active as many boys of his age. As he was *o
active, I advised that a very light apparatus be worn as a mat-
ter of precaution simply, though I have not regarded the patient
as being under treatment since May, 1890. The curvature lias
not increased.
On November 5, 1890, Miss J. B., of Brooklyn, aged ten
years, consulted me, bringing a letter of introduction from Dr.
Samuel T. Hubbard. The patient had Pott's disease of the first
and second lumbar vertebras, with abscesses very much like
those existing in the case just related — viz., large intrapelvic,
gluteal, and femoral abscesses— the two last named being espe-
cially large and prominent. The patient did not have any rise
of temperature above the normal. The antero-posterior spinal
apparatus was applied, and the patient was brought to me from
Brooklyn every week. Constitutional remedies were used, and
the patient was instructed to go out of doors every pleasant
day. At the end of two months there was a perceptible de-
crease in the size of all the abscesses, and at this date (Septem-
ber, 1891) fluctuation can not be detected at any point, and the
patient is in remarkably good health. The apparatus is still
worn, and the patient is still under professional observation.
The kyphosis has not increased.
I have related the histories of these two cases, among
many others that might be cited, because the abscesses were
very large; and because they may be regarded as extreme
cases. Simple abscesses in Pott's disease do not occasion
me any anxiety, and I have not a single case to record in
private practice where, after deciding to pursue the policy
of non-interference, I have had occasion to regret it. The
cases that have been the most troublesome and the most
unfortunate are those in which the abscesses have been
208
CAILL&: BROMAMIDE.
[N. Y. Med. Joca.r
opened when the indications for so doing were not plainly
evident.
This is only the experience of a single individual. I
submit it as a contribution to the study of a very important
subject.
BROM AMIDE :
A NEW ANTIPYRETIC AXD ANTINEURALGIC REMEDY.
A Preliminary Report of an
Experimental Research into its Therapeutic Value.
By AUGUSTUS CAILLfi, M.D.,
PROFESSOR OF DISEASES OF CHILDREN,
NEW TORK POST-GRADUATE MEDICAL SCIIOOL ;
CHAIRMAN OF PEDIATRIC SECTION, NEW YORK ACADEMY OF MEDICINE ;
VISITING PHYSICIAN TO THE GERMAN HOSPITAL AND DISPENSARY, NEW YORK,
ETC.
This drug is described by its discoverers, Messrs. F. H.
Fischedick and Charles E. Koechling, of New York city, as
a new bromine compound of the anilide group containing
seventy-five per cent, of bromine (C6H2Br3XH.IIBr).
It is in the form of colorless, needle-shaped crystals,
nearly odorless and tasteless, insoluble in hot or cold water,
slightly soluble in cold alcohol, and soluble in sixteen parts
of boiling alcohol. Chloroform, ether, and the fixed oils
dissolve it, but it is insoluble in benzine. Its action toward
litmus paper is neutral. It is a very stable compound, not
being affected by any of the ordinary reagents. It melts
at 243° F., and volatilizes at 310° F. without change,
subliming in beautiful feathery crystals.
Bromamide was first given to dogs and rabbits, in doses
of 2 grammes (30 grains), without noticeable deleterious in-
fluence and without affecting the composition of the blood
in these animals. The administration of from 0-6 to 1
gramme (10 to 15 grains) to healthy adults was followed
by a slowing of the pulse without sweating. The admin-
istration of 0-06 to 0-2 gramme (1 to 3 grains) to children
from one to three years of age was accomplished without
untoward symptoms.
The experiments as to the therapeutic properties of
bromamide were carried on at the German Hospital from
June 1 to November 1, 1891, and suffered embarrassing in-
terruption in the beginning of the experimental terra, in
consequence of the resignation of the entire house staff.
Bromamide was administered in the following class of cases :
Typhoid fever, acute articular rheumatism, chronic rheumatic
arthritis, chronic nephritis, acute fibrinous pneumonia, rheu-
matic fever with acute endocarditis, general and localized
dropsy due to hepatic, renal, or cardiac disease, and diverse
forms of neuralgia ; and special attention was given to a
possible antipyretic, diuretic, diaphoretic, antineuralgic, and
sedative action of the drug.
Case I. — G. P., aged twenty-four; typhoid fever, third week.
June 4, 1891. — Bromamide, 10 grains (0-6). Temperature:
5 p.m., 104-2°; 6 p. m., 104°; 7 p. m., 103-3°; 8 p. m., 102-9°;
9 p. m. (bromamide 10 grains), 102-9° ; 10 p. m., 102-7° ; 11 p. m.,
102-5°; 12 m., 1033°.
7th and 8th. — Ten grains of bromamide at 5 p. m., with re-
sults as above stated.
9th. — Bromamid, 10 grains. Temperature: 5 p. m., 103-4°;
6 p. If., 103-3°; 7 p.m., 103-3°; 8 p.m., 100-9°; 9 p.m., 100-6°;
10 p. m., 101° ; 11 P. m., 100-6° ; 12 m., 100-6°.
10th.— Temperature : 1 a. m., 100-8° ; 2 a. m., 101-1° ; 3 a. m.,
101-1°; 4 a.m., 101-4°.
Bromamide was not again administered after June 10th, as
the temperature continued to remain low. In this case the
pulse and respiration were not materially influenced, and no
sweating or evil efFects were observed.
Case II. — F. B., aged twenty-six; attacks of severe cardial-
gia, with a history of vomiting of blood (ulcus ventriculi?) ; 0-6
(10 grains) of bromamide promptly relieved the pain on four
different occasions. When administered the fifth time it had no
effect, and other treatment was adopted.
Case III. — G. H., aged twenty-three; acute articular rheu-
matism, acute endocarditis, anasarca.
June 6th. — At 8 p. m., 0 6 bromamide (10 grains). Tempera-
ture, 103-5° F. On the following morning the temperature was
still high, and three doses of bromamide (10 grains each) were ad-
ministered during the day, at intervals of three hours. The even-
ing temperature, June 7th, was 99° F., the temperature declin-
ing uniformly. Six hours after the last administration of broma-
mide this patient was seized with severe cramps in the abdomen,
which radiated around both sides of the body and down the
front of the thighs; the features were tightly drawn, indicating
excruciating pain, the face became somewhat cyanotic, the pulse
rapid, weak, and intermittent, the legs were flexed upon the
abdomen, the skin became cold and clammy, a condition of gen-
eral collapse being imminent. After several hours of energetic
stimulation the patient rallied and recovered. In the opinion
of the writer, the severe colic and subsequent collapse in this
patient, with acute and extensive endocardial inflammation, were
not brought about by the administration of bromamide.
Case IV. — F. G., chronic nephritis; general anasnrca; re-
sponding poorly to usual treatment.
August 4 to 10, 1891. — Bromamide, 10 grains morning and
afternoon each day. Urine: On the 4th, 2,900 grammes ; 5th,
3,000 grammes ; 6th, 2,500 grammes ; 7th, 2,500 grammes ; 8th,
2,000 grammes ; 9th, 1,600 grammes ; 10th, 1,600 grammes.
The temperature in the above case was normal, the pulse
rather slow. No change was observed in the constituents of the
urine, and the diuretic powers of bromamid in this case were nil*
Case V. — C. P., aged twenty-six; typhoid fever; admitted
June 4th. Patient received 10 grains each of calomel and
jalap after admission, and an enema daily, and no other medi-
cine.
June 6th.— Temperature, 9 a. m., 104-2° F. ; 10 grains of
bromamide. The temperature fell in two hours to 102-9°. Tem-
perature, 6 p. m., 103° ; 10 grains of bromamide.
7th. — Temperature, 9 a. m., 103" ; no fall. Temperature, 6
p. m., 103-6° ; 10 grains of bromamide.
8th. — Temperature, 9 a.m., 101-8°; 6 p. m., 104-2° ; 10
grains of bromamide. Temperature, 10 p. m., 100-6°.
The amount of urine passed was not satisfactorily recorded.
Case VI. — S. L., aged thirty-three; chronic nephritis, with-
out oedema.
October 20, 1891. — Passed 1,100 grammes urine in twenty-
four hours. Received 10 grains (0-6) of bromamide daily.
Urine. — October 21st, 1,800 grammes; 22d, 1,600 grammes;
23d, 1,800 grammes; 24th, 1,800 grammes; 25th, 1,300
grammes; 26th, 1,300 grammes; 27th, 1,900 grammes. Xo
marked diuretic action was observed. Patient complained of
no unpleasant symptoms.
Case VII. — O. S., aged twenty-three, servant. Diagnosis,
typhoid fever.
September 17th.— Temperature, 4 p.m., 103° F., 1*0 of brom-
amide; 8 p.m., 104-1°.
18th.— Temperature, 4 P. Mi, 103-2°, 10 of bromamide; 8
p. M., 103-8°.
Feb. 20, 1892.] MAJOR: PARALYSIS OF EXTERNAL TENSORS OF THE VOCAL BANDS.
209
19th. — Temperature, 4 p. m., 102-8°, <W> of bromamide ; 8
p. if., 103-8°.
In this case the administration of bromamide was not fol-
lowed by a reduction of temperature, and its further use was
discontinued.
Case VIII. — G. EL, aged twenty-three ; confectioner. Diag-
nosis, acute articular rheumatism. Admitted May 26, 1891, and
treated for four months with all traditional and recognized
methods of treatment without deriving more than temporary
benefit, and with frequent and irregular periods of exacerbation.
September 24th. — Temperature, 103-G° ; pulse, 120; respira-
tion, 24; urine, 1,300. Bromamide, two doses, each 0-6, at 9
a. m. and 8 p. m.
25th.— Temperature, 2 a.m., 100-8°; 4 a. m., 99-2°; 6 a. m.,
98- 8°; 8 a.m., 100°; at noon, 99°; 4 p.m., 100°; 8 p.m., 99°.
Urine, 1,850 grammes.
26th. — Two doses of bromamide, each 0'6. Temperature, 4
a. m., 99°; 8 a. m., 99° ; 4 p. m., 99-6° ; 8 p. m., 100°. Patient
rather stupid but sleepless.
27th.- — Bromamide, 0-6, morning and evening. Temperature
throughout the day below 100°, except at 4 p. m., when it was
101-8°. Fair appetite; open bowels; urine, 1,950 grammes in
twenty-four hours.
28th. — Two doses of bromamide. Temperature, 8 a. m.,
99- 3° ; 4 p. m., 102° ; 8 p. m., 99°. Urine, 2,200 grammes.
29th. — Bromamide, two doses. Temperature as on previous
day. Patient states that he considers himself improving.
October 3d. — The temperature has remained normal for the
past three days, and the administration of bromamide is dis-
continued. The patient remained under observation for a week
more, during which time the temperature was normal, except
on one occasion, when it was 101°.
Case IX. — Child, aged three; acute fibrinous pneumonia,
first stage. In this case the morning and evening temperatures
were both high (above 104° F.).
October 18, 1891.— Temperature, 8 a. m., 104-3°, 0-2 (3
grains) of bromamide; 11 a. m., 102-5°; 6 p. m., 104°, 0-2 of
bromamide; 9 p.m., 102-8°.
On the following day the same amount of bromamide was
given, with about the same result; the case terminating fa-
vorably in the usual time, without further medication.
Bromamide was administered symptomatically in a num-
ber of cases of neuralgia from various causes.
1. Compression myelitis, with intercostal neuralgia. No
beneficial effect from 10 to 20 grains of bromamide.
2. Premenstrual headache, 15 grains of bromamide;
marked relief in two hours.
3. Reflex hemicrania from carious tooth; 15 grains of
bromamide ; relief in three hours.
It will be seen from a perusal of the foregoing that the
trials thus far made are encouraging, and may warrant
further experiments, especially in other forms of disease.
Bromamide has the power of reducing the temperature
in most cases of febrile disease from 1° to 2-5° F., without
the excessive sweating as produced by other antipyretic
d-ugs. It has, according to the above-recorded experiments,
no pronounced diuretic action, and it is, so far as could be
ascertained, free from unpleasant symptoms as regards the
digestive tract. The lancinating abdominal pains noticed in
several of the severe forms of disease can not fairly be at-
tributed to the use of bromamide, because such phenomena
were never observed when the drug was administered to
healthy subjects.
Bromamide can safely be given in 10- to 15-grain doses
(0-6 to 1) several times a day, as an antipyretic and anti-
neuralgic to adults, and in doses of from 1 to 5 grains
(0-06 to 0-3) to children. It may be given in capsule, in
wafer, or dry upon the tongue, or suspended in a fluid.
In conclusion, I take pleasure in expressing my indebt-
edness to Dr. Kurth, Dr. Inglis, and Dr. Moscovich, of the
house staff, for valuable assistance in securing these notes.
OBSERVATIONS ON PARALYSIS OF THE
EXTERNAL TENSORS OF THE VOCAL BANDS*
By GEORGE W. MAJOR, M. D.,
MONTREAL.
Ox the 3d day of January, 1891, G. G., aged twenty-five
years, a bartender by calling, applied at the clinic for diseases
of the throat and nose, Montreal General Hospital, for treat-
ment for loss of voice. He stated that on the 2d of January he
had driven a fast horse for ten miles in the face of a very cold
wind with his throat unprotected. At the time he experienced
some discomfort; this was succeeded by slight pain referred to
the front of the larynx. On rising on the morning following
the drive he was unable to utter a sound. On palpation of the
throat, a tender spot was discovered over the region occupied
by the crico- thyreoid muscles. It, was also noticed that, on at-
tempted phonation, these muscles failed to contract. There
were no other sensitive areas, nor was there evidence of swell-
ing anywhere in the neck. The patient was in the enjoyment
of his usual health, and no indication of constitutional disturb-
ance existed. The voice was muffled, coarse, and in monotone.
The breathing was noisy and, if judged by the peculiar sound
produced on inspiration and expiration alike, might be consid-
ered difficult, but there was a total absence of dyspnoea. The man
himself claimed that his respiration was quite satisfactory. A
laryngoscopic examination revealed the fact that the free edges
of the vocal hands presented the wavy outline that is considered
to be characteristic of paralysis of the crico-thyreoid muscles —
the external tensors of the vocal bands. On expiration, the vo-
cal bands appeared to be convex on their upper surface, and on
inspiration somewhat concave. On phonation, the vocal bands
seemed flaccid and relaxed, and the points of contact between
the free edges were not constant. The larynx was otherwise in
a normal state. On the 20th of January the patient, whose
habits of life were most irregular, contracted a severe cold, and
he was admitted into the wards of the hospital. There was
now some tenderness over the whole thyreoid gland, but no
apparent swelling ; the tonsils and pharynx were red, swollen,
and painful. By the third day the thyreoid gland was very
much increased in size and tender. Breathing was also difficult
when recumbent; the laryngeal image, however, underwent no
alteration in configuration. The swelling had almost entirely
disappeared in four or five days under the use of linseed poul-
tices and other suitable treatment, and the difficult breathing
had ceased. The patient was discharged on the 1st of Febru-
ary, eleven days after admission, cured, 'the vocal condition
was still unchanged. As he left for England, the subsequent
history is unknown.
Paralysis of the external tensors is a rare affection, and
therefore worthy of being recorded when met with in prac-
* Read before the American Laryngoloftical Association at its tliir,
teenth annual congress.
210
LEADING ARTICLES.
[N. Y. Med. Jouk.,
tlce. It is very exceptional indeed to encounter a case
where the recognized symptoms were so very well marked
as in this instance.
The wavy outline of the glottis, the convexity of the
upper surface of the vocal bands on expiration and on pho-
nation, the concavity on inspiration', the unstahleness of the
points of contact of the free margins of the vocal bands at
different intervals, and the flaccid and relaxed appearance
of the vocal bands — were all well-developed features. The
contraction of the crieo-thyreoid muscles on phonation when
the cricoid cartilage was elevated in front, and which can be
readily felt in the average throat, was entirely ahsent.
The occurrence of the acute inflammation of the entire
thyreoid gland during the period of paresis (without alter-
ing the configuration of the image) was also an unusual and
interesting complication. The freedom from dyspnoea and
the presence of noisy breathing during the paralysis are
points worthy of note. The difficulty of respiration, which
supervened when the iufiammation of the thyreoid gland
was at its height without modification of the laryngeal
image, is presumptive of tracheal rather than nerve press-
ure.
The West End Medical Society. — At the annual meeting, held on
the 6fli iast., officers for the ensuing year were elected as follows: Er.
F. J. Bowles, president ; Dr. G. W. Leonard, vice-president ; Dr. F.
Spencer Halsey, recording secretary ; Dr. H. G. Myers, corresponding
secretary ; Dr. S. V. Ten Eyck, treasurer; and Dr. C. N. Dowd, patholo-
gist.
The Hospital Graduates' Club. — At the next meeting, to be held at
the Arena, on Thursday evening, the 2oth inst., Dr. Parker will read a
paper on The Surgery of the Gall Bladder.
The Pan-American Medical Congress. — At the recent meeting of
the Medical Society of the State of New York a committee was ap-
pointed to co-operate in promoting the interests ol the congress. The
committee consists of Dr. A. Walter Suiter, Dr. A. Van Derveei, Dr.
James D. Spencer, Dr. Seneca D. Powell, Dr. W. W. Potter, Dr. D. B.
St. John Roosa, and Dr. .lohu 0. Roe.
A Case of Coloboma of the Optic Nerve with Simultaneous Mela-
noma of the Ciliary Process. — " Dr. Talko publishes in the Przeglad
Lekarski the case of a hoy of five years old who, from his birth, had
been suffering from considerable impairment of sight. He discovered
in both eyes a coloboma without a vestige of the hyaloid, and a mela-
noma of the ciliary process as well, the first case of the kind he had
seen in his ophthalmic practice of thirty years. No such case has, as
far as he know-, ever been mentioned in medical literature. Dr. Talko
is not certain if the embryonic deformity of the ciliary processes is
merely a complication of the coloboma, or whether it may be found in-
dependei.tlv of other deformities of the eyeball. The case, as the first
of its kind, certainly deserves to be recorded." — Lancet.
Thilanine. — " This is a new modification of lanolin, obtained by
Liebels by the action of sulphur on lanolin, and which is stated to be a
definite compound. Dr. Sadlfeld, of Berlin, has experimented with it
in his dermatological practice, and reports very favorably on its action
in various affections. It gives rise to no irritation and allays all itch-
ing, and is said to be destined to supersede Hebra's ointment in derma-
tological work." — British and Colonial Druggist.
The Melting Point of a Mixture of Salicylic Acid and Acetanilide,
says the British ami Colonial Druggist, has been found by H. Prusse
[Pharm. Ztg.) to be lower than that of either of the separate ingredi-
ents, the greatest difference being produced in a mixture of one mole-
cule of acetanilide and half a molecule of salicylic acid. Theie is be-
lieved to be no chemical change, and that the bodies act upon each
other menjy as solvents.
THE
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine,
Published by Edited by
D. Appleton & Co. Frank P. Kosteb, M. D.
NEW YORK, SATURDAY, FEBRUARY 20, 1892.
THE CARTWRIGHT LECTURES.
Professor Osbohn gave the first lecture of the series on
Friday evening of last week. It was devoted to the evolution
of the human body by development and by degeneration. The
fundamental facts that structures on which an increased func-
tional demand is made to correspond with change- in the sur-
roundings of the race undergo a development that fits them for
new or heightened action, and that parts which have become
almost or altogether unnecessary or useless gradually disappear
by degeneration— these facts were illustrated by many striking
and interesting examples. And these were both kept clearly
di-tinguished from mere anomalies.
Among the instances of development mentioned were the
following: The elaboration of the spines of the cervical verte-
brae, with the division of the upper ones io the higher races!
the increase of the antero-posterior curves of the vertebral col-
umn in the same races as compared with the nearly straight
spine of the negro ; the encroachment of the pelvic on the
dorso-lumbar and thoracic portions of the vertebral column, as
exemplified in the increasing tendency of the twelfth dorsal
vertebra to become the first sacral, and of the twelfth rib to
disappear : the increased size of the cranium and the later
closure of its sutures in the higher races, as contra-ted with
the earlier closure of the sutures of the face in those races and
of the cranial sutures in the negro; the widening of the base
of the scapula in the higher races, associated by Gegenbaur
with the development of the scapulo-humeral muscles and the
greater play of the humerus as a prehensile organ; the perfec-
tion of t lie hand in its adaptability to precise work, as con-
trasted with the fitness only for seizing objects in remote times,
when the thumb was incapable of being opposed to the fingers;
the progressive divergence of the female pelvis from that of
the male in type; and the increased development of the great
toe, so that the heel and the ball of the great toe constitute
practically the points of support in standing, walking, etc., with
the consequent eversion of the foot.
As examples of evolution by degeneration Professor Osborn
mentioned, among others, the diminished size of the jaw in the
modern man, that of the Englishman of the period having been
found by Collins to be one ninth smaller than that of the an-
cient Briton, and about half as large as that of the aboriginal
Australian, as compared with the size of the skull; the disap-
pearance of the third incisor tooth and the impending disap-
pearance of the wisdom tooth ; the dwarfing of the outer por-
tion of the foot, before alluded to, and especially the disappear-
ance in many instances of the la-t phalanx of the little toe; and
the tendency of the flexor hallucis loi.gus to fuse with the flexor
hallucis communis.
Feb. 20, 1892.J
MINOR PARAGRAPHS.
211
Professor Osborn's way of putting what he has to say might
well serve as a model to most members of the medical profes-
sion. Although not himself ajiiedical man, he, shows great apti-
tude at turning his anatomical knowledge to account from the
medical point of view. Some of his expressions are effective
largely by virtue of their humor. The following are examples:
" From the typical mammalian standpoint man is a degenerate
animal ; his senses are inferior in acuteness ; his upright posi-
tion, while giving him a superior aspect, entails many disadvan-
tages, as recently enumerated by Clevenger, for the body is not
fully adapted to it ; his feet are not superior to those of many
lower Eocene plantigrades ; his teeth are mechanically far infe-
rior to those of the domestic cat. In fact, if an unbiased com-
parative anatomist should reach this planet from Mars he could
only pass favorable comment upon the perfection of the hand
and the massive brain. Holding these trumps, man has been
and now is discarding many useful structures. I refer especially
to civilized man, who is more prodigal with his inheritance thai)
the savage. By virtue of the hand and the brain he is, never-
theless, the best adapted and most cosmopolitan vertebrate."
Referring to a compensatory readjustment of parts so that the
nutrition of an entire region remains the same, to which process
the term metatrophism was applied, he spoke. of it as "the ger-
rymander principle in nature." He mentioned the eighth rib
as having been " recently floated from the sternum." It was
putting it pithily when he said "structure lags far behind func-
tion in evolution."
We are glad to be able to say that Professor Osborn's audi-
ence was large and seemed to be appreciative.
MINOR PA II A GEA PUS.
THE TREATMENT OF MALARIAL AFFECTIONS WITH
METHYLENE BLUE.
The recent experiments of Guttmann and Ehrlich with
methylene blue as a remedy in malarial diseases, employed on
account of its property of coloring the Ilcematozoon malarial,
have been repeated by Laveran, the discoverer of that organ-
ism. The former reports were favorable to the utility of the
agent in such diseases. Laveran injected methylene blue under
the skin of pigeons having hfematozoa in their blood, but the
organisms did not decrease in number and did not seem to take
the color. He also gave from thirty to forty centigrammes a
day to two patients having malarial disease, giving to one as
much as 7"4 grammes (more than 110 grains). There were no
particular haemotic phenomena, and there was no diminution of
the organisms; the fever returned at the usual hour, and, aside
from the coloration of the urine, there was no effect trom the
administration of the drug. So it may be concluded that in
this drug no new specific has been added to our resources.
TYPHUS IN NEW YORK.
The recent importation of typhus into New York and its
consequent dissemination through various part> of the country
call for quite as vigorous measures as the New York Hoard of
Health is carrying out. That these measures will result in keep-
ing the disease within manageable limits we thoroughly believe.
Therefore we see no reason for the public to apprehend a wide-
spread epidemic. At all events the community should under-
stand that typhus is not a disease that strikes down all sorts and
conditions of men indiscriminately, but is confined to those
whose surroundings are decidedly insanitary. Moreover, there
is no danger of its spreading from one house to another, except
through human intercourse ; hence, the use of houses in various
parts of the city for purposes of isolating patients involves no
danger to persons living near such buildings.
RICORD'S EPITAPH.
In an interesting address on Ricord delivered at the annual
meeting of the Societe de chirurgie by the secretary-general, M.
Monod, which is published as a feuilleton in the Union medicate,
we are told that M. Ricord had, long before his death, made
careful preparations for his interment, and had written his own
epitaph, which he often read to his friends, and with which he
seemed to be pleased. The lines are as follows :
Aux portes de l'Eternite,
Quand j'aurai fini ma carriere.
S'il me reste un peu de poussieie
De cette triste humanite,
Que le tombeau seul s'en empare ;
Qae de mon ame se separe
Cette cause de mes douleurs ;
Car l'ame pure et sa matiere
Doit etre un rayon de lumifere
Que ne troubleront plus les pleurs.
A NOYEL USE OF A BENZOINOL SOLUTION OF MENTHOL.
Dr. Elizabeth N. Bradley has sent us a brief note on the
case of a patient, sixty-four years old, of a rheumatic diathesis,
who had been suffering forseveral days from the pneumonic and
cardiac complications of la grippe, when an attack of ac ute pro-
lapsed hasmorrhoids ensued one night. The usual remedies hav-
ing proved unavailing, either in alleviating the pain or in over-
coming the spasm of the sphincter, it occurred to the doctor
that spraying the haemorrhoids with a benzoinol solution of
menthol, which had proved very efficacious in controlling a
paretic tendency of the laryngeal muscles in the same case,
might so stimulate the muscular structure of the hemorrhoidal
veins as to accomplish a sufficient diminution in the volume of
the pdes to render them reducible. The spraying of the haemor-
rhoids was followed almost instantaneously by a cessation of
pain and by such a decrease in the volume of the tumors that
their spontaneous reduction speedily ensued.
THE MARINE-HOSPITAL SERVICE.
The Annual Report of the Supervising Surgeon- General of
the Ma rive- Hospital Service of the United States for the FiicUl
Tear 1891, a volume of 354 octavo pajjes, comprises a well-ar-
ranged and satisfactory account of the operations of the service
during the year, of much the same character as has been given
in the reports for former years. The new Surgeon-General, Dr.
Walter Wyman, has proved an efficient and acceptable officer,
as was to be expected at the time of his promotion. In his o«n
report he recommends measures for isolating persons affected
with leprosy, but he does it temperately and without commit-
ting himself to the doctrine that the disease is contagious, merely
remarking that where indifference is manifested as to the isola-
tion of patients it slowly spreads.
THE OLDEST AMERICAN EX-HOSPITAL INTERNE
At an annual meeting of the Hospital Graduates' Club, of
New York, held two or three \ears ago, a letter from the late
212
MINOR PARAGRAPHS.— ITEMS..— PROCEEDINGS OF SOCIETIES.
[N. Y. Med. Jour.,
Dr. Henry I. Bowditch, of Boston, was read, and the announce-
ment was made that, so far as could be ascertained, Dr. Bow-
ditch had " walked the hospitals" earlier than any other Ameri-
can physician then living, having been a house officer in the
Massachusetts General Hospital in 1829. Dr. John L. Vander-
voort, who for so many years was the librarian of the New
York Hospital, and who died last summer, was an interne in that
institution in 1832, and Dr. Benjamin W. McCready followed
him in 1834. So far as we are able to ascertain, there is no
American physician now living who antedates Dr. McCready as
a'hospital interne.
TUBERCULOSIS IN BUDAPEST.
TnE Deutsche Medizinal-Zeitung cites a statement of Pro-
fessor [Fodor's, in the Pester medicinisch-chirurgische Presse,
No. 52, 1891, to the effect that the mortality from tubercular
disease is relatively greater in Budapest than in any other large
city in the world, the annual number of deaths being between
590 and COO to each 100,000 inhabitants, while in Vienna it is
between 540 and 550, and in London only between 180 and
190.
THE UNIVERSITY OF BUFFALO.
We learn from the Illustrated Buffalo Express that work
has been begun on a handsome and spacious new building for
the School of Medicine, almost as large as that of the corre-
sponding school in Columbia College. The Buffalo Medical
College has for many years stood high among our American
schools, and we are glad to note this evidence of prosperity.
ITEMS, ETC.
Infectious Diseases in New York. — We are indebted to the Sanitary
Bureau of the Health Department for the following statement of cases
and deaths reported during the two weeks ending February 16, 1892 :
DISEASES.
Week ending Feb. 9.
Week ending Feb. 10.
Cases.
Deaths.
Cases.
Deaths.
0
0
86
0
Typhoid fever
Scarlet fever
9
7
7
6
210
25
225
39
Cerebro-spinal meningitis
2
1
0
' 1 *
Measles
132
13
204
10
Diphtheria
122
23
123
37
11
2
8
1
Erysipelas .
0
0
4
0
Varicella
0
18
0
0
0
1
3
Insanity in Paris. — Progres medical says that a book recently pub-
lished by Dr. Paul Gamier, physician to the special infirmary of the
Prefecture de police, shows that between the years 1872 and 1888 in-
sanity increased about thirty per cent, in Paris.
Society Meetings for the Coming Week :
Monday, February 22d : Medical Society of the County of New York ;
Boston Society for Medical Improvement ; Lawrence, Mass., Medi-
cal Club (private) ; Cambridge, Mass., Society for Medical Improve-
ment ; Baltimore Medical Association.
Tuesday, February 23d : New York Academy of Medicine (Section in
Laryngology and Rhinology) ; New York Dermatological Society
(private); Buffalo Obstetrical Society; Boston Society of Medical
Sciences (private).
Wednesday, February 2£th: New York Surgical Society; New York
Pathological Society; American Microscopical Society of the City of
New York; Metropolitan Medical Society (private) ; Auburn, NY.,
City Medical Association; Berkshire, Mass., District Medical So-
ciety (Pittsfield) ; Philadelphia County Medical Society.
Thursday, February 25th: New York Academy of Medicine (Section
in Obstetrics and Gynaecology); New York Orthopaedic Society;
Hospital Graduates' Club (New York) ; Brooklyn Pathological So-
ciety; Roxbury, Mass., Society for Medical Improvement (private).
Friday, February 26th : Yorkville Medical Association (private) ; New
York Society of German Physicians ; New York Clinical Society
(private); Philadelphia Clinical Society; Philadelphia Larvugologi-
cal Society.
Saturday, February 27th : New York Medical and Surgical Society
(private).
|1rocccL)ings of Societies.
MEDICAL SOCIETY OF THE STATE OF NEW YORK.
Eighty-sixth Annual Meeting, held at Albany on Tuesday,
Wednesday, and Thursday, February 2, 3, and 4, 1892.
The President, Dr. A. Walter Suiter, of Herkimer, in the
Chair.
(Concluded from page 188.)
Early High Amputation in Senile Gangrene.— Dr. 0.
A. Powers, of New York, reported a case in which he had am-
putated through the middle of the femur, at the New York
Cancer Hospital, for arterio-sclerotic gangrene in a man of sixty-
seven years, whose gangrene had extended to the foot and lower
leg. His patient died on the fourth day from hypostatic pneu-
monia, yet a post-mortem examination of the stump revealed firm,
primary union, no pus, and no areas of malnutrition. The paper
was in support of Mr. Jonathan Hutchinson's recommendation
that when the gangrene had extended from the toes to the sole
or dorsum of the foot immediate recourse (barring contra-indii
cations) should he had to amputation above the knee, inasmuch
as it was more than probable that a lower amputation would be
followed by gangrene of the liaps and increased danger to life.
Dr. Powers cited some twenty-five cases of Kuster's, recently
reported by Heidenhain, an analysis of which gave strong con-
firmation of the proposition that in order to obtain sound tis-
sues one must amputate through the thigh.
In the discussion, Dr. Willy Meyer, of New York, and Dr.
Herman Mynter, of Buffalo, cited personal cases shoe ing the
value of the procedure.
Surgical Shock.— Dr. J. H. Packard, of Philadelphia, read
a paper thus entitled. Shock and collapse were said to be non-
identical, though their phenomena were similar. Collapse
might result from other causes than shock. The various defi-
nitions of shock were referred to and criticised. Shock always
signified suddenness of occurrence. It might be followed by
reaction and that in turn by collapse. The term shock had
come into use less than sixty years ago, though the condition
had been recognized for ages. In former times shock had been
supposed to be peculiar to gunshot wounds. Since the genera
introduction of machinery and the development of railroads
with the injuries which attended such modern appliances, the.
cases in which shock occurred had multiplied. Delcnsse wrote
upon this subject in 1834, and denominated the condition cor
motion. Morris described the condition in 1867, and since tha
date the condition had been referred to by many writers. Shock
was a very common accompaniment of burns, especially if the'
were of a severe character. The condition was evidently drj
to a depression of nerve force, and it was intensified in cases in
which there was great loss of blood. The temperature wa
usually lowered in such cases, though it might rise several d«
grees when reaction occurred. Cases were recorded in which!
the temperature had fallen to as low a point as 80° F., and
such cases were almost invariably fatal. The symptoms ol
Feb. 20, 181*2.]
PROCEEDINGS OF SOCIETIES.
213
shock were sometimes apparent in cases in which anaesthesia
was induced in patients with an abundance of food in the stom-
ach. Emesis having occurred, the symptoms of shock would
disappear. Undue exposure of a patient during an operation or
the use of an abundance of water in irrigating a wound encour-
aged shock, and this fact taught that patients should be kept as
warm as possible at such times. Delays in operating should be
avoided as far as possible, no time being lost in demonstrating
the steps which were taken. If irrigation was necessary, only
hot water should be used. The propriety of operating in the
presence of shock, as in the case of accidents, had long been
questioned ; such a procedure seemed to check or prevent re-
action, and'death was often tbe|resnlt. When the pulse became
irregular|and'weak, the anaesthetic should be withheld. Alco-
hol was sometimes harmful as a means of relief in shock ; it was
also sometimes usefuljby its rapid diffusion. External heat was
a valuable means of treatment, and morphine was indicated if
severe pain was present."
Dr. A. Van Deryeer, of Albany, called attention to'the pro-
found shock [that frequently attended injuries from crushing
weights, and said that injuries of this character were often fol-
lowed by bad results. It was by no means necessary that the
loss of blood should be great for profound shock to occur.
Dr. L. S. Pilcher, of Brooklyn, suggested the hypodermic
:injection of nitroglycerin, in doses of of a grain every hour
for two, as one of the efficient means of overcoming shock.
Dr. Mynter did not think that shock was usually due to loss
,of blood. One of the operations which was most frequently at-
tended by profound shock was linear craniectomy, especially if
ihe operation was prolonged by operating on both sides of the
cranium. The loss of blood in such cases was small, but the
nerve injury was apparently serious.
Dr. R. F. Weir, of New York, suggested the hypodermic use
of strychnine, in of- a- grain doses, as a means of relieving
shock, also nitroglycerin, in ^-of-a-grain doses, and rectal ene-
mata of hot water.
Dr. Robert T. Morris, of New York, suggested as means of
treatment the inhalation of nitrite of amyl until there was Hush-
ing of the face, also the measures suggested by the previous
speaker.
A Discussion on the Surgical Management of Genito-
urinary Calculus— Dr. J. D. Bryant, of New York, discussed
the question of diagnosis and the indications for surgical treat-
ment of stone in the kidney. The condition and shape of the
stone would depend on the state of the kidney at the time the
formation was accomplished. The diagnosis of stone in the kid-
ney was often very difficult, and even in cases in which the symp-
toms pointed almost unmistakably to that condition an operation
sometimes failed to reveal its presence. Rough and irregular
stones caused much more disturbance than smooth ones ; they
might even cause serious disorganization of the kidney and death,
and yet be very small. The symptoms might be classified as sug-
gestive and convincing, the former leading to a possible diagno-
sis, the latter pointing to the condition with greater probability.
Such symptoms as renal or lumbar pain and vesical and urethral
irritation were suggestive symptoms. Abnormities in the con-
stituents of the urine might exist and no stone be present. Such
a symptom was, however, suggestive, and might, at a subsequent
period, be convincing, the stone in the mean time having devel-
oped. The true condition was sometimes revealed by vesical
irrigation and cystoscopy. Operative and exploratory treatment
was to be advocated if the suggestive symptoms did not disap-
pear.
Dr. L. A. Stimson, of New York, discussed the question of
the surgical treatment of stone in the kidney. The subject was
a complex one. If the stone was large and the kidney not dis-
organized its removal by nephrotomy was indicated. If the
kidney was severely diseased, nephrectomy should be performed.
In some cases nephrectomy was required as a secondary opera-
tion. The operation could be performed by the extraperitoneal
or the transperitoneal method, the former being preferable and
usually performed. The kidney was reached by a longitudinal
incision in the lumbar region which was met by a transverse
one. The kidney being exposed, its pelvis was to be explored
with a needle or with the finger. Entrance to the organ was
to be effected by an incision through its pelvis, if possible, but,
if this was impossible or impracticable, the incision must be
made through the cortex. Not only should the interior of the
organ be explored and all calculi removed, but the exploration
should be carried as far as possible into the ureter. The wound
should then be packed with gauze and drained. If the organ
was to be removed, all manipulations of it should be made with
as little force and violence as possible. Special care should bo
exercised in securing the pedicle. The artery might be ligated
separately, or, if a mass ligature was used, it should be an elastic
one.
Dr. Arthur T. Cabot, of Boston, discussed the question of
stone in the ureter. Impaction of calculi within the ureter
might be caused by irregularities in their contour. Impaction
might be so firm as to cause serious injury to the ureter, the
kidney, or both, or the stone might be dislodged by the press-
ure of the urine from behind. The pain caused by a stone in
the ureter was a most important consideration, not only on ac-
count of its subjective influence, but also on account of its in-
fluence in determining a diagnosis. Thickening of the wall of
the ureter was one of the conditions that might, attend the pres-
ence of a calculus. The state of affairs being assured, it would
next be of importance to find out the exact location of the
offending body, and this was usually very difficult except in the
lowermost portion of the ureter, where it could be palpated
through the vagina or rectum. Palpation through the abdomen
in very thin people would sometimes enable one to locate it as
high as the brim of the pelvis or even higher. In other cases
the location must be determined by an abdominal incision. The
treatment of this condition was considered as preventive, non-
operative, and operative. Operative procedures would be influ-
enced by the question of the presence of stone in only one or in
both kidneys, and it must be remembered that if there were a
stone in one there often was a stone in the other also. If an
operation was decided upon, it was very desirable that it should
be performed without opening the peritonaeum. The incision
which should be made in the loin to reach the ureter followed
an irregular line and was described. This incision would enable
one to reach all but the lower three or four inches of the ureter.
An anterior incision was not practicable for the removal of the
calculus, though it might be useful in locating it. The posterior
incision obviated the division of the peritonamm. The ureter
having been reached and incised, and the stone removed, the
wound could either be closed with fine silk or allowed to remain
open and heal by granulation. The latter method was believed
to be preferable.
Dr. Edward L. Keyes, of New York, discussed the question
of stone in the bladder, ami (hat of what special indications
should goyern a choice of operation as betw een lithotomy and
lithotrity. He remarked that the three modern procedures, litho-
lapaxy, cystoscopy, and prostatectomy, bad changed the course
of the treatment of stone in the bladder. The size of the stone
did not now affect the treatment, so far as the result was con-
cerned, or perhaps it would be more correct t<> say that the
smaller stones were better treated with the lithotrite, the larger
ones with the knife. Lithotomy, in some respects, required
more skill' than lithotrity, and yet it was not always euBj to
214
PROCEEDINGS OF SOCIETIES.
[N. Y. Med. Jodu.,
grasp and crush a small stone without doing injury to the tis-
sues of the bladder. The age of the patient was not now a
matter of such consideration as formerly. Crushing could be
performed upon persons of all ages, and it should be preferred
as an operative procedure in all cases prior to the period of
puberty. For persons in middle life the perineal section was
frequently the preferable operation, especially if stricture of the
urethra or cystitis was present. For cases in which the stone
was sacculated the suprapubic operation was to be preferred.
For old men with enlarged prostate the suprapubic operation
was to be preferred, and the prostate might be operated upon
at the same time.
Dr. L. B. Bangs, of New York, discussed the indications for
choosing between suprapubic lithotomy and lithotrity.
Fibroid Disease of the Heart.— Dr. A. L. Loomis, of New
York, read a paper on this subject. Heart failure with pneu-
monia, resulting fatally, was frequently attributable to fibrosis.
Changes in the coronary arteries, or anything which caused
changes in the parenchyma of the heart, might precede fibrosis.
Some of the causes that induced fibrosis were toxic changes in
the blood, mechanical interference with nutrition, and trauma-
tisms of various kinds. The most important causes were those
that interfered with cell nutrition and lowered the vital force.
Toxic causes acted primarily upon the cardiac walls. The diag-
nosis of fibrosis of the heart could sometimes be made during
life, and even in the early stages of the disease. The disease
should be carefully distinguished from valvular disease. Irregu-
larity of the heart's action was likely to occur early in the dis-
ease and to be permanent. The heart's action was feeble and
intermittent, and palpita'ion was frequently complained of.
Unusual efforts of all kinds would cause difficulty. Precordial
anguish followed at a later stage <>f the disease. If the diagno-
sis was made early, the development of the disease might be
prevented, or its progress delayed. The treatment would con-
sist mainly in the regulation of the diet, exercise, and mode of
life. All suitable means should be adopted to increase elimina-
tion and improve the nutrition. The best remedial agents were
mercury and iodide of potassium in small doses. Digitalis and
other drugs of similar character would do no good and might
do harm.
Dilatation and Drainage of the Uterus for Disease of
the Endometrium.— Dr. W. Gill WyliE, of New York, read a
paper thus entitled. Until recent years chronic endometritis
had been supposed to be due principally Jto displacements of the
uterus, especially anteflexions, and the treatment had been
adapted mainly to the straightening of the organ. This treat-
ment had consisted in the use of pessaries and various forms
of intra-uterine stems. Such measures were usually ineffective,
because the principle of drainage was usually overlooked. The
author's method of treatment consisted in divulsion of the
uterine canal and the introduction of a grooved, hard rubber
stem within the uterus, which allowed of a free escape of all
secretions. The treatment of the uterine cavity should be based
upon the same principle as the treatment of any other diseased
cavity, and drainage was at the foundation of such treatment.
The intra-uterine tube should be left in position for a week or,
in some cases, for a longer period. If the disease proved obsti-
nate and pointed to the existence of serious lesions in the tubes
and ovaries, it might be necessary to remove the latter.
Dr. VV. M. Polk, of New York, believed that drainage as a
general principle was most important in the treatment of en-
dometritis. If it was ignored, the uterus might retain products
of decomposition and serious results ensue. He dissented from
the statement that the uterus could not be dilated sufficiently in
all oases to admit the introduction of a gauze tampon and retain
it. lie believed th.t antiseptic gauze was the best material for
an intra-uterine tampon. He also insisted that the dilatation of
the uterus and introduction of the tampon should be performed
under an amesthetic. He believed that by means of the tam-
pon a certain number of cases of pyosalpinx could be efficiently
drained, and that in this way abdominal operations might some-
times be avoided.
Dr. Mordeoai Price, of Philadelphia, believed that dilata-
tion, drainage, and packing of the uterus were all useless. In
cases in which such measures were taken it would usually be
found that pyosalpinx was the cause of the trouble, and the
trouble could be relieved only by removing the cause.
Dr. Joseph Price, of Philadelphia, believed that indications
for operations within the pelvis were present now which had
not been present, at least to any considerable extent, ten or fif-
teen years ago. It was this condition of affairs which justified
the pelvic surgery of to-day. He also was of the opinion that
there had been an excess of uterine and intra-uterine treatment.
Perhaps it was responsible for much of the existing pelvic dis-
ease. Sterility, for which much of the gynaecological treatment
was given, was better treated in many instances by rest on the
part of the woman and separation from her husband.
Dr. P. F. Munde, of New York, believed in the existence of
chronic endometritis, and in certain well-recognized methods of
treatment. It was not fair to assume, as some of the previous
speakers had, that those who advocated intra-uterine treatment,
and did so after extensive experience, were lacking in judg-
ment. The speaker was an advocate of both the dilator and the
curette, and he also sometimes used the gauze tampon and the
intra-uterine stem. He was also in favor of astringent and
caustic applications to the uterus on proper occasions. He
sometimes used a fifty-per-cent. solution of chloride of zinc in
the uterus after curetting.
Dr. II. J. Boldt, of New York, was in favor of drainage of
the uterus by means of the gauze tampon. If disease of the an-
nexa was ever caused by gynaecological treatment, it was owing
to want of care on the part of the one who administered the
treatment.
Dr. Joseph Hoffman', of Philadelphia, believed that endo-
metritis was usually due to some form of displacement, or was
the consequence of a tear in the vaginal portion of the cervix.
He objected to the use of caustics in the treatment of this dis-
ease, but was in favor of dilatation to a certain extent.
Four Cases of Uniocular Blindness immediately follow-
ing Injuries of the Skull.— Dr. P. A. Callan, of New York,
read a paper in which the cases were narrated and the principle
was deduced that in these and similar cases blindness was
caused by compression of the optic nerve at the foramen opti-
cum.
Methods of advancing the Internal Rectus for Divergent
Strabismus. — Dr. L. Howe, of Buffalo, read a paper thus entitled.
The methods heretofore in use were described and their defects
pointed out. The author showed a forceps that he had devised
for seizing the muscle after it and its opposing muscle had been
divided. Keeping control of this muscle, preventing its retrac-
tion, would obviate one of the most annoying features of the op-
eration. He also described a method of introducing the sutures
which would prevent their slipping, and also prevent the puck-
ering of the muscle under the conjunctiva, which was some-.'
times a source of great annoyance to the patient. This plaD
was also designed to prevent over-correction of the strabismus,
and was believed to be an improvement upon Prince's method.
A Hip Splint was shown by Dr. S. R. Morrow, of Albany
It was similar in construction to the Gibney and the Taylor-
Davis splint, but very much lighter, the metallic portion beinj
of aluminium. Its weight was about sixteen ounces; the othe;1
instruments weighed five or six pounds. This difference ill
Feb. 20, 1892.1
PR 0 ( 'EEDINGS OF SO CIETIES.
215
weight would offer a decided advantage to the delicate children
who were usually the subjects of hip disease.
NEW YORK ACADEMY OF MEDICINE.
SECTION IN ORTFIOP/EDIO SURGERY.
Meeting of Jan uary 15, 1892.
Dr. Samuel Ketch in the Chair.
The Disappearance of Large Psoas Abscesses.— Dr. T.
Halsted Myers presented a case of lumbar Pott's disease to il-
lustrate the disappearance of very large psoas abscesses without
material interference with the general health during the pro-
cess. In this case, which had a strong family tendency to tu-
berculosis, the abscesss had appeared early, had gradually in-
creased in size, but after an attack of measles it had become
much larger, so as to fill both iliac fossaa and form pouches in
both inguinal regions as large as a man's fist. At this time the
liver had been slightly enlarged, but there never had been a
trace of albumin in the urine. Eight months later, though still
anfemic, the child had felt well, had had an excellent appetite,
and the liver had regained its normal size. Absorption was
rapidly progressing. At present the child had a temperature
ranging between 98-4° and 99-6° E., and a few of the cervical
glands were enlarged ; but he played hard all day, had a good
appetite, and felt well. The abscesses had almost entirely dis-
appeared, and recovery seemed assured.
Dr. Newton M. Shaffer said that he had seen this case from
time to time, and could testify to the large size of the ab-
scesses. This case would certainly have been considered by
some a fit one for operative interference, notwithstanding such
an operation would necessarily have proved rather serious,
on account of its extent. As usual under proper mechanical
treatment, the abscesses had disappeared.
Dr. V. P. Gibney said that in connection with this subject
he desired to report an instructive case. About fifteen years
ago a boy had been brought from the West to the hospital with
I disease of the lumbar spine. The brace at that time in vogue at
the hospital had been applied, and the child had done well for
two or three years, when he had experienced some pain in the
left thigh and a tumor had appeared in the left iliac fossa. The
speaker had advised the systematic use of hot-water douches
over the parts, and the result of this treatment had been con-
sidered at the time to be quite brilliant. He had only just
► learned the sequel of this patient's history. Shortly after the
disappearance of the abscess from the iliac fossa, and while still
wearing the spinal support, an elongated tumor had made its
appearance in Scarpa's space, and had then burrowed down
until it had nearly reached the inner condyle. There had been
then some redness and tenderness, so the hot douches had been
resumed, with the effect of causing an entire disappearance of
' the tumor. Nothing further had occurred until several years
afterward, when, after a fall or strain of some kind, a large and
tender tumor had made its appearance very suddenly on the
outer side of the thigh, at the junction of the middle and upper
thirds. This had been accompanied by pain and considerable
constitutional disturbance, and a surgeon had incised the ab-
, acess, removed some bone detritus, and irrigated the cavity.
i Since then, although the sinuses had been washed out daily with
bichloride-of-mercury solution, and afterward with peroxide of
hydrogen, and then dressed with sublimate gauze, they had
been discharging pretty constantly, and there had been occa-
sional symptoms of sepsis. The remnant of the sac could still
be felt in the iliac fossa. The tumor, which appeared on the
outer side of the thigh, was probably nothing more than the old
abscess deflected by the concussion of the fall. The speaker
8<iid that he had narrated the history of this case because it
was one of those in which the abscess had disappeared under
what was considered to be good treatment, and yet he was not
entirely satisfied with this treatment. He had seen many cases
in which the abscess had disappeared in this way, and he was
glad when this had occurred, but sometimes he could not help
feeling that it might be better if he could, under thorough anti-
sepsis, remove this pus by a surgical operation, and so relieve
the patient from this constant menace.
The Use of Iodoform in the Local Treatment of Stru-
mous Joint Diseases.— This was the title of a paper by Dr. J.
D. Bryant, who used the terms " strumous disease " and
"tuberculous disease" synonymously. For practical purposes
the products of tuberculous joint disease might be said to
be located in the joint cavity and its lining membrane and
in the circumarticular tissue associated with this membrane.
The rice and melon -seed bodies in these diseased joints
were often infected with the tuburculous agents. In the pres-
ent paper the author excluded from consideration disease of
the integument and of the immediate subcutaneous tissues.
The preparations of iodoform which had been used by the
author had been ten-per-cent. solutions with ether or glycerin.
The ethereal solution was easily obtained in an aseptic condi-
tion, it flowed freely through needles of small caliber, and, by its
rapid diffusibility, quickly deposited the iodoform upon the dis-
ease products. But this very property of rapid diffusibility
made it objectionable on account of the liability of producing
constitutional effects and because of the irritation produced by
the fluid, which made the injections extremely painful and often
gave rise to circumscribed abscesses. A solution of iodoform
in sterilized glycerin or oil had the advantage of not producing
these unpleasant constitutional effects and of not being painful
when injected, but, on account of its viscidity, it was necessary
to employ needles of large caliber. It was well to remember
that all iodoform solutions were prone to undergo chemical de-
composition, especially when nearly saturated or when exposed
to sunlight. Camphor had the property of increasing the solu-
bility of iodoform in these fluids, so that a saturated solution of
camphor in olive oil would dissolve six per cent, of iodoform.
No definite rule could be laid down as to the amount of iodo-
form which could be injected without danger of producing con-
stitutional effects; thus, a grain and a half had been known to
give rise to these symptoms, while in other cases no such re-
sult had followed the introduction of one hundred and fifty
grains. It was generally considered that thirty grains of iodo-
form might be injected, but the difference of action of the
ethereal and the glycerin solution must be borne in mind.
The author then spoke of the different manifestations of
iodoform poisoning, those cases being considered the most dan-
gerous in which there was a rapid and compressible pulse,
either with or without fever. Then the presence of iodoform
in the human system was shown by a disagreeable taste; the
introduction of a silver piece into the mouth would immediately
develop a garlic taste, which, according to Poncet, was charac-
teristic of the presence of iodoform. Another test was the pro-
duction of a canary-yellow color when calomel was mixed with
the saliva. He related in detail the histories of two cases to
illustrate the action of the iodoform in the treatment of joint
disease. In the first one the patient, aged eighteen, had been
admitted to Bellevue Hospitalon February 17, 1891, with a his-
tory of having suffered from disease of the knee joint for three
years, during which time he had been treated in various ways
without benefit. The synovial cavity had been greatly distended
with fluid, there had been no special tenderness, and no increase
in the temperature of the joint. There had been much relaxa-
tion of the ligaments, and lateral motion on hyperextension
>
216
Walking had not caused pain, but there had been so much relaxa-
tion of the lateral ligaments that locomotion had been imprac-
ticable' without confining the joint with a bandage or splint. On
February 21st the joint had been opened by a free incision, and
its cavity thoroughly irrigated with a l-to-2,000 solution of bi-
chloride of mercury. Numerous melon-seed bodies had been
evacuated and the wound then closed. The wound had healed
by primary union and the joint had been diminished in size, but
the previously overdistended soft parts had remained fleshy
and the relaxed ligaments had made the joint very insecure.
On April 1st the joint had been opened in two places — at the
site of the former incision, and at the outer side of the quadri-
ceps tendon — so as to lead directly into the outer pouch of the
upward prolongation of the synovial cavity. After a thorough
irrigation with a l-to-2,000 solution of bichloride of mercury
and the complete removal of numerous " rice-seed " bodies,
the cavity had been irrigated with a ten-per-cent. ethereal solu-
tion of iodoform and the wounds closed as before. Primary
union had occurred without reaction. A portion of the synovial
membrane had been removed at this operation, and had been
sent to Dr. Biggs, who had reported that there was no doubt
about its being involved in the tubercular infection. From this
time until May 1st the knee had diminished in size and in-
creased in stability, yet the latter had not been sufficient to
render the joint secure. On May 9th a small quantity of fluid
had still remained in the joint, and, as the patient had been anx-
ious to leave the hospital, two ounces of a ten-per-cent. solution
of iodoform in glycerin had been injected directly into the joint
cavity. There had been no reaction, and, after four or five days'
rest in bed, the patient had been allowed to go around the
ward, and on June 16th he had been discharged. There had
been no pain, tenderness, or effusion for two weeks prior to his
leaving the hospital. Should a similar case come under his ob-
servation, the author said that he should prefer to open the
joint at once in two places, clean out the cavity by irrigation
and manipulation, and, after perfect union had been secured,
inject into the cavity two or three ounces of a ten-per-cent.
solution of iodoform in sterilized glycerin or oil.
In a second case, one of old knee-joint disease, attended
with considerable flexion of the leg and subluxation of the head
of the tibia, occurring in a man twenty years of age, iodoform
injections had been begun after other recognized methods of
treatment had failed to produce any noteworthy local improve-
ment. The case had been under the care of Dr. J. H. Girdner.
Eight drops of a twenty-per-cent. solution of iodoform in ether
had been injected at each of three separate points of greatest
tenderness, into the deepest tissues, and perhaps some portion
into the joint itself. Great pain had been produced at the site
of the injection, followed by numbness of the limb, and per-
sistent nausea for twelve hours; and as the same symptoms had
followed a second injection, it had been decided to substitute a
twenty-per-cent. solution of iodoform in glycerin. This latter
preparation had caused less pain in the limb and no systemic
disturbance. The injections had been repeated every two or
three days. At the end of thirty days the joint had been free
from pain and swelling, the doughy feeling had gone, there had
been voluntary motion, and considerable weight could be borne
by the limb. His general condition had also kept pace with the
local improvement and at the present time the limb was nearly
as strong as the other; there was considerable motion, so that
the patient could walk on it without artificial aid. There could
be no reasonable doubt of the tuberculous nature of the disease
of the joint in this case, or of the curative effects of iodoform.
Dr. A. B. Jttdson had failed to see the necessity or desira-
bility of using iodoform in joints which were under mechanical
treatment. In children thus affected, local medication might be
[X. V. Mki>. Joub.,
ignored in favor of general treatment. He believed that the
trouble was not so much a local fault as a failure, for some
reason or other, of the system to arrest the morbid action and
repair the damage already done, and the system, rather than
the affected part, should receive most attention. Mechanical
treatment was a local application, but its indirect action was of
the utmost importance in relieving pain, permitting sleep, facili-
tating locomotion, and promoting general well-being. It pre-
vented the injurious effects of habitual trauma, and provided for
ultimate symmetry and ability. Beyond this roborant and re-
constructive treatment, general medication was in order, re-
enforced by hygiene and an abundance of rich and wholesome
food, in which cream and other forms of animal fat should be
in excess. He believed the effects thus produced left no room
for the administration of anti-strumous injections.
Dr. Royal Whitman had been surprised to hear the previ-
ous speaker express doubt as to the influence of iodoform on
tuberculous processes, for it was not a matter of opinion, but
of record. Bruns, Krause, and other investigators had shown
that the membrane of tuberculous abscesses ordinarily consisted
of four layers: (1) An outer layer of thick porous tissue, (2) a
layer of spindle cells in a state of active proliferation, (3) actual
tuberculous granulations, and (4) necrotic and degenerated tis-
sue. The two inner layers contained the tubercle bacillus.
Under the iodoform treatment it was found that healthy granu-
lations sprang from the spindle-cell layer, the bacilli disap-
peared, and the tuberculous granulations and inner layer were
converted into a fluid, which might be absorbed or withdrawn
with an aspirator. Arens, in a recently reported series of two
hundred aud fifty-five cases of tuberculous disease of various
joints, had stated that under the iodoform treatment forty per
cent, had shown very marked improvement. The most favorable
cases were those of disease of the wrist and elbow. Trendelen-
burg had given up the use of the ethereal solution in his clinic
because of the pain produced. Instead, he used a twenty-per-
cent, solution of iodoform in oil, injecting about one teaspoon-
ful at intervals of eight days. Krause used a larger quantity-
thirty to eighty cubic centimetres, injecting at intervals of three
weeks. Bruns stated that eighty per cent, of all abscesses'
might be made to disappear by the use of iodoform, and the
specific action of this drug on the tubercle bacillus seemed tc
be very generally recognized. Trendelenburg was now using
oil and iodoform at a temperature of 100° F., with the object ol
making a solution of the iodoform in the oil and of securing its
deposition in a more finely divided state.
Dr. Samuel Lloyd said that he had seen very remarkable
results in his clinic following the use of injections of iodo-
form emulsion, both in joint difficulties and in tubercular adenitis:
in fact, in the latter class of cases they acted so satisfactorily
that they had been used almost to the exclusion of operative
measures. In many cases where tubercular deposits had been
found in the lungs, the change had been very decided after the
injections, especially when these had been pushed up to the poinl
of producing constitutional effects. In one or two cases where
operative procedures had been undertaken, and, secondarily, in
jections had been used on a recurrence of the disease, the im
provement had been much more rapid than after the first
operation when the iodoform had not been employed. Whe
using the iodoform injections in abscess cavities the results hac
not proved good until the cavity of the abscess had beer
washed with hot water or with some antiseptic solution. Il
was advisable, then, to inject the emulsion up to the point o:
causing some distention. Dr. N. Senn had had a similar expe
rience, and in his recently published article on this subject h(
had said that he used weaker solutions of iodoform, but in large)
quantities.
PROCEED INGS OF SOCIETIES.
Feb. 20, 1892. J
BOOK NOTICES.
217
Dr. R. H. Sayre said that in using these injections he had
felt the necessity of employing the iodoform in a more finely
divided state, and therefore he thought it was an advantage to
use the heated oil. He recalled two cases of suppurating ankle-
joint disease, one of which had been treated by injections of
iodoform, and the other by injections of aristol. They had
done equally well, and after about two months of treatment the
evidences of inflammation had entirely disappeared and there
had been no pain or tenderness about the ankle. A splint had
been applied to take off the weight of the body. In a case of
tubercular inflammation of the thumb he had obtained a good
s result from the injection of a ten-per-cent. solution of iodoform,
and likewise in some abscesses.
Dr. H. L. Taylor said that he indorsed what Dr. Judson
had said as to the value of mechanical treatment, and yet wel-
comed the method presented in the paper. His experience
with iodoform in a few cases had convinced him that it had a
, specific action on tubercular tissue. One of his most striking
. cases was that of a typically tubercular subject, a youth of
seventeen years, who had been for some time under observation
of Dr. Da Costa for suspected pulmonary disease. He had
been hobbling about without crutches, in spite of advice, for
about a year after the development of symptoms of tarsal dis-
\ ease before he had come under the speaker's care. He had
been made to use crutches, and the foot had been immobilized
| with an apparatus. After some months, a sinus having ap-
peared, on the advice of Dr. Abbe, injections of an ethereal
solution of iodoform into the joint had been begun. He
could honestly say that the entire appearance of the af-
fected parts had been changed after one injection, and the
subsequent progress of the case to complete cure, although
slow, had been steady. He had also used the iodoform
emulsion in sinuses about joints, and he believed that this
treatment produced beneficial effects, independently of its anti-
septic action.
The Chairman said that about two years ago, while visiting
the clinics in Germany, he had seen a good deal of this treat-
ment with the ethereal solution of iodoform, and he had been
impressed with the great frequency of symptoms of iodoform
poisoning and with the general disregard of mechanical treat-
ment shown by the German surgeons. Still he believed that in
, these iodoform injections we had a valuable adjunct to me-
chanical treatment, and one which had not been sufficiently
i tested by American orthopaedic surgeons.
Dr. Bryant said that he had not had the slightest idea of
substituting the iodoform injections for mechanical treatment,
but he had thought that it could not fail to be a valuable adju-
vant to this treatment, on account of its well-known influence
upon the tubercle bacilli, and because the injections could be
made so easily. In the case of knee-joint disease that he had
described, where the rice and lemon-seed bodies were in such
large numbers, he did not believe that mechanical treatment
alone would have cured the case; in fact, the patient had had
this treatment and had not been benefited by it.
Text-book of Comparative Anatomy. By Dr. Arnold Lang,
Professor of Zoology in the University of Zurich, etc. With
Preface to the English Translation by Professor Dr. Ernst
Haeokel, F. R. S., Director of the Zoological Institute in
Jena. Translated into English by Henry M. Bernard, M. A.
Cantab., and Matilda Bernard. Part I. London and New-
York: Macmillan & Co., 1891. [Price, $5.50.]
The constantly increasing attention that is being given in our
American colleges to the subject of comparative anatomy makes
the appearance of this translation of Professor Lang's famous
work particularly timely and appropriate.
In the commendatory preface to the volume Professor
Haeckel states that the author has, more than any former writer,
made use of the comparative history of development in explain-
ing the structure of the animal body, endeavoring always to give
the phylogenetic significance of ontogenetic facts.
The present volume has chapters on the Protozoa, Metasoa,
Platodes, Vermes, and Arthrovoda. Prefacing each chapter
there is a systematic review of the various classes and orders of
each race, and at the close there is a list of the important litera-
ture on the subject.
The volume contains almost four hundred excellent illustra-
tions, and is provided with a good index.
The Physician as a Business Man; or, How to obtain the Best
Financial Results in the Practice of Medicine. By J. J.
Taylor, M. D. Philadelphia: The Medical World, 1891.
Pp. 144.
The physician is proverbially a poor business man. There
is probably no class of men who realize so little financially from
their labors and from the capital invested, and who lose so large
a percentage of their just dues. The very nature of the general
practitioner's duties renders a certain amount of loss a necessity
which the humane man can never prevent. Much, however, is
preventable by good business methods. Such methods the
writer of this little book endeavors to explain, and with a fair
degree of success. The general principles proposed are excel-
lent, but details regarding fees and methods of collection can
apply only to limited regions, as customs in these matters are so
widely different.
The best part of the book is that devoted to a discussion of
the true value of medical and surgical services. The doctor's
losses are largely due to lack of appreciation of such value by
himself as well as by the patient, by long terms of credit, and
by carelessness and loose business methods.
History of Circumcision from the Earliest Times to the Present.
Moral and Physical Reasons for its Performance, with a
History of Eunuchism, Hermaphrodism, etc., and of the Dif-
ferent Operations practiced upon the Prepuce. By P. C.
Remondino, M. D. (Jefferson), Member of the American
Medical Association, of the American Public Health Associa-
tion, and of the State Board of Health of California. Phila-
delphia and London : F. A. Davis, 1891. Pp. x-346.
This book, while it evinces great study and research and
contains a vast store of information regarding the subjects of
which it treats, contains also a large amount of rubbish, some of
it extremely disgusting. It is a strange combination of science
and balderdash. The astonishing statement is made that a large
number of physicians have had themselves circumcised while in
college or after entering practice, as the result of their own
convictions regarding its value. The author's sympathy for
"the unlucky and unhappy wearer of a prepuce" will seem to
most readers to be wasted. The more serious and scientific
parts are marred by his strong prejudice in favor of the opera-
tion, which has biased his judgment and rendered his conclu-
sions of little value. From a literary point of view the work is
slovenly in the extreme. As a history of circumcision, emasou-
BOOK NOTICES.— REPORTS ON THE PROGRESS OF MEDICINE. [N. Y. Med. JoujJ
218
lation, castration, eunuchism, infilmlation, muzzling, and numer-
ous other strange practices, it contains much that is curious and
interesting, and will repay reading.
BOOKS, ETC., RECEIVED.
A Treatise on the Ligation of the Great Arteries in Continuity.
With Observations on the Nature, Progress, and Treatment of Aneu-
rysm. By Charles A. Ballance, M. B., M. S. Lond., F. R. C. S., Assistant
Surgeon to St. Thomas's Hospital, etc., and Walter Edmunds, M. A.,
M. 0. Cantab., Resident Medical Officer, St. Thomas's Home. Illus-
trated by Ten Plates and Two Hundred and Thirty-two Figures. Eon-
don and New York : Macmillan & Co., 1891. Pp. xxviii to 568.
[Price, $10.]
The Chinese, their Present and Future : Medical, Political, and So-
cial. By Robert Coltman, Jr., M. D., Surgeon in Charge of the Presby-
terian Hospital and Dispensary at Teng Chow Fu, etc. Illustrated with
Fifteen Fine Photo-engravings. Philadelphia and London : F. A. Davis,
1891. Pp. viii to 212. [Price, $1.75.]
The Treatment of Typhoid Fever, and Reports of Fifty-five Consecu-
tive Cases, with only One Death. By James Barr, M. D., Physician to
the Northern Hospital, Liverpool, etc. Introduction by W. T. Gaird-
ner, M. D., LL. D., Professor of Medicine in the University of Glasgow,
etc. London: H. K. Lewis, 1892. Pp. x to 212.
Hospitals and Asylums of the World; their Origin, History, Con-
struction, Administration, Management, and Legislation, etc. By Henry
C. Burdett, formerly Secretary and General Superintendent of the
Queen's Hospital, Birmingham, etc. London: J. & A. Churchill, 1891.
Vols, i and ii. Pp. xvi — 701 ; x — 348.
Nursing in Abdominal Surgery and Diseases of Women. A Series
of Lectures delivered to the Pupils of the Training School for Nurses
connected with the Woman's Hospital of Philadelphia, comprising their
Regular Course of Instruction on such Topics. By Anna M. Fullerton,
M. D., Physician in Charge of and Obstetrician and Gynaecologist to the
Woman's Hospital of Philadelphia. Illustrated. Philadelphia: P.
Blakiston, Son, & Co., 1891. Pp. xiii-17 to 284.
Syphilis in Ancient and Prehistoric Times. By Dr. F. Buret, Paris,
France. Translated from the French, with Notes, by A. H. Ohmann-
Dumesnil, M. D., Professor of Dermatology and Syphilology in the St.
Louis College of Physicians and Surgeons. " Syphilis To-day among
the Ancients." In Three Volumes. Volume I. Philadelphia and Lon-
don : F. A. Davis, 1891. [Price, 81.25.] [No. 12 in the Physician*1
and Students' Ready-reference Series.]
Diseases of the Skin. A Manual for Practitioners and Students.
By W. Allan Jamieson, M. D., F. R. C. P. Edin., Extra Physician for
Diseases of the Skin, Edinburgh Royal Infirmary, etc. Third Edition,
revised and enlarged. With Woodcut and Nine Colored Illustrations.
Philadelphia : Lea Brothers & Co., 1892. Pp. xvi to 644. [Price, $6.]
Consumption : How to Prevent it and how to Live with it. Its Na-
ture, its Causes, its Prevention, and the Mode of Life, Climate, Exer-
cise, Food, Clothing necessary for its Cure. By N. S. Davis, Jr., A. M.,
M. D., Professor of Principles and Practice of Medicine, Chicago Medi-
cal College, etc. Philadelphia and London: F. A. Davis, 1891. Pp.
viii to 143. [Price, 75 cents.]
Tubal and Peritoneal Tuberculosis, with Special Reference to Diag-
nosis. By George M. Edebohls, M. D., New York. [Reprinted from
the Transactions of the American Gynaecological Society.]
Addresses on Anatomy. I. Comparative Anatomy as a Part of the
Medical Curriculum. II. On the Teaching of Anatomy to Advanced
Medical Students. By Harrison Allen, M. D., Philadelphia.
The Treatment of Appendicitis, with Illustrated Cases. By J. E.
Summers, Jr., M. D., Omaha. [Reprinted from the Omaha Clinic]
The Relation of Orthopaedic Surgery to General Surgery. By New-
ton M. Shaffer, M. D., New York. [Reprinted from the Boston Medical
and Surgical Journal.]
Tumor of the Brain. A Clinical Lecture delivered at the Arapahoe
County Hospital, October 31, 1891. By J. T. Eskridge, M. D., Denver.
[Reprinted from the Denver Medical Times.]
Bromoform in the Treatment of Pertussis. By E. J. Mellish, M. D.
[Reprinted from the Chicago Medical Recorder.]
A Case of Orbital Cellulitis and Primary Mastoiditis Interna com-
plicating Influenza ; Opening of Mastoid Process ; Recovery. By
Charles Zimmermann, M. D., Milwaukee. [Reprinted from the Archivet
of Otology.]
The Treatment of Inguinal Hernia. By Alexander Dallas, M. D.„
New York. [Reprinted from the Medical News.]
Biennial Report of the Board of Trustees and Superintendent of the
East Mississippi Insane Asylum, for the Years 1890 and 1891.
Report of the Sixth Annual Meeting of the Association of Execu-
tive Health Officers of Ontario, held at Trenton, August 18, 19, and 20
1891.
Roosevelt Hospital, New York. Twentieth Annual Report, from
January 1, 1891, to December 31, 1891.
ileports on tbe progress of Itiebicinc.
REPORT ON OPHTHALMOLOGY.
By CHARLES STEDMAN BULL, M. D.
Some Experiments to determine the Lesion in Quinine Blindness,
— De Schweinitz (Ophth. Rev., February, 1891) gives the details of eight
experiments on dogs, and draws the following conclusions: When
quinine is given hypodermically to dogs in quantities varying from one
grain to the pound to four grains to the pound, blindness, generally ac-
companied by other general disturbance, is apparent in from three to
fourteen hours. The exact date of the onset of the loss of vision was
not determined ; the earliest date of its appearance after injection
which was noted was three hours. The blindness remained practically
complete in one animal twenty-nine days after a single injection of
three grains and three quarters to the pound. In one there was slight
return of vision after thirty-six hours of blindness. In these animals
the ophthalmoscopic picture w as similar to that seen among human be-
ings with quinine amaurosis; in one there was complete oblitera-
tion of the vessels on the optic disc, and in another blurring of the
edges of the optic discs. In all, the pupils were immovably dil ited.
There were no very gross lesions, with one exception, in either the
cross-sections of the nerves, or in the optic-nerve entrances, or the ret-
inae. In one case there was decided dilatation of the blood-vessels,
and the central vein was plugged with a clot, with long fibrin prolonga-
tions, while white thrombi filled the smaller veins. In the other cases
there was some dilatation of the blood-vessels at the nerve entrance,
but to a much smaller degree. The transverse cuts of the nerves did
not exhibit any marked lesion. In a few there appeared to be some
slight increase in the connective tissue. In others the nerve bundles
between the trabeculae of connective tissue were wider than normal
As regards the brain, the same lesion was present in all instances in
sections taken from the cuneus — namely, a remarkable dilatation of the
pericellular lymph spaces, with degeneration of the protoplasm of the
cell. In dogs blind for a month there was no atrophy of the nerve
fibers in the sense in which the word is ordinarily used ; nor was there
any appearance in the earliest stage of the blindness of neuritis.
Operations upon Eyes blinded by Sympathetic Ophthalmitis.—
Story {Ophth. Rev., March, 1891) lays down the following propositions
for discussion : 1. No operation should be performed on an eye unti
all signs of sympathetic inflammation have disappeared, unless the
intra-ocular pressure is acutely glaucomatous. 2. If an operation musi
be performed for glaucoma during active ''sympathy," it should be t
corneal or scleral incision, and no iridectomy should be attempted. 3
When all inflammation has disappeared, the best method of operatin{
is that of Mr. Critchett, by which the iris is not wounded, haemorrhagi
is reduced to a minimum, and the least possible occasion is given to in
flammatory reaction ; and, lastly, no large opening is made in the globe
through which a fluid vitreous may escape, as it does occasionall;
through an iridectomy, in quantities sufficient to produce collapse of th
eyeball.
Feb. 20, 1892,]
REPORTS ON THE PROGRESS OF MEDICINE.
219
Aniridia and Glaucoma. — Collins (Ophth. Rev., April, 1391) reports
three eases beariug on this subject. The first was in a man, aged thirty-
four, who had good sight when a boy, but could not bear a bright light.
For two years previous to his admission to the hospital there had been
a gradual failure of sight in his left eye, while that of the right, pre-
viously defective, had improved. He had worn glasses of sph. + D. 6
for eighteen months. He had three children, two of whom had the
same ocular malformation as himself. An examination showed com-
plete absence of both irides. Some fine granular opacities and a few
vacuoles were seen in the right lens. There was deep cupping of the
optic nerve in this eye. The tension was increased and vision was
The nasal and lower parts of the field were much contracted. The lett
lens was opaque, and tension of the left eye was increased. The sec-
ond case was in a woman, aged twenty-two, with congenital aniridia in
both eyes and a perforating ulcer of the right cornea. There was
ptosis with marked nystagmus. The left eye was normal as to cornea
and lens. The right eye was enucleated, and, on its being opened, the
ciliary processes were found stretched and atrophied, especially in the
region of the ciliary staphyloma. The optic disc was deeply cupped,
and the retina and choiioid were detached. The filtration area of the
cornea was blocked by the intimate bit of the rounded nodule in which
the ciliary body terminated. The examination showed that the ap-
parent complete congenital aniridia, or the presence of a congenital
coloboma of the iris, did not diminish the likelihood of a relief of
tension being obtained by a sclerotomy in the former case, or an
[ iridectomy in the latter. The third case was in a man, aged twenty-six,
I who twelve years before had had the right eye wounded by a chisel,
which had caused blindness. The blind and staphvlomatous eye was
excised. The examination showed a thinning and bulging of the
sclerotic in the whole circumference of the globe ; there was a dense
white cicatrix passing across the entire cornea, and adherent to this
l was the lens capsule. The nucleus and most of the cortex of the lens
were absent. Theie was complete aniridia; the ciliary body was
stretched and atrophied, and the optic disc was deeply cupped. The
ciliary processes were intimately adherent to the posterior surface of
the cornea at its periphery, in the region of the ligamentum pecti-
natum.
Results of operating in Cases of Xerosis coexisting with Trichiasis.
1 — Scott (Ophth. Rev., June, 1891) reports two cases illustrating this
subject. The first was in a man, aged forty-live, who had trichiasis and
xerosis in both eyes. He was seen three months after the operation
for trichiasis, and in both eyes the cornea, fully sensitive, was clear
and its surface was polished. The lacrymal secretion was normal, and
' the ocular conjunctiva had quite lost its former dried appearance and
was smooth, glistening, and sensitive. The second case was also in a
man with exactly the same condition, but in one eye.
Filamentous or Fibrous Formation in the Cornea. — Czermak (Kl.
Mori. f. Aug., July, 1891) draws the following conclusions from his ob-
servations : 1. Exudative material coming from an inflamed conjunc-
tiva may, in some way not yet perfectly understood, gain entrance into
the cornea through some ulcerated spots. '2. These filamentous struct-
ures contain mainly leucocytes within their vitreous basic substance.
3. By the movements of the eyelid and eyeball they undergo a milling
or rubbing, which causes deformity in the shape of the cells, and, by a
pressing and rotation together, leads to the development of these spiral
filamentous formations.
Parageusia with Ophthalmoplegia. — Wherry (Ophth. Rev., June,
j 1891) describes the case of a man, aged forty-seven, who had homony-
' mous diplopia, which increased on looking toward the right side. There
were no signs of tabes or of active neuritis. Both irides were dilated
1 and immovable. Vision was not affected. The attack began three days
previously while at dinner. He noticed that everything tasted bitter,
and there w as occasional diplopia. Two weeks later there was marked
divergence with crossed diplopia, though each eye could move separate-
ly in every direction. Convergence was impossible. Some spots of
numbness were noticed on the outer side of the left thigh and left little
'; finger. There was severe nocturnal pain in the head. The parageusia
lasted acutely during five days. The external squint and dilatation of
the pupils lasted ten days longer, and then disappeared gradually. It
was thought probable that the ocular symptoms were due to a syphilitic
lesion affecting the nuclei of the third nerve about the aqueduct of
Sylvius, probably very minute.
The Treatment of Squint by Advancement of the Eecti Muscles. —
Bronner ( Ophth. Rev., July, 1891) bases his opinions on the records of
fifty cases of strabismus treated by advancement of one of the recti
muscles according to Schweigger's method. He thinks it of the great-
est importance that the size and condition of the muscle should be as-
certained as nearly as possible before the advancement is performed.
In many of the cases tenotomy of the antagonistic muscle was neces-
sary, and in some tenotomy or advancement had to be done on the
muscles of the fellow-eye. In cases of divergent strabismus, tenotomy
of the externus and advancement of the internus were necessary. In
no case should the same muscle be cut more than once. Bronner
thinks that advancement of the muscle is the best operation in all
cases in which the squinting is amblyopic, and in which the angle of
deviation measures more than 30°.
Incipient Cataract ; its JEtiology, Treatment, and Prognosis. — Ris-
ley (Ophth. Rev., August, 1891) refers to former papers of his in whieh
the opinion was urged that, by regarding the hard cataract as one of
the unavoidable concomitants of old age, the tendency had been to
overlook the more potent factors in its production to be found in the
pathological states of the intra-oeular tunics. He thinks the opaque
lens must be regarded as an extraordinary condition to be explained by
other causes than senility. In many cases it is well known that the
apparently progressing opacity of the lens can be arrested ; in others,
the rapidity of its increase can be greatly retaided, thus maintaining a
useful acuity of vision for a longer time, and, failing in this, the treat-
ment instituted will place the eye in a more favorable state for opera-
tive interference. There are many cases of eyes suffering from irrita-
tive and chronic inflammatory processes of the retina and chorioid,
which, as a rule, do not present the gross ophthalmoscopic changes
which characterize the more destructive forms of retinal and chorioidal
disease. These eyes are weak eyes, suffering from " eye-strain," and
the majority of them show some refractive error, usually astigmatism,
as well as muscular anomalies. The uncorrected errors of refraction
are doubtless the most frequent cause of the conditions here described.
In these eases there are almost always some changes in the lens, usu-
ally peripheral, which might come under the head of " incipient cata-
ract." The results of treatment in this group of cases, faithfully pur-
sued, are sufficiently encouraging. The improvement of vision noted
in almost all the cases successfully treated was in no case due to the ab-
sorption of the opacities already formed in the lens, but to the improved
condition of the chorioid and retina and the clearing up of the vitreous
webs, or the granular or sand-like deposit so frequently discovered in
the anterior part of the vitreous body. The treatment adopted was to
require as complete rest as possible from all work at a near point, the
use of smoked glasses when exposed to bright light, and the local
employment of mild washes and astringents to the conjunctival sac, to-
gether with the moderate use of mydriatics, preferably homatropine.
Internally potassium iodide or ferrous iodide, and potassium bromide cr
lithia if headache was a marked symptom. Any existing error of re-
fraction is to be carefully corrected, and the correcting glasses are to
be worn constantly, suitable correction for a near point being allowed
for all necessary work. Risley draws the following conclusions : 1.
Cataract, though a disease of advanced life, is not necessarily a senile
change, but originates in local pathological states involving the nutri-
tion of the eye itself. 2. In the stage of incipiency cataract is amena-
ble to treatment by such measures as are calculated to remove the
pathological conditions upon which it depends, and we are justified in
giving a more hopeful prognosis to many persons with commencing
cataract, 3. Although the treatment may fail to arrest the progres-
sive degeneration of the lens, the eye will still be in a better condition
to undergo the trials of surgical interference.
The Consensual Pupillary Light Reflex in Cases showing the Ar-
gyll Robertson Pupil Symptom in One Eye.— Jessop (Ophth Rev.,
August, 1891) gives notes of five such cases; thiee were cases of
tabes, one of doubtful tabes, and one probably of sclerosis of the pos-
terior and lateral columns. In all, though the conti action of the pupil
associated with accommodation was present in both eyes, the direct
and consensual light reflex was lost in one and the same eye. In all
220
REPORTS ON THE PROGRESS OF MEDICINE.
[N". Y. Med. Joub.,
the cases the consensual light reflex was present in the sound eye, thus
showing that the optic nerve was capable of carrying impulses to the
light-reflex center of the opposite eye. The lesion in these cases is
probibly one affecting the light-reflex center for one eye near the ter-
minations of the afferent part of the reflex aic. These cases strengthen
and uphold the theory of the decussation of the optico-pupillary fibers.
The Action and Uses of Prismatic Combinations. — Percival (Ophth.
Rev., October, 1891) believes that prisms which correct the muscular
defect completely will be almost always successful in these cases of
hyperphoria, as the error in each eye rarely exceeds 2°, and is generally
much less. The tendency to deviation in the horizontal plane requires
closer study. There are two classes of cases of this nature which
must be carefully distinguished : First, those characterized by feeble-
ness of one or more of the muscles, with which is associated an im-
pairment of movement. Second, those in which the tange, though not
contracted in extent, is in an unavailable situation. Jn such cases,
indeed, the amplitude of the movement is often greater than normal,
yet symptoms arise owing to the fact that the position of minimum
tension is not consistent with parallelism of the visual axes. In the
first class of cases, due to muscular weakness, prisms to relieve the
defect should never be given if cure of the affection is the object in
view. Progressive deterioration of the condition, necessitating re-
peated alterations in the glasses, is almost invariably the result if this
line of treatment is pursued. It sometimes happens that our object is
not to cure the affection — that is, in those paralytic cases which we
regard as incurable. It is in the second class of cases — in those in which
the range of movement is represented by an angle of 18° or more — that
prismatic combinations may be ordered to be constantly worn, and
here they are only applicable when the error is not greater than 2° in
each eye. If the defect exceeds this limit, tenotomy of the preponder-
ating muscles is indicated. Tenotomy has the disadvantage of dimin-
ishing the amplitude of movement, so that, unless the range is of the
normal extent, advancement of the feeble muscles would be preferable,
as thus the range is increased in amplitude, while it is also rendered
more available by the alteration of its position.
The Correction of Aphakia by Glasses. — Dimmer (A7. Mori. f. Aug.,
April, 1891) thinks that when a sphero-cylindrical lens is ordered for
an aphakial eye, after the usual method of examination, the glass as
ground by the optician overcorrects the error. This is particularly
the casein spherical lenses of more than D. 10, in combination with a
cylindrical lens, and the visual acuity may thus be apparently de-
cidedly diminished. In order to avoid this it is necessary to determine
the error of refraction by a piano convex spherical glass placed in
front of the cylindrical glass in the test-frame.
The Ophthalmoscopic Appearances in Hypermetropia and their
Significance. — Bristowe (Ophth. Rev., November, 1891) considers that
the peculiar appearance called the " hypermetropic disc" is found at
all ages, and probably continues through life. It in no way interferes
with the acuteness of vision, nor damages the usefulness of an eye, nor
has it any definite relation to the degree of hypermetropia. An intense
"pseudo-neuritis" maybe present with a very low degree of error.
The " watered-silk " retina exists only in early life, probably to in-
fancy, and disappears with the advent of puberty. The " concentric
striation" appears under exactly the same conditions as does the
"watered-silk" retina, and like it has no relation either to the acute-
ness of vision or to the degree of error. He thinks there are two
forms of hypermetropia — one where the eyeball is fully formed but
has an abnormally small antero-pnsterior diameter, and another in
which the hypermetropia is due to the immature development of the
globe and its contents.
Papilloma of the Cornea. — Ayres ( Ophth. Rev., September, 1891)
reports a case of this nature occurring in a woman, aged fifty, who had
a large growth on the anterior portion of the left eye, involving the
entire front of the ball. It looked like a cauliflower and projected
one centimetre from the sclera ; its horizontal diameter was 3-5
centimetres and its vertical diameter two centimetres. It began to
grow six years before. Four years later it was excised, but grew again
very rapidly. A portion was then excised every few weeks for six
months. In August, 1887, it was as large as a hazel-nut and protruded
between the lids. In August and September, 1887, small portions
were again cut away. In May, 1889, it had grown to an immense
size, and was removed by Ayres, together with the eyeball. On ex-
amination, its structure was found to consist of exceedingly delicate
papilla?, which appeared to spring from almost the entire anterior
surface of the cornea. The growth probably originated in the con-
junctiva.
The Pathology of the Ophthalmoplegias. — Collins and Wilde
(Ophth. Rev., October, 1891) point out in this paper that accumulat-
ing evidence makes it impossible any longer to regard a group of
symmetrical oculo-motor paralyses as isolable into a unique malady
called ophthalmoplegia, but that these must be considered in relation
to ocular monoplegia on the one hand, and bulbar paralysis, loomotor
ataxy, and infantile spinal paralysis on the other. The so-called
ophthalmoplegia interna can no longer be classed as a peripheral palsy
or as due to disease of the lenticular ganglion. Anatomical, physio-
logical, and clinical facts point to nuclear lesion, most probably in the
anterior part of the floor of the aqueduct of Sylvius. The authors
have collected 141 eases of ophthalmoplegia. Syphilis was the cause
in at least thirty-three per cent. When palsy of either iris or ciliary
muscle coexisted with extra-ocular palsy, it was more frequently the
former, which fact was a corollary to the accepted relation of the
centers for them in the nucleus of the third nerve.
A Theory of Glaucoma. — Rheiudorf (Kl. A/on. f. Aug., February,
1 891) does not believe that the existencs of increased tension alone,
or the so-called typical pressure excavation alone, or both these symp-
toms together, suffice to justify a diagnosis of glaucoma. There must
be also present the clinical symptoms in the pupil, iris, and anterior
chamber. He advises the removal of the transparent or cloudy lens in
glaucoma, and rupture of the hyaloid membrane under the following
circumstances: 1. When the anterior chamber does not re-establish
itself alter iridectomy. 2. When the anterior chamber does re-estab-
lish itself, but the visual acuity continues to diminish. 3. In absolute
glaucoma in place of enucleation.
The Formation of Vesicles at the Equator of the Lens. — Magnus
(A7. Mon.f. Aug., September, 1891) describes a peculiar pathological
condition met with in some eyes. It consists of large vesicles along
the equator of the lens and involving the neighboring parts of the lens.
They are cone-shaped, perfectly transparent, and of varying size. Their
broad bases lest against the surface of the lens and their points extend
partly into the posterior chamber and partly into the canal of Petit.
The cone-shape is always marked, but the slope from base to apex is
gradual. The surface is smooth and without a wrinkle. The lens in
their vicinity is perfectly transparent. The shape of the cones varies
with the direction of the illumination. Sometimes these cones form a
continuous circle round the lens. Magnus thinks that they have some
connection with the fibers of the zonule. They vary in number as well
as in size. They are probably produced by an exudation of fluid be-
neath the capsule, which lift the latter like a vesicle from the stratum
beneath.
The So-called Blennorrhoea of the Lacrymal Sac in New-horn In-
fants.— Peters (Kl. Mon.f. Aug., November, 1891) thinks there are a
number of such cases in very young infants which are not caused by
inflammation of the mucous membrane, and hence should not be called
"blennorrhoea." They are due to a defective absorption of the tissue
at the entrance of the lacrymal duct, which hinders the exit of the
cellular material in the lumen of the duet. There is therefore an actual
atresia of the lacrymal duct. Here it suffices to press out the con-
tents of the sac and then to fully irrigate the eyes, in order to bring
about a perfect cure.
A Case of Malignant Fibroid of the Orbit. — Dunn (Amer. Jour, of
Ophth., December, 1890) describes an interesting case of orbital tumor
occurring in a negro, aged nineteen, who had a growth protruding from
between the lids of his left eye. It had made its appearance about
nine months previously. Four months before the growth had been
partially removed. Since then it had giown very rapidly, and when
Dunn saw him it had filled the interpalpebral space. It consisted of
two parts, an incapsulated central part and its prolongations along the
conjunctiva and subconjunctival tissue of the lower eul-de-sae. The
incapsulated portion was as large as a hickory-nut and pushed the eye
upward and backward. The eyeball was apparently perfectly healthy,
Feb. 20, 1892.]
REPORTS ON THE PROGRESS OF MEDICINE.
221
but below were a number of small vessels running from the tumor to
the edge of the cornea. The surface of the growth was red, rough, and
warty, and was covered with a dirty, purulent secretion. It was sensi-
tive to the least pressure. The eyeball was first enucleated, and the
growth was then removed in what seemed its entirety. It was no-
where adherent to the eyeball. On section, it was found to consist
mainlv of bands of fibrous tissue and individual fibrillar, and contained
but few small round cells.
The Treatment of Blepharospasm. — Allport {Amer. Jour, of Ophth.,
January, 1891) advises that spasm of the orbicularis muscle be treated
systematically by stretching its fibers forcibly. The procedure consists
merely in placing a strong, short speculum between the lids, and open-
ing its blades until it is deemed that the muscle has been thoroughly
stretched. The speculum is then firmly set and allowed to remain in
its expanded condition for about five minutes, when it should be re-
moved. The procedure is quite painful, and in some cases may require
general anaesthesia. It is often advisable to repeat the operation sev-
eral times at intervals of a few days.
The Injurious Influence of the Accommodation upon the Increase of
Myopia of the Highest Degrees. — Fukala (Amer. Jour, of Ophth.,
March, 1891) considers that the loss of the power of accommodation in
myopes of the highest degree is not a disadvantage, but is of consider-
able advantage. The use of the accommodation, according to eminent
authors of our own times, injures such eyes, in that the myopia is in-
creased, because accommodation increases the intra ocular pressure.
Myopes use their accommodation less than hypermetropes, therefore
the accessory portion (or circular fibers) atrophies. The atrophy once
begun, and being transmitted by heredity, is certain to progress, as
does also the elongation of the optical axis. Under the influence of
this condition the ciliary muscle is more and more changed into a tensor
chorioidea?, which in its turn causes the pathological changes in the
sclerotic and chorioid. By its contraction the ciliary muscle of the
myope must necessarily pull more forcibly on the chorioid than the
1 muscles of the hypermetrope, in whose eyes the circular fibers are
much more developed.
Remarks on the Ophthalmometer of Javal and Schiotz. — Ostwalt
(Rev. gen. (Tophthal., March 31, 1891) draws the following conclusions
from his use of this instrument: 1. This ophthalmometer indicates ex-
i actly the radius of the cornea. 2. The number of dioptries indicated
by the instrument is a quarter too great. 3. The steps of the sight are
also a quarter too great. 4. The astigmatism of the cornea is there-
I fore only about three quarters of what the instrument shows. 6. A
good part of what has been regarded as correcting contractions of the
| ciliary muscle is explained by this difference between the values indi-
cated by the ophthalmometer and the actual values of the corneal as-
tigmatism. (J. Hence the results and conclusions from the observa-
tions made with this ophthalmometer must be carefully controlled by
other means of examination. 7. The ophthalmometer of Leroy and
Dubois has much greater precision, though even here the values given
are a quarter too great.
The Refracting Power of the Cornea ; Ophthalmometry and the Cor-
recting Cylinder for the Corneal Astigmatism. — Ostwalt (Rev. gen.
Cpopkthal., May-June, 1891) gives the following resume of his observa-
tions : 1. The refracting power of different meridians of the cornea is
found a quarter too large by the ophthalmometers actually in use. The
same is true of the corneal astigmatism. 2. The corneal astigmatism
is not identical with the correcting glass placed in front of the cornea,
but is a quarter less. The correcting cylinder should not be considered
as a separate and distinct glass. It only represents the difference be-
tween the two spherical glasses which correct the ametropia of the two
principal meridians.
The Micro-organism of Trachoma, Microsporon Trachomatosum. —
Noiszetvski ( Ctrlbl. f. prakt. Aug., March, 1891 ) has discovered a micro-
organism which differs from any hitherto described. By the aid of a
certain solution of gold and glycerin and by the simultaneous action of
the sun's rays on the degenerated tissue of the conjunctiva, he has
found the micro-organisms of trachoma, which consist of mycelium,
hyphens, and conidia in irregular masses. He has succeeded in
producing cultures on gelatin and causing them to grow in calves'
eyes, and in these cultures the long, perfectly straight lines of Miero-
sporon trachomatosum are very characteristic. Inoculations of pure
cultures upon the conjunctiva of rabbits always give positive results,
but only after four or five weeks have elapsed.
The Action of Tuberculin on the Inoculated Tuberculosis of the
Rabbit's Eye. — Alexander (Ctrlbl. f. prakt. Aug., July, 1891) gives the
following results of his experiments: 1. The tuberculous process in the
eye was not arrested by the injections, but steadily advanced. 2. The ne-
crosis of the tuberculous tissue showed no difference in any of the ani-
mals under observation. 3. Haemorrhages appeared in all three of the
injected cases, but did not occur in the fourth animal, used for a check
experiment. 4. The number of tubercle bacilli were much greater
in the three injected animals than in the fourth control animal." 5.
The shape and appearance of the bacilli were in all cases perfectly
normal.
A Case of Lepra of the Eye. — Hirsehberg (Ctrlbl. f prakt. Aug., Oc-
tober, 1891) reports a case of nodular lepra of the eye occurring in a
Greek, aged thirty-nine, who had lived for ten years in upper Egypt,
and who had suffered from general lepra for about six years and from
ocular lepra for a year. The right eve read Sn. XII at six inches, the
left eye read Sn. !-£ at the same distance. On the temporal margin of
the cornea in the right eye there was a reddish nodule on the sclera,
about 8 mm. long in a horizontal diameter, fi mm. wide, and 4 mm. thick.
The nodule encroached on the cornea. There was a grayish exudation
upon the iris in the inferior quadrant reaching to the periphery. There
were also posterior synechias. The left eye showed a similar but smaller
nodule exactly at a corresponding spot, which was partially separated
from the cornea, but sent a tongue of infiltration into the cornea. The
patient declined any operative interference.
The Gland of the Aqueous Humor, Ciliary Processes, or Uveal Tract.
— Kicati (Arch, d'ophtha/., xi, 1 and 2) draws the following general con-
clusions from his investigations: The aqueous humor is secreted by the
surface which covers internally the ciliary processes, from the ora ser-
rata to the commencement of the iris. Conducted by the canal of Pe-
tit, the openings of the spaces between the ciliary processes and the
suspensory ligament, the posterior chamber and the pupil, it is emptied
into the anterior chamber, whence it is absorbed by the lymphatic chan-
nels of the iris. This secretion is the product of a gland, the uveal
gland, composed of an epithelium (pars ciliaris retinae), a vascular and
serous well or spring (the chorio-capillaris), and a contractile apparatus
(the cilio-chorioidal muscle), which accumulates the blood in the well.
There are two kinds of aqueous humor: the ordinary, non-tibrinous va-
riety, and the fibrinous or neuro- paralytic variety. The ordinary, non-
fibrinous variety is secreted by the glandular epithelium, which inter-
poses as a barrier to the salts introduced by the blood. It does not
diffuse these salts unless the blood contains an inordinate quantity of
them. Division of the cervical sympathetic favors this diffusion. The
liquid of the anterior chamber is subject to an incessant movement of
circulation, which prevents stasis and the deposit of opacities on the
posterior surface of the cornea. The fibrinous variety, which is pro-
duced when the anterior chamber has been emptied, or the nerves of
the cornea have been divided, is secreted by the interstices between the
epithelial cells. Physiologically it is a reflex secretion provoked by a
disturbance of equilibrium between the ocular pressure and the blood
pressure. The nerves of the deep corneal layers are the peripheral seat
of this reflex. The nervous mechanism of the fibrinous secretion con-
sists of a secretory apparatus constantly in a state of tension, situated
in the ophthalmic ganglion, and of an inhibitory apparatus situated in
the medulla and ganglion of Gasser. The reflex or secretion occurs
whenever the inhibition is suspended, either automatically by puncture,
or directly by experimental division of the trifacial. Irritation of the
iris and isolated paralysis of the blood vessels of the eye hasten and ex-
aggerate the reflex. Two pathological conditions are the result of dis-
eased conditions of this uveal gland — glaucoma and detachment of the
retina. Glaucoma is, generally speaking, synonymous with retention of
the aqueous humor This retention in youth produces distention of the
channels and spaces in which the aqueous humor circulates, or anterior
hydrophthalmia. It provokes, by compression of the retina, venous
stasis in this membrane and in the vitreous — that is, oedema of the ret ina
and vitreous, or hydrophthalmia posterior. The acute attack is in-
duced by spasmodic oedema of the choriocapillaris consecutive to irrita-
222
MISCELLANY.
[N. Y. Med. Jouh.,
tion of the iris. The progressive anterior detachment of the retina is
produced by the aqueous humor flowing through a rupture of the canal
of Petit.
Destruction of the Lacrymal Sac by the Thermo-cautery and its
Total Extirpation in Fistulae and Rebellious Tumors. — Terson (Arch,
d'ophthal., xi, 3) draws the following conclusions : ]. In lacrymal fistu-
la;, cauterization of the sac by the thermo-caut< rv should be done as
soon as the ordinary means of treatment have failed. 2. In certain
cases of purulent inflammation, with slight dilatation and without fis-
tula, the thermo cautery should he employed. 3. In voluminous lacry-
mal tumors, and especially when the pocket is encysted, the total extir-
pation of the sac, followed or not by the thermo-cautery, gives the most
satisfactory results.
(To be continued.)
Ifti s c c 11 ix it g .
The Systematic Use of the Eye in Teaching Anatomy. — The Medi-
cal JVews for February 13th publishes the following abstract of a paper
read by Dr. W. P. Carr, of Washington, at the recent meeting of the
Association of American Anatomists:
In this iconoclastic age a sentiment seems to be growing among
medical men that lectures are of little use for didactic purposes. 1
wish to enter my protest against this idea, and to point out what I
consider an important method of enhancing their value. The aim of
the lecturer, I take it, is not so much to teach anatomic details that
are much better learned from books and dissections, as to teach the
student, first, how to study, how to understand, how to fix in mind the
broad outlines and piinciples of the laws of morphology, the meaning
of structures ; and, secondly, to teach him those methods of observa-
tion that will enable him to add the necessary details for himself. In
doing this we all recognize the importance of engaging the eye as well
as the ear of the student. I have become more and more convinced
of the importance of a systematic appeal to the student's eye and
ear at the same time, and more and more convinced that word-
pictures alone, no matter how forcible and true, make but compara-
tively dim and transient impressions upon the brain. Most ana-
tomic facts are remembered by means of mental pictures — mental
photographs upon the brain. Suppose you wish to remember the
shape of some object. You call up a mental picture of it that vou
have, at some former time, stored away in your brain. Not only so,
most of these mental photographs are composite photographs, made
by numerous impressions, placed one over the other. Especially is
this the case when the object to be remembered is a familiar one; and
frequently, blended in the general outlines of the picture, and yet dis-
tinct, you may recognize some individual object of the class you wish
to recall. Let me mention the great trochanter of the femur. Im-
mediately there rises before your mind's eye a representation of the
upper end of that bone. You see the trochanter, its position, shape,
and relations; and most likely you recognize in the composite the out-
lines of some particular femur that you have handled oftenest, or that
diagram in your anatomy that so frequently meets your eye. These
facts show, 1 think, that it is by means of composite mental photo-
graphs that we retain the memory of form, memory of relation, and
memory of position. The important question is how best to produce
and fix these images.
Naturally, different persons possess in very different degrees this
power of mental photography, as is evidenced by the ease with which
some recall the features of absent friends, and the utter lack of such
ability in others. But I am sure the faculty can be cultivated and
brought to a satisfactory degree of efficiency in all, or nearly all, per-
sons. To do this we must begin with simple figures, and gradually add
details. Every one can remember such simple figures as the cross,
square, circle, etc., but fe.v can carry in mind a complicated arabesque.
I think the older anatomists had some such idea in mind when they
tried to find in the bones fanciful resemblances to familiar objects.
They were trying, perhaps unconsciously, to use some simple image
already formed upon the brain as a durable basis upon which to build
a more elaborate composite. But the idea may to great advantage be
carried much further. I shall never forget how, when beginning the
study of anatomy, I was helped in fixing the human ethmoid by a few
chalk marks placed upon the board by my professor, Dr. Elliott Canes
[Cones ?]. Simply a cross, to represent a front view of the vertical
plate and crista galli, and the horizontal plate, and an oblong mass of
white suspended from the arm of each cross, to represent the lateral
masses. By comparing this image with the bone itself, a mental photo-
graph was formed too simple ever to be forgotten. Having formed in
thi-< way a simple, durable image, it becomes an easy matter to modify
it in detail. We may add the turbinal processes, the ossa plana, show
their relation to the orbits and the frontal bone, and, having gone as
far as convenient with the chalk, refer to more elaborate diagtams for
details, and finally let the student finish by studying the bone itself.
And how much more intelligently he can do it after we have prepared
him in this w ay, by giving him a simple, durable, but plastic image as
a basis, and by explaining to him the morphologic significance of the
bone, as well as other interesting and practical facts relating to it. All
the other bones may be treated in the same manner. The superior
maxilla, for instance, may be built up on a triangular pyramid; the
scapula upon a triangular prism, corresponding exactly to the triangular
rod of cartilage from which it is developed ; and even a bone of as
variable form as a vertebra may be illustrated in such manner that
a composite mental photograph of it is formed in which all of its varia-
tions are recognized, from the stunted tip of the coccyx to the typical
dorsal vertebra, or the occipital bone, and even the other vertebral seg-
ments of the skull.
The ruder the drawing the better, for we do not now wish to im-
press the shape of the component parts, but the shape of the bone as a
whole, and the relative position of its parts simply represented by
masses of black and white.
There are, however, some things that can not be illustrated by even
the most carefully prepared flat picture. Such things as the facial
nerve in the aqueduct of Falloppius, the ventricles of the brain, the
fissure of Sylvius, can not be drawn satisfactorily upon a plane surface.
It is impossible to show the thing itself to a large class of students on
account of its small size. In such cases we must resort to models large
enough to be seen from all parts of the room. It will not answer to
have a small model in the hands of each student, unless, with a pointer,
we have a demonstrator stand over each student as the lecture proceeds.
For teaching purposes I have a large, rough model of the left side of
the brain, made of papier-mache, five feet long and yet light and easily
handled. It is rough and apparently simple-looking, and yet I can
show upon it the relative position and general shape of nearly every
important part of the brain, both internal and external. I conceived
the idea of making it mainly to show what I can not show in diagrams,
the lateral ventricle, particularly its descending horn, the manner in
which the pia mater enters to form the chorioid plexusus, the velum in-
terpositum, etc., and the fact that the five vesicles of the foetal brain
remain distinct in the adult.
My conclusions are :
1 That we remember form, position, and relations by means of
mental photographs.
2. That these are composite photographs.
3. That they may be easily modified from time to time, but can not
be easily effaced or radically altered.
4. That these images are formed by the eye and understood through
the ear.
5. That the power of mental photography varies in different per-
sons, but may be cultivated in all, or nearly all, to a satisfactory poiut.
6. That the way to do this is to produce, first, a very simple impres-
sion, which, consequently, will be durable ; and then more and more
complicated images, that will not only coincide with and strengthen the
first, but will, at the same time, add the necessary details.
7. That in doing this the primitive designs are best drawn upon
the blackboard before the student's eyes; and that, afterward, a series
of large diagrams should be used, or models in case diagrams aie not
satisfactor
Feb. 20, 1892. J
MISCELLANY.
223
S. That the student is by these means taught how to appreciate
and study Nature for himself in a calm, scientific, and observing
manner.
An Army Medical Board will be in session in New York city, N. Y.,
during April, 1892, for the examination of candidates for appointment in
the Medical Corps of the United States Army, to fill existing vaeaneii s.
Persons desiring to present themselves for examination by the board
will make application to the Secretary of War, before April 1, 1892, for
the necessary invitation, stating the date and place of birth, the place
and State of permanent residence, the fact of American citizenship, the
name of the medical college from whence they were graduated, and a
record of service in hospital, if any, from the authorities thereof. The
application should be accompanied by certificates, based on personal
knowledge, from at least two physicians of repute as to professional
standing, character, and moral habits. The candidate must be between
twenty one and twenty-eight years of age, and a graduate from a regu-
lar medical college, as evidence of which his diploma must be submit
ted to the boar J. Further information regarding the examinations may-
be obtained by addressing the Surgeon-General, U. S. Army, Washing-
ton, D. C.
The Medical Department of the Army consists of one surgeon-gen-
eral with the rank of brigadier-general ; one assistant surgeon-general,
one chief medic il purveyor and four surgeons with the rank of colonel ;
two assistant medical purveyors and eight surgeons with the rank of
lieutenant-colonel ; fifty surgeons with the rank of major; and one hun-
dred and twentv-five assistant surgeons with the rank of first lieuten-
ant of cavalry for the first five years of service, and of captain of cav-
alry subsequently until their promotion by seniority to a majority.
With the rank stated in each case the pay and emolument;- of the
rank are associated. The salary of each grade is a fixed annual sum
payable monthly ; but at the end of each period of live years of seivice
the annual sum representing the pay of the grade is increased by ten
per cent, until forty per cent, is added. After twenty years of service
the forty per cent, additional continues to be drawn, but the further in-
crease of the pay by ten per cent, additions ceases — i. e., an officer, al-
though he may have served twenty-five or thirty or more years, can,
under existing laws, have no more than forty per cent, added to his pay
proper by way of increase for length of service. The pay of a first lieu-
tenant of cavalry, or of a medical officer during the first five years of
his service, is $i,600 a year, or $133.33 a month. At the expiration of
his five years of service he becomes, by virtue of that fact, a ciptain,
and his pay is that of a captain of cavalry, $2,000 a year, increased by
ten per cent, for his years of service, viz., $2,20" annually, or $183.33
monthly. At the end of his tenth year of service this rate of pay is
increased by the service-addition to §2,400 annually, or $2C0 a month,
and after five years more the service-addition makes his pay $2,000 an-
nually, or $21(;.t>7 a month. If l.e continues in the rank of captain, at
the end of twenty years of service his monthly pay becomes $233.33 ;
but about this time promotion to a majority is usually obtained, and a
major's annual pay of $2,500 with forty per cent added, makes the
monthly pay of the major and surgeon $291.07. Subsequent promo-
tion, iuvesting the individual with the rank of lieutenant-colonel, colo-
nel, and briga. tier-general, augments the monthly pay respectively to
$333.33, $375, and $458.33. Compulcory retirement at the age of six-
ty-four years increases the rapidity of promotion to the \oungei men ;
and when retirement is effected, either by age or by the accidents of
service prior to reaching the retiring age, the rate of pay subsequently
drawu is seventy-five per cent, of the total salary and increases of the
rank held by the individual at the time of his retirment. Thus, a major
retired for broken health after twenty years' service draws seventy-rive
j per cent, of $291.67 a month; a colonel retired for age, seventy-five
per cent, of $375. The medical officer has the right of selecting quar-
ters in accordance with his rank, and when stationed in a city where
there ate no Government quarters, commutation money, intended to
cover the expense of house rent, is paid to him. The Government pro-
Tides forage and stable room for the horses of the medical officer, and
when he is traveling under orders the expenses of transportation are
paid by the Quartermaster's Department.
Among the privileges granted to medical as to other officers of the
army is that of leave of absence on full pay. The authorized leave
amounts to thirty days annually. This leave is not forfeited if not
taken during the year, but is credited to the officer, who may thus ac-
cumulate a continuous leave of four months on full pay. If he desires
to be absent for a longer peiiod than four mouths, and the permission
is accoided him, he is reduced to hall' pay for all time in excess of the
fcur months or maximum of cumulated leaves of absence. Absence
from duty on account of sickness does not affect the relations of the
officer with the paymaster ; he continues to draw full pay.
A commission in the Medical Department of the Army is an instru-
ment which is good for life, premising conduct consistent with its re-
tention on the part of its possessor ; but it involves no contract which
binds the individual to service for any given number of years. On the
contrary, should the medical officer find on experience that civil life has
greater attractions lor him than that of the army, there is nothing to
prevent him from at any time tendering the resignation of his com-
mission.
A young medical officer on appointment is usually assigned to duty
for a few months at some large post where there are other officers of
his department, to afford him opportunity of becoming acquainted
with the requirements of the Army Regulations and the routine duties
of military life. After this he goes to some post west of the Missis-
sippi River, where he serves a tour of duty of four years. An assign,
ment in the East follows the leave of absence which is usually taken at
this time; and in after years his stations are selected so as to give him
a fair share of service at what may be called desirable posts as an off-
set to the time spent at less desirable stations.
Candidates lor appointment to the Medical Corps should apply to
the Secretary of War for an invitation to appear before the Army
Medical Board of Examiners. The applicat on should be in the hand-
writing of the applicant, should give the date and place of his birth and
the place and State of which he is a permanent resident, and sh uld be
accompanied by certificates based on personal acquaintance from at
least two persons of repute as to citizenship, character, and moral
habits. Candidates must be between twenty-one and twenty-eight years
of age (without any exceptions), and graduates of a regular medical
college, evidence of which, the diploma, must be submitted to the
board. The morals, habits, physical and mental qualifications, and
general aptitude lor the service of each candidate will be subjects for
careful investigation by the board, and a favorable report will not be
made in any case in which there is a reasonable doubt.
The following is the general plan of the examination :
1. The physical examination will be rigid; and each candidate will,
in addition, be lequired to certify "that he labors under no mental or
physical infirmity or disability of any kind which can in any way inter-
fere with the most efficient discharge of any duty which may be re-
quired "
2. Oral and written examinations on subjects of preliminary edu-
cation, general literature, and general science. The board will sat-
isfy itself by examination that each candidate possesses a thorough
knowledge of the branches taught in the common schools, especially of
English grammar, arithmetic, and the history and geography of the
United States. Any candidate found deficient in these branches will
not be examined further. The examination on general science will in-
clude chemistry and natural philosophy, and that on literature will em-
brace English literature, Latin, and history, ancient and modern.
Candidates piofessing proficiency in other blanches of knowledge —
such as the higher mathematics, at cient and modern languages, etc. —
will be examined therein, and receive due credit for their special quali-
fications.
3. Oral and written examinations on anatomy, physiology, surgery,
practice of medicine, general pathology, obstetrics, and di.-eases of
women and children, medical jurisprudence and toxicology, materia
meciica, therapeutics, pharmacy, and practical sanitation.
4. Clinical 'examinations, medical and surgical, at a hospital, and
the performance of surgical operations on the t adaver.
Due credit will be given for hospital training and practical experi-
ence in surgery, practice of medicine, and obstetiics.
The board is authorized to deviate from this general plan whenever
necessary, in such manner as it may deem best to secure the interests
of the service.
224
MISCELLANY.
IN. Y. Med. Jour.
The board reports the merits of the candidates in the several
branches of the examination, and their relative merit in the whole,
according to which the approved candidates receive appointments to
existing vacancies, or to vacancies which may occur within two years
thereafter. At the present time there are fifteen vacancies to be
filled.
An applicant failing in one examination may be allowed a second
after one year, but not a third.
No allowance is made for the expenses of persons undergoing ex-
amination, but those who are approved and receive appointments are
entitled to transportation in obeying their first order assigning them to
duty.
Mortality in Cities in the United States. — The following table
represents the mortality in the cities named, as reported to Dr. Walter
Wyman, Surgeon-General of the Marine-Hospital Service, and pub-
lished in the Abstract of Sanitary Reports for February 1 2th :
New York, N. Y
Brooklyn, N. Y
St. Louie, Mo
St. Louis, Mo
Boston, Mass
Baltimore, Md
San Francisco, Cal . . .
Cincinnati, Ohio
Cleveland, Ohio
Pittsburgh, Pa
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8
The Function of the Hair-tufts in Man. — In the January number
of the Jov/rnal of Anatomy and Physiology, says the Lancet, Dv. Louis
Robinson formulates a theory to account for the persistence in man
of the tufts of hair usually present in the axillae and over the pubes.
These he imagines to be the persistent remnants of hair-tuft developed
with reference to the clinging or grasping power of the young, and as a
means of enabling them to cling to the parent when he or she, as the
ease might be, was not in a position to spare an arm without much im-
periling the chances of escape or rendering movement difficult. Natu-
ralists have observed that young apes hang beneath the body of the
mother and sustain themselves by grasping the hair, and it is stated
that, certain male gibbons assist in carrying the helpless young. It is
an interesting point that jn these apes the period of immaturity is
prolonged almost as much as in man. Other considerations which Dr.
Robinson looks upon as supporting his theory are the appearance of
the hair at puberty, its appearance in both sexes, and the fact that it
often appears earlier and more plentifully on the female. It also ex-
ists in parts where the young of tree-climbing animals could attach
their hands without danger of violent contact from obstacles, and Dr.
Robinson has ascertained by measurement that in most cases the situa-
tion of the axillary and pubic tufts is within easy reach of the hands
and feet of infants when their limbs are extended, if the body of the
adult is in the position taken by that of an anthropoid ape in climbing.
The theory is no doubt ingenious ; but objections to it readily occur.
Dr. Robinson considers some of the most obvious of these, such as the
existence of similar hair elsewhere and the sensitiveness exhibited by
the skin when the hair in those parts is pulled. These, of course, are
capable of being explained ; but the theory would be very much
strengthened if any example could be (pioted of an anthropoid ape in
which these tufts are actually used in the manner suggested by the
author. Their development, if the theory is correct, must have been
very much greater in his ancestors than it is in man at the present
time to account for their persistence now, not only in the absence of
any use for them for so many ages, but actually in spite of very con-
siderable drawbacks to their existence, such as must exist in the fric-
tion to which they are exposed.
The New York Academy of Medicine. — At the next meeting of the
Section in Obstetrics and Gynaecology, on Wednesday evening, the 25th
inst., the following papers are to be read : Floating Kidney and Dis-
ease of the Generative Organs in the Female, by Dr. T. Schmitt; and
Manual Rectification of Occipito-posterior Positions, by Dr. Egbert H.
Grandin.
To Contributors and Correspondents. — The attention of all who jtwjxm
favoring us with communications is respectfully called to the follow-
ing :
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dressed to the publishers.
THE NEW YORK MEDICAL JOURNAL, February 27, 1892.
features attb lUirresi3.es.
GASTRIC ULCER:
A CLINICAL LECTURE
DELIVERED AT THE WOMAN'S HOSPITAL OP PHILADELPHIA,
By FREDERICK P. HENRY, A.M., M. D.,
PROFESSOR OF THE PRINCIPLES AND PRACTICE OP MEDICINE IN THE
WOMAN'S MEDICAL COLLEGE OF PENNSYLVANIA .
I wish to make this clinic both complementary and sup-
plementary to the didactic course, and, with this end in
view, I will endeavor to illustrate the latter by appropriate
cases, and occasionally I will introduce a patient for the ex-
press purpose of enabling me to discuss a subject which
otherwise would have to be postponed until the next win-
ter's session.
The patient before you is one of the complementary
cases — that is, her symptoms all point to an organ the dis-
eases of which we have lately been studying in systematic
detail. She has pain in the epigastric region shortly after
eating, of a dull aching character, felt at times in the spine
between the shoulder blades, and immediately relieved by
vomiting. The relief which follows emesis is so prompt
and so decided that the patient has acquired the habit of
vomiting by irritating the fauces with her index finger.
There is some tenderness in the epigastrium, only elicited
by strong pressure, which is perhaps due to the fact that
the layer of adipose tissue on the abdominal surface — the
, panniculus adiposus, as it is technically styled — is decidedly
thick. It may also be due to the fact that the lesion which
is the cause of this tenderness is seated on the posterior
wall of the stomach.
I would specially direct your attention to the well-nour-
ished condition of this patient. She is stout and florid, and,
in fact, presents every external appearance of health. In
speaking of gastric ulcer, you may recollect that I empha-
sized the fact that the external appearance, the so-called
facies, of the sufferers from this disease was often such as to
contradict the idea of an organic affection. This, of course,
only obtains in the early stages of gastric ulcer, and you may
also recollect my having mentioned that when in these cases
failure of health occurred, it was apt to be sudden and decided.
From the fact of my having mentioned gastric ulcer, you
have doubtless already surmised that I suspect this affection
' to be present in the case before us. Before, however, for-
mally pronouncing a diagnosis of gastric ulcer, we must be
careful to exclude other affections which resemble it. Can-
cer is out of the question. There is no symptom of steno-
sis of either orifice ; there is no emaciation ; on the con-
trary, the woman is stout and well nourished ; there are no
, enlarged supraclavicular lymphatic glands; and, finally, as
I hope to be able to show you presently, hydrochloric acid
is abundantly present in the gastric secretions.
Let us next inquire as to the possible presence of chronic
gastric catarrh. You are all familiar with the symptoms of
this affection, for we have lately studied it in what I believe
to be as thorough a manner as is possible with our present
means of research. We have learned that while there is in
catarrh a sense of uneasiness and distention after eating, act-
ual pain is rarely present, and when complained of is not de-
scribed as being severe. The anorexia is also more complete
than in ulcer. In fact, in ulcer the appetite may be good,
being restrained for fear of the pain excited by its incTwli-
gence. Vomiting, when present, occurs at irregular periods,
for example, before breakfast, and the vomited matters are
mingled with mucus, or may consist solely of this substance.
Symptoms other than pain, referable to the nervous system,
are more common in chronic gastric catarrh than in ulcer,
such as vertigo, insomnia, and hypochondria. The tongue
is usually heavily coated, whereas in ulcer it is often remark-
ably clean. Finally, hydrochloric acid is often absent from
the gastric secretions in cases of catarrh, especiallyT when it
is attended with abundant secretion of mucus.
Functional gastric disorder, the so-called nervous dys-
pepsia, is another affection that must be excluded before we
can regard our patient as a case of gastric ulcer.
In nervous dyspepsia there are eructations of gas which
are distinguished from those occurring in cases of catarrh
by the fact that they are tasteless and odorless. Vomiting
is rare. The appetite may be altogether absent or anorexia
may alternate with periods of hyperorexia or bulimia. In
catarrh the appetite is persistent ly absent. In nervous dys-
pepsia there is often pain in the stomach, but it occurs at
irregular periods, not immediately after eating, as in ulcer,
and, in fact, the pain may sometimes be relieved by eating.
The tenderness in these cases is sometimes relieved by firm,
steady pressure, whereas in ulcer the tenderness is in direct
ratio to the degree of pressure.
There is one symptom to which I have not yet alluded,
and which, if present, would settle this diagnostic problem
offhand. This is hajmatemesis, which, of the three affec-
tions we have in mind — viz., ulcer, catarrh, and dyspepsia
nervosa — is characteristic, not to say pathognomonic, of
the first. Now, it is uncertain whether or not this patient
has vomited blood. You may well inquire why there
should be any uncertainty about the matter, and the reply
is that recently streaks of blood appeared in the vomited
matters, and that the slight haemorrhage may have been due
to the patient's efforts to relieve herself by vomiting. You
will recollect my having told you that she excites emesis
by thrusting her finger down her throat, and it is possible
that in performing this manoeuvre she may have injured
the mucous membrane of the fauces. There are, however,
no traces of any such injury.
In lecturing on gastric ulcer, I insisted on the fact that
an ulcer can not be produced in a healthy animal by an
injury of the gastric mucous membrane; but I said that if
after such injury the gastric juice was rendered hyperacid
by the occasional injection into the stomach of a solution
of hydrochloric acid — for example, of the strength of five
pro mille — the loss of substance, instead of rapidly healing,
would degenerate into a typical round ulcer.
Again, ulcer will develop after an injury to the stomach
of a chlorotic woman, even though the gastric juice be of
normal acidity. Injury alone will not excite ulcer; other-
wise this disease would be one of the commonest, for the
226
HENRY': GASTRIC ULCER.
[N. Y. Med. Jodk.,
stomach is daily exposed to traumatism from thermal and
mechanical causes.
For the production of gastric ulcer two things are
necessary: 1. Traumatism. 2. A disproportion between the
composition of the gastric juice and that of the blood.
This disproportion usually lies in the direction of hyper-
acidity of the gastric juice ; but in a chlorotic woman
whose gastric and other tissues are ill nourished, the gastric
juice may be relatively hyperacid, even although the per-
centage of hydrochloric acid may be normal. In other
words, the gastric tissues of a chlorotic female are less
prone to heal after injury than are those of a person in
good health— that is, they are less able to resist the corrod-
ing action of the gastric juice, and less able to institute the
process of repair.
Our patient is certainly not chlorotic, and therefore if
she is suffering from gastric ulcer we should expect to find
a hyperacid condition of her gastric juice.
In the bottle in my hand there are two or three drachms
of a perfectly clear, watery fluid, which is the filtrate of
the matters vomited by this woman about an hour after
eating. In this other bottle is a small amount of a yel-
lowish liquor, which is composed of phloroglucin, two
grammes ; vanillin, one gramme ; absolute alcohol, thirty
grammes. This is the famous test for hydrochloric acid in
the gastric secretions invented by Dr. Gunzburg, of Ger-
many, about which I have said so much in my lectures on
the diseases of the stomach. It is undoubtedly the best
test for the presence of hydrochloric acid in the gastric se-
cretions, and is practically free from all sources of fallacy.
I am, besides, especially interested in Gunzburg's test be-
cause I believe I was the first to call public attention to it
in this country. You will find it described by me in an
editorial article in the Medical News for January 14, 1888,
entitled Free Hydrochloric Acid in the Gastric Juice. The
original article in which it was described by Gunzburg
appeared in the Centralblatt fur klinische Medicin for Oc-
tober 1, 1887.
I will now proceed to apply this test in your presence.
I pour two or three drops of the gastric filtrate into a watch-
glass and add to it the same amount of the test solution.
I then heat the mixture over a spirit-lamp, taking care not
to boil it, and in a few seconds brilliant streaks of red ap-
pear in the edges of the fluid — i. e., in its thinnest por-
tions— which gradually spread until the bottom of the glass
is entirely red. I advise you by all means to use a watch-
glass for this test instead of the porcelain dish usually em-
ployed by chemists, because the watch-glass can be placed
under the microscope and examined with a lower power by
transmitted light. If this is done, it will be found that the
red material which has formed on heating the mixture is
largely made up of minute crystals which present a beauti-
ful microscopic picture.
The object of heating the fluid was simply to drive off
the water by evaporation, and thereby make the solution of
hydrochloric acid more concentrated. This test is one of
extraordinary delicacy, demonstrating hydrochloric acid in
the gastric secretions when it is present in them to the
extent of one twentieth of one per mille — 0*05 pro mille.
I have now demonstrated the existence of free hydro-
chloric acid in the gastric juice of our patient, and, from the
decided response to Gunzburg's test, I am confident that it
is present in undue amount. In cases of more doubtful diag-
nosis than the one we are studying we should go further in
our chemical research and determine the percentage of hy-
drochloric acid in the fluid vomited or withdrawn from the
stomach. This is readily ascertained by the well-known
chemical process of titration. I did not attempt a quanti-
tative analysis, because the amount of the filtrate was in-
sufficient for that purpose. •
I believe myself to be fully warranted in pronouncing a
diagnosis of gastric ulcer in this case. Everything points
in this direction : The sex — ulcer largely preponderating in
females ; the age, which is certainly not advanced ; the
character of the pain and its immediate relief by vomiting;
the comparatively good state of the bodily nutrition ; and,
last, and most important, the abundant presence of hydro-
chloric acid in the gastric juice. These facts, I repeat, each
one of which is significant, point unmistakably in the direc-
tion of gastric ulcer.
Prognosis. — We come now to consider the question of
greatest interest to the patient — the prospect of recovery.
Barring accident, this, under proper treatment, is good.
We can not see this ulcer, and therefore know nothing
concerning its area and its depth. It may have destroyed
nothing more than the mucosa, while, on the other hand, it
may have destroyed the submucosa and the muscularis, be-
ing prevented from perforation by the delicate serous cov-
ering of the stomach. Again, its base may be adherent to
neighboring organs. Such considerations should make us
guarded in our prognosis.
Hasmorrhage is another event that may occur at any
moment.
The best safeguard against accident is the immediate
institution of proper
Treatment. — The patient should be placed at rest.
Bodily exertion of all kind should be strictly forbidden, for
muscular movements might rupture protective adhesions, and
so cause the fatal accident of perforation. Of all muscular
acts, those concerned in vomiting are most injurious in these
cases, and therefore pain should be relieved and muscular
irritability allayed by opium or one of its preparations.
Opium also accomplishes another important indication in
obtunding the sense of thirst so often present in these
cases. Nourishment should be administered for a few days '
by the rectum, but, in case of objection to this repugnant
measure, the diet for a week at least should consist of pep-
tonized milk mingled with lime-water. The latter sub-
stance is added for the purpose of neutralizing the excessive
acidity of the gastric juice. Bicarbonate of sodium will
accomplish the same result, but is not a safe remedy on
account of the evolution of gas which follows its adminis-
tration. Beef peptones and eggs may be gradually added
to the peptonized milk, and by degrees a more liberal dief
is permitted.
Medicinally, I can recommend nothing in addition tc
opium except the subnitrate of bismuth in large doses-
say thirty grains three or four times daily. It serves tc
Feb. 27, 1892.)
WHITMAN: THE RADICAL CURE OF CONFIRMED FLAT-FOOT.
227
neutralize acidity, and may, as some hold, form a protect-
ive coating upon the ulcerated surface. Benefit has appar-
ently been derived from the use of nitrate of silver, but, in
my opinion, such benefit is only apparent. It seems to me
absurd to expect any local effect from nitrate of silver in
these cases. The stomach is surcharged with acid secre-
tions, which decompose this drug immediately. It might
as well be decomposed beforehand by placing it in a glass
of salt and water, and the patient directed to swallow it.
We will advise this patient to live on an exclusive diet
of peptonized milk mingled with lime-water, in the propor-
tion of half an ounce of the latter to four ounces of the
former. We will keep her strictly quiet, in bed if possible ;
and we will order, besides, half a drachm of subnitrate of
bismuth every four hours. In addition we will allay pain
and vomiting with suitable amounts of morphine. For the
latter purpose, one eighth of a grain daily may suffice,
while, on the other hand, one grain in divided doses may
be necessary.
If these directions are carried out, I hope to present her
to you, on some subsequent occasion, much improved in
every respect.
(Original Communications.
the
radical cure of confirmed flat-foot*
By ROYAL WHITMAN, M. D., M.R.O.S.,
ASSISTANT SURGEON TO OUT-PATIENTS,
HOSPITAL FOR RUPTURED AND CRIPPLED.
The term fiat-foot is in some respects an unfortunate
one, in that it does not correctly describe the affection, of
which the important condition is abduction, and because
most physicians and patients understand by flat-foot an in-
herited weakness which is to be endured or relieved by
braces rather than to be actively treated and permanently
cured.
i I propose, therefore, to call your attention to some of
the predisposing and exciting causes of weak foot, its pro-
gressive character and results, and to explain somewhat in
detail the treatment which has been very successful in the
cases falling under my observation.
Clinically, without attempting to enumerate all the
varieties of this very common affection, cases may be di-
vided into groups.
1. The cases known as weak ankles in weak or rhachitic
children, or accompanying slight knock-knee.
2. The long weak foot seen in- adolescence. These
children are usually brought on account of prominence of
jthe internal malleoli which are thought to be "growing
out." The symptoms are awkwardness in walking, with
j fatigue on any overexertion. Here we find a prominent
scaphoid, slight abduction and limitation of the movement
of adduction, but usually no pain or tenderness on press-
. ure. These cases are of importance, because in later years,
under the increased work to which the feel are subjected,
they may develop into the most confirmed and painful de-
formity.
3. Weak feet in older subjects, particularly women who
are obliged to stand much of the time. In these cases the
pain is very severe, but ceases when the feet are not used.
There is usually but little spasm of muscles or limitation of
motion — that is, the feet can be easily replaced in proper
position, but are markedly flattened when weight is borne.
There is great sensitiveness to pressure on the painful
points, and often redness and swelling. This variety is
very common, and is the form that most physicians associ-
ate with the term fiat-foot.
4. The most interesting and important class with which
this paper is chiefly concerned, usually seen in young
adults. Here we find marked deformity and muscular
spasm, so that the foot is quite rigid and can not be re-
placed in normal position. The arch is more or less flat-
tened, but the important condition is the abduction — that
is, when the feet are placed side by side there is a wide in-
terval between the two great toes wliich the patient can
not lessen, the power of adduction being limited or lost.
In these cases the disability is very great, and the pain per-
sists even when the feet are not actively used.
5. True flat-foot, or pes planus, which may be actually
inherited or the result of rhachitis in infancy. There are
often no symptoms, and the condition need only be con-
sidered when pain is present.
It must be borne in mind that these varieties blend with
one another, and that pain and discomfort do not in any
sense correspond with the degree of deformity.
Flat-foot is considered by the writer as an acquired
partial dislocation, caused by a disproportion between the
weight to be sustained and the strength of the supporting-
structures. This broad definition includes everything that
may weaken the foot or place it at a disadvantage in the
performance of its functions, such as improper shoes and
their consequences — corns, bunions, ingrown toe-nails, de-
formities of the toes, etc. — improper attitudes in activity
and rest, local injury, or acquired or inherited weakness or
disease ; while overweight may mean long standing, labori-
ous occupation, or simply increase in body weight. The
examination of a large number of sufferers from flat-foot, a
considerable proportion of whom were young and vigorous
adults whose muscular development enabled them to en-
gage in the most laborious of occupations, has confirmed
me in the belief that the breaking down of the arch, in
this class at least, is not the result of intrinsic weakness of
muscles,* or primary relaxation of ligaments, f or congenital
deformities of bone, J or because there was some peculiar
disease of cartilage,* or primary muscular paralysis, atrophy, ||
or spasm, A or because the patient had worn high heels Q —
according to the various theories that have been advanced
by writers on the subject — but because the feet, originally
sufficiently strong, had been placed at a serious disadvan-
tage in the performance of their functions.
As a clear understanding of the causes of flat-foot is
* Read before the Harvard Medical Society of New York, October
1891.
* Tbe usually accepted theory-. \ Tillaux and I.cfort.
\ Stokes. * Oosselin. | Sayre. A Duclienne. v Mayo-Collier.
2&'8
WHITMAN: THE RADICAL CURE OF CONFIRMED FLAT-FOOT. [N. Y. Med. Jouh.,
essential to a proper apprehension of its successful treat-
ment, I shall try to explain what these disadvantages are
and how they may be overcome and avoided.
Attitudes. — The attitude of adduction is the strong po-
sition, the attitude of abduction the weak one.
The elastic walk of a barefoot child illustrates the first,
a soldier presenting arms the second position. In the first
instance the feet are under the control of the adductor mus-
cles, and the ligaments are relieved from strain ; in the sec-
ond, or attitude of rest, the ligaments bear the greater part
of the weight. Thus adduction, which implies muscular ac-
tivity, is the most favorable attitude for supporting weight ;
abduction, the most unfavorable." A glance at the ana-
tomical structure of the foot will make this clear. In a
general way it may be divided into two arches — an outer or
strong arch, solidly braced and usually in direct contact
with the sole of the shoe, composed of the os calcis, cuboid,
and two outer metatarsals ; and an inner and weaker arch,
made up of the os calcis, astragalus, scaphoid, three cunei-
form and three inner metatarsal bones, directly under con-
trol of the adductor muscles, whose strength and activity
are essential to its support. Again, the astragalus is perched
upon the os calcis, " like a lady on horseback," at a point
somewhat internal to its base, so that the weight of the
body transmitted through it tends to tip the os calcis over
to the inner side, allowing the astragalus to slip downward
and inward. A certain amount of inward rotation of the
astragalus as the foot broadens and flattens under weight is
normal, * but before it becomes excessive the strong adduc-
tor muscles contract, the great toe is braced to resist the
lowering of the arch, and the weight is thrown toward the
outer side of the foot.
The more the feet are habitually turned outward in
standing and walking, the greater the strain upon the arch ;
the more they are turned inward toward the line of the
walk, the greater the protection of the weaker side of the
foot. To illustrate, if the feet in walking are pointed
straight ahead in the line of the walk, flexion and extension
at every step, or muscular activity, is essential, because the
toes, being in front of the body, must be walked over, and
the weight of the body lifted at every step by muscular
contraction. If they are turned outward, the weight is first
thrown upon the heel, then directly upon the weakest part
of the foot, and we have the passive, inelastic walk of the
weak, aged, and flat-footed. If the foot is to be actively
used, it is essential that its component parts should be in
healthy condition ; thus it will be understood how corns,
bunions, ingrown toe-nails from improper shoes, weakness
from injury, or the result of gout or rheumatism, may make
active flexion of the foot painful so that it is avoided by
turning the toes outward. I have also shown in a former
paper that the faulty position of the feet is habitual in a
very large proportion of individuals.f Muscles are weak-
ened by disuse and improper shoes, and under the influence
of
overwork, injury or disease, overstrained arch and later
* Whitman. Observations on Forty-five Cases of Flat-foot. Boston
Medical and SurgicalJournal , June 14, 1888.
\ Transactions of the American Orthopaedic Association, i.
flat-foot may develop. To illustrate this point Fig. 1 and
Fig. '2 have been drawn from life. Fig. 1 represents the
passive walk with eversion of the feet, the weight of the
body falling on the inner or weaker side. Fig. 2 shows the
proper attitude, the muscular activity and protection of the
arch being very apparent. The subject of this paper being
the treatment of confirmed flat-foot, I shall briefly describe
Fig. l. Fio. 2.
the anatomical conditions which may be present in such a
case, with its symptoms, and then the steps by which a ;
radical cure may be accomplished.
In confirmed flat-foot we shall find an exaggeration of i
the condition before indicated : the os calcis tipped over to
the inner side and rotated inward ; the astragalus rotated
inward and dislocated downward and inward ; the entire
fore-foot, everything in front of the medio-tarsal joint,
thrown downward and outward ; the foot is as it were I
broken in the center. The arch has to a great extent dis- ,1
appeared ; there is a marked projection on the inner side J
caused by the displaced astragalus and scaphoid, while the j
foot is lengthened and broadened in shape.
The overworked peronei muscles are in a state of spasm j
or are actually shortened, and resist any attempt at reduc- I
tion of the deformity. The adductors have lost their power, ■ I
and, in addition, there is usually a loss of function of the I
toes with callosities and corns. Often there is more or less £
swelling of the feet with excessive sweating.
Dissection * shows weakened and atrophied muscles, I
overstretched ligaments, changes in the bones with the for- 1 1
mation of new facets, and other evidence of the chronic in- I
flammation which has accompanied the gradual progression 1 1
of the affection. Such changes are, however, the result of I
many years of neglect, and illustrate the importance of )
early diagnosis and treatment.
The affection is easily recognized. Persistent pain, | i
* Symington, Journal of Anatomy and Physiology, October, 1884.A
Humphrey, Lancet, March 20, 1886. Stokes, Annals of Surgery, Octo-11
ber, 1885. Von Meyer, Ursache und Mcchanismns dcr Enlslehung de* \\
erworbenen Ptattfusses, 1883. Hueter, Grundriss der Chir., 1882.
Feb. 27, 1892.] WHITMAN: THE RADICAL CURE OF CONFIRMED FLAT-FOOT.
229
weakness, and discomfort about the arch of the foot, in-
creased by standing- or walking, particularly on going up or
down stairs, which necessitates an extra exertion of the
affected joints, with tenderness on pressure at the junction
of the astragalus and scaphoid, are perhaps the earliest
symptoms. In some cases the arch may appear perfectly
normal, while in others the foot is entirely flat.
The usual symptoms, some of which are always present,
are as follows :
1. The peculiar inelastic walk, the weight being thrown
upon the heels, the feet turned outward to avoid activity ;
as patients express it, "the feet have lost their spring."
2. The deformity — the flattening of the arch, and the
projection on the inner side of the foot, when weight is
borne — a deformity which later becomes permanent, from
muscular spasm, contraction, and shortened ligaments, with
inflammatory adhesions between the bones.
3. Pain in the feet, with local tenderness on pressure,
referred to the following points in order of frequency :
1. The astragalo-scaphoid junction.
2. Below the external malleolus.
3. The dorsum of the foot.
4. The center of the heel.
5. Beneath the great toe joint.
The pain is often reflected up the inner or outer side of
the leg to the knee or hip.
4. Extreme stiffness of the feet after sitting, or on ris-
ing in the morning, or cramps at night in the feet or calves,
symptoms usually associated with the more advanced cases,
indicating, I believe, beginning changes in the bones, with
the formation of new facets. To illustrate, two patients
have recently consulted me who refused to sit down in my
office because the effort to stand was so painful after the
momentary relaxation of the muscular tension.
In considering the question of early diagnosis, the inter-
1 mittence of symptoms should be borne in mind ; thus, a
' weak foot when subjected to overstrain becomes painful.
After a few weeks' rest the pain ceases, to recur several
months later under similar irritation. There are, too, rheu-
matic symptoms in a weakened foot ; the pain, often accom-
panied by redness and swelling, is worse in damp weather,
or the affection may be the result of weakness following
: true rheumatic inflammation, although this is comparatively
rare. As flat-foot is so constantly mistaken for rheuma-
tism, it would be well to remember that rheumatic inflara-
» mation is rarely confined to one member or joint, that per-
sistent pain in the feet is almost always of local origin, and
that local treatment for local pain and deformity is always
i in order, while medicinal treatment, except for the rest of
the affected parts, which may be advised, is worse than use-
less, as it postpones the recognition and proper treatment
| of the true affection. If this proposition, that persistent
'■ local pain demands local examination and treatment, were
■ accepted, many sufferers might be relieved from years of
pain and discomfort.
In considering the treatment of a case of flat-foot, the
important question is this : Can it be replaced in proper
, position ? If it can — that is, if its movements are free
and unembarrassed, not limited by muscular spasm or in-
flammatory adhesions — the treatment is very simple. An
efficient support, a proper shoe, an avoidance of faulty
positions, with exercises for strengthening the weakened
muscles, will at once relieve the patient. If, however, the
reduction of the deformity by manipulation is impossi-
ble, it should be treated as any other dislocation should
be — adhesions should be broken up and the deformity
reduced. This variety, which I have included in the fourth
class, is the most interesting and important, because the
patients are usually young adults ; the deformity is ex-
treme ; the affection rapidly progressing ; the patients are
almost completely disabled ; the symptoms, are so urgent
that they are very amenable to treatment, and the results
are most satisfactory. Excessive muscular spasm and ri-
gidity in a young person I have come to look upon as a
very favorable indication, as it shows muscular strength
and integrity of bone — the same distinction that one might
make between a recent dislocation with the accompanying
pain and the passive acceptance of the situation in a dis-
placement of long standing. A radical cure is possible in
all recent cases of flat-foot, and relief of pain and, to a
great extent, of deformity may be assured in every case.
Some writers hold out the forlorn hope that when the
deformity is complete — that is, when the astragalus rests
upon the sole of the shoe — pain ceases. I need only men-
tion the fact that I have treated patients after twenty years
of continuous and increasing discomfort. The treatment of
this class of cases is conducted on the following principles :
1. Forcible reduction and overcorrection of the de-
formity.
2. A temporary support to prevent relapse.
3. A proper shoe.
4. Manipulation to stretch contracted and shortened tis-
sues.
5. Exercises to strengthen weakened muscles.
6. A re-education of the patient in the proper manner
of walking and supporting weights.
In brief, the application of the simplest surgical princi-
Fio. 3.- Flat-foot before operation. A, Flo. 4.— The over-corrected foot, w ith
the projection of the displaced a-trag- the reversal of the lines of displace-
alus and scaphoid ; 15, the inner mal- nient.
leoltis ; C, the mediotarsal joint, show-
ing the outward displacement before,
the inward rotation behind, this point.
pies. Under ether, the foot is forcibly moved in all direc-
tions to break up adhesions, and is then forced into a posi-
tion of extreme adduction or equino-varus and retained there
230
WHITMAN: THE RADICAL CURE OF CONFIRMED FLAT-FOOT. [N. Y. Med. Joub.,
by a well-padded plaster bandage. Although great force is
sometimes used, the after-symptoms are usually slight, and
the patient, if he desires, is allowed to walk about on the
plaster bandages on the following day. In about a week,
or earlier, if there is no pain in the feet, the bandages are
removed and plaster casts are taken for the support which
is to be used.
Casts are easily and quickly made in the following man-
ner : Seat the patient in a chair ; in front of him place an-
other chair of equal height ; on it lay a thick pad of cotton
batting and cover it with a square of cotton cloth. Put
about a quart of cold water into a basin with a tablespoon-
ful of salt ; sprinkle plaster on the surface, stirring until the
mixture is of the consistence of thick cream, then pour it
upon the cloth. Flex the patient's knee and allow the outer
side of the foot, previously oiled, to sink into the plaster,
raising the edges of the cloth until rather more than one
half the foot is covered. When this is hard, spread vase-
line on its upper surface, and, having mixed a smaller quan-
tity of plaster, cover the exposed surface of the foot ; the
toes need not be included. When hard, the two halves are
removed and their inner surfaces oiled. They are then band-
aged to one another and the interior filled with plaster of
the same consistence as before. When the outer shell is
removed, we have a reproduction of the foot ready for fur-
ther manipulation. This consists in changing the cast with
the exercise of a certain amount of judgment, so that it
may resemble a perfect foot — that is, to scrape away the
projection on the inner side if any remains, and to deepen
the inner and outer arches. Several years ago I was in the
habit of making the brace on an actual reproduction of the
foot, but experience showed that it was possible, by the
treatment to be described, to still further overcome deform-
ity which could not be corrected by the forcible reposition
under ether. When completed, the casts should stand square-
ly on the table with no inclination to either side ; they are
then sent to the founder to be reproduced in iron.
The feet are, if the case is one of long standing, again
placed in adduction and the plaster bandages reapplied.
No anaesthetic is necessary, as the previous overstretching,
with the subsequent rest, has to a great extent removed the
resisting muscular spasm. In from one to three weeks, ac-
cording to the judgment of the surgeon, the bandages are
removed and active treatment begun. The Hat-foot on
which forcible over-correction has been performed is now,
although in good position, stiff, and all its movements are
restricted and painful, and if the patient is allowed to go
about without support and further treatment, a recurrence
of the deformity is inevitable.
The subsequent treatment is carried out with the aim
of regaining free and painless movement in every direction,
particularly in adduction. The foot is first immersed for
ten minutes in hot water, afterward vigorously massaged,
especially about the dorsum, and is then slowly forced into
a position of adduction. This manipulation, first described
by me in the New York Medical Journal of October 11,
1890,* has gradually assumed greater importance, and is
now considered an essential for the successful treatment of
the affection. It is conducted as follows : The patient is
seated in a chair ; the surgeon stands in front of him. Let
us suppose that the left foot is to be adducted or, as pa-
tients express it, twisted. The surgeon places the foot be-
tween his knees ; his left hand encircles the heel, the fin-
gers grasping the projecting os calcis and tendo Achillis ;
the ball of the palm lies against the mediotarsal joint on
the inner aspect of the foot ; the right hand grasps the outer
side of the fore-foot and toes ; then by steady pressure of
the thigh muscles the fore-foot is forced inward over the
fulcrum formed by the projecting palm which lies upon the
left knee, the fingers holding the heel steadily in place. This
inward twisting is at first resisted by a mixed voluntary and
involuntary muscular spasm, which gradually gives way un-
der steady pressure. When the limit of adduction has been
reached, the foot is firmly held until all pain has subsided,
when the patient is instructed to make voluntary move-
ments while the foot is in the corrected position, flexion
and extension of the toes, and to contract the flexor mus-
cles of the foot. The foot is then released, and twenty
minutes of voluntary exercise follow, and at intervals dur-
ing the day the patient, by active muscular efforts and
passive motion, constantly works to one end — namely, to
regain the lost power of adduction — while once daily the
inward twisting is performed by the surgeon. Under this
treatment the pain and stiffness rapidly disappear, and the
foot constantly assumes a better position. The results that
can be attained by this treatment persistently carried out,
even in cases of long standing and apparently hopeless de-
formity, are surprising. I wish to call your attention to
the fact that forcible over-correction followed by persistent
passive stretching of contracted tissues is quite different in
principle from the simple forcible correction of deformity
with indefinite retention of the feet in plaster and silicate
bandages, as practiced by Roser, Lorenz, and Smith. Mean-
while the brace is made of thin steel.*
It is molded on the iron cast while hot, and is then
tempered so that it is unyielding under the weight of the
body.
Its shape may be seen in the diagrams (Figs. 5, 6,
and 7). A broad internal upright portion covers the
Fig. 5. — A, the astragalo-ecaphoid joint.
astragalo-scaphoid joint, the weak point of the foot ; a
molded arm reaches from the center of the heel to a
point just behind the bearing surface of the ball of the
* Persistent Abduction of the Foot.
* The best sheet steel, No. 19 or 20 gauge, cut with the grain.
Feb. 27, 1892.]
WHITMA X:
THE RADICAL CURE OF CONFIRMED FLAT-FOOT.
231
great toe ; an outer arm passes beneath the os calcis and
cuboid bones, and upward slightly on the outer aspect
of the foot, which is thus held firmly
in the brace, and can not slip away
to the outer side, as is the case with
braces which depend upon the shoe
to hold the foot in position. As the
patient is instructed in the proper
walk, he throws his weight first on the
outer side of the foot, thus pressing
the external arm down against the
sole of the shoe, a movement which
at the same time causes the internal
projection to press more firmly against
the inner side of the foot. This press-
ure tends to turn the fore-foot inward,
relieving the arch from weight. In
addition, this brace differs in the fol-
lowing points from those with which
I am familiar, in that it is an accurate
adjustment to a cast of the corrected
foot; that it, by the inward flange,
prevents abduction, a movement which precedes the lowering
of the arch ; that the brace is complete in itself and does not
depend upon the shoe to prevent deformity ; that it is not
Fig. 6.— C, the great-toe
joint ; D, the center of
the heel.
Fig. 7. — B, the calcaneocuboid joint.
in any way attached to the shoe, but retains itself in prop-
er position — it may thus be changed from one shoe to
another, and may be kept clean and free from rust ; that it
allows the foot to rest upon its natural supports, the heel and
the ball of the foot, provides support only to the weak
points, and does not in any way restrict normal motion
and activity, which are to be encouraged by insisting that
| the patient shall assume the proper attitude in walking.
This brace is not a spring ; it is inelastic, as it is intended
to hold the foot in normal position, not to allow a recurrence
' of previous deformity. Finally, it is comfortable ; the pain-
ful pressure on the sole of the foot, often complained of
when simple arched supports are used, being absent,
i 1 It is nickel-plated or tin-plated and is then japanned.
No covering is used, and, as it fits the foot perfectly, its
presence in the shoe can not be detected.
The shoe to be recommended is one of the Waukenphast
pattern, with a sole broad enough to support the foot, hav-
ing an inward twist to allow room for the great toe. In ad-
vanced cases of fiat-foot I usually build up the inner side of
the sole after the method known as Thomas's, in order to
throw the weight more to the outer side while the foot is
still weak. The patient is then allowed to go about his
usual occupations, no restriction being placed upon walking,
provided the proper attitude, with but little divergence of
the toes, is assumed.
The entire treatment described has consumed on an
average three weeks. Daily exercises are still continued
with the stretching until the movements of the foot are
absolutely free and unembarrassed. One of the best gym-
nastic exercises for strengthening the feet is to raise the
body on the toes twenty or thirty times, morning and night,
as recommended by Ellis (Lancet, September 26, 1885). It
will, however, be remembered that the best possible exercise
is a proper walk. In an ordinary case the braces can be dis-
pensed with in about six months, when a cure may usually
have been accomplished, although all symptoms have dis-
appeared long before.
The limits of this paper have simply allowed me to out-
line this method of treatment ; many aids in gymnastic and
local treatment will suggest themselves. The essentials
for entire success are a complete reduction of deformity, a
complete recovery of the lost power of adduction, an in-
crease in muscular strength and activity, and an avoidance
of improper attitudes in standing and walking. The success
that follows persistent treatment of confirmed flat-foot is
most gratifying, and my experience justifies me in asserting
that no affection of equal importance can be so easilv re-
lieved and permanently cured.
In conclusion, it may be well to mention the operative
treatment of flat-foot. The operation described by Guid-
ing Bird,* Ogston,f and, with modifications, J by various
others, consists essentially in destroying the mediotarsal
joint by producing an ankylosis between the astragalus and
scaphoid bones. I have not seen a sufficient number of
cases to judge of its merits ; the few that I have seen pre-
sented a stiff but useful foot with a partial relief of pain
and deformity. Most of the reported operations have been
performed on children and young adults, the most favor-
able class for cure with preservation of normal joints, a re-
sult which must be vastly superior to any relief that may be
obtained by an operation which aims at the destruction of
the most important joint of the foot. The essential differ-
ence between the two methods of treatment is this : The
one recognizes the fact that a foot subjected to the predis-
posing and exciting causes outlined may, by slow progres-
sion, reach a stage of extreme deformity ; and that the
affection is curable by a reversal of the conditions under
which it developed. The other assumes the impossibility
of cure and endeavors to relieve the symptoms by substi-
tuting an ankylosed joint for muscular strength and activity.
The first method requires patience, persistence, and the in-
telligent co-operation of the patient. The second requires
nothing but the ability to perform a cutting operation.
There is, however, a class of patients in most destitute cir-
cumstances, with no shoes, no money, no homes. Here
* Ghi/'k Hospital Re/torts, 1882.
f Gaston. Lancet, January 26, 1884.
% Hare. Lancet, November 9, 1889.
232
ASCH: A CASE OF INTRINSIC EPITHELIOMA OF THE LARYNX. [N. Y. Mki>. Joue.,
hospital treatment is a necessity, and hospital treatment for
flat-foot at least implies an operation. For this class the
operation — and, in my opinion, the only cutting operation
which should ever be performed for flat-foot — is the supra-
malleolar osteotomy of Trendelenburg,* first performed here
by Dr. Willy Meyer.f The object of the operation is the
production of artificial bowlegs, thus throwing the weight
off the arch to the outer side of the foot. Dr. Meyer's
results have been very satisfactory. The disadvantages of
the operation are the time that is necessary for consolidation
of the divided bones and the very noticeable bowing of the
legs, which would preclude its use in patients of more
aesthetic temperament. I should suggest that the breaking
up of adhesions and over-correction of the deformity would
be a useful preliminary to the operation. Finally, I may
again urge the importance of an early recognition and in-
telligent treatment of this affection which has such an im-
portant influence on the future prospects of the young, and
in later years may reduce the sufferer and those dependent
on him to the most extreme destitution.
V>>> West Fifty-ninth Street.
A CASE OF
INTRINSIC EPITHELIOMA OF THE LARYNX. \
By MORRIS J. ASCH, M. D.
R. G., aged seventy years, came to me in the autumn of
1889, complaining of hoarseness. He had no cough or any
evidence of disease beyond the interference with his voice. lie
was a hale, hearty man, living much in the open air, hunting
during the winter in the South, and yachting and devoting him-
self to the care of his country place in the North during the
summer. He was a retired physician, and consequently able to
describe his symptoms with accuracy. He complained only of
the hoarseness, which was brought to his notice by his inability
to call his dogs as formerly, and which he attributed to having
taken cold. There was no pain, dyspnoea, or dysphagia. A
laryngoscopic examination was difficult, owing to the extreme
sensitiveness of the pharynx, but the application of an eight-per-
cent, solution of cocaine soon produced tolerance. Even then,
owing to the thickened and depressed epiglottis, an examina-
tion wa> difficult, but the mirror revealed the ventricular band
of the left side irregular in outline and swollen to such a de-
gree as to conceal the vocal cord of that side. The left arytamo-
epiglottic fold was unchanged; the mucous membrane darker
than normal, smooth, and without ulceration. The subglottic
region was invisible, owing to the narrowing of the rima glot-
tidis. The laryngeal image was that of a chronic hypertrophic
laryngitis. A few topical applications were made with appar-
ent relief of the hoarseness, and the patient left for his South-
ern home. In the spring of 1890 he returned. He was full of
life and vigor, was perfectly well in every way, except that the
hoarseness persisted. The larynx presented nearly the same
general appearance as at the previous examination, except that
the deposit in the ventricular band of the left side had increased
and there was some swelling in that of the right side. There
was no dyspnoea or pain, and the local applications were con-
* Archiv fur Mm. Chir., xxxix, 4.
f N. Y. Med. Journal, May 24, 1800.
X Read before the American Laryngological Association at its thir-
teenth annual congress.
tinued and seemed to give relief; but the continuance of the
swelling for so long a period and the absence of any improve-
ment after treatment caused me to apprehend the existt-nce of
malignant disease, although there was nothing in the condition
of the patient or in the appearance of the part to warrant any
such diagnosis w ith certainty. There was no soreness over the
larynx, though the thyreoid cartilage was slightly enlarged ;
neither was there any glandular enlargement in its vicinity. In
November the patient, on his way South, returned again to the
city, with no change in his condition or in the appearance of the
larynx. He was cheerful, and sure that a mild climate would
bring him back in the spring quite cured, although he was
warned of the probable gravity of his case.
In March, 1891, he presented himself unexpectedly at my
office, showing evidence of great suffering. His voice was al-
most extinct, his breathing difficult, and he was weak and ema-
ciated to a degree. The increasing dyspnoea had compelled him to
return North thus early in order to obtain relief. Examination
showed the lumen of the larynx almost entirely occluded by an
irregular swelling from both sides, the merest chink remaining
to give passage to air, which found its way between the irregular
prominences on either side ; no ulceration of any kind was visi-
ble, and the appearance was that of an irregular swelling with a
smooth surface. There was a small, enlarged submaxillary gland
on the left side. The patient was at once informed of the
gravity of the situation and an immediate tracheotomy advised.
This he declined, although the danger of delay was pointed out
to him, until he could terminate certain important business
affair?; to this I was obliged reluctantly to consent, though I
feared that a sudden termination might occur at any moment.
The dyspnoea was so extreme that comfort in respiration was
only secured when the patient wras at rest. He visited me daily,
always refusing to permit the operation until the morning of
April 5th, when he presented himself with his respiration em-
barrassed to such a degree that there was no longer any ques-
tion as to delay. He was taken to the New York Eye and Ear
Infirmary, where, in the presence of Dr. C. T. Poore and the
house staff, I performed tracheotomy. The dy&pncea by this
time was so intense that I deemed it unsafe to administer an
anaesthetic, and I injected a few drops of a two per-cent. solution
of cocaine over the proposed line of incision, with the effect of
rendering the parts insensible to pain and enabling the patient
to undergo the operation without inconvenience. Jt was found
impossible to extend the neck to any degree, as, on attempting
to raise the shoulders, suffocation immediately ensued, and in
consequence the operation was rendered extremely difficult, the
cricoid cartilage being nearly at the level of the epistcrnal notch.
The first incisions, which were almost bloodless, having been
made, the trachea was opened through the upper rings. Owing
to its ossification, a partial resection had to be made to permit
of the introduction of the tube, the relief from which was im-
mediate. The patient did well for some days, when a severe
attack of grippe — which w;.s prevalent at the time— caused him
considerable discomfort, and from the effects of it he did not
recover for three weeks. Immediately after the operation de-
glutition was painful, but this soon passed away, and on April
26th, when he left the iufirmary to return to his lodgings, he
could swallow with perfect comfort. His only annoyance next
to his weakness, which persisted, was the frequent clogging of
the tracheal tube with a sticky mucns, which required constant
attention to prevent untoward results. As his neck was ex-
tremely thin, it was thought that perhaps this might be caused
by irritation resulting from the impinging of the tube on the pos-
terior wall of the trachea, so a new one was ordered, having a
shorter horizontal member than the one in use, and with a
curve of a quarter of a circle. This tube partially relieved the
Feb. 27, 1892.| - ASGH: A CASE OF INTRINSIC EPITHELIOMA OF THE LARYNX.
233
symptom, but not entirely. About the middle of May the
expectoration was streaked with blood, which, as the lungs
were perfectly sound and the external wound in good condi-
tion, gave rise to the fear that the disease might be spreading
downward and ulcerating. Early in June the patient, having
gained strength, was removed to his country seat on the North
Eiver, where for a time he did well. In a few weeks, however,
spasmodic attacks of dyspnoea came on, which he attributed to
plugs of solid mucus occluding the tube, and which he relieved
by removing the tube and coughing the mass through the open-
ing in the trachea. Desirous to have my opinion as to the
cause of the trouble, he took passage on the night of the 11th
of July on a night boat on the Hudson River. Soon after his
embarkation a severe attack of dyspnoea came on, which his
attendant was unable to relieve. A thick fog prevailing at the
time prevented the captain of the boat for several hours from
making a landing to obtain the services of a physician, and when
finally medical aid came, he was dying from exhaustion.
Autopsy — Permission having been granted to examine the
larynx only, the condition of the other organs could not be as-
certained. The body was thin, but much less emaciated than
before the operation. Externally, the opening of the tracheal
wound was in good condition, no granulation or diseased tissues
being observed, nor was there any trace of disease external to
the larynx. The larynx and three rings of the trachea were re-
moved from the body. On inspection from above, the lumen of
the larynx was seen to be entirely occluded by smooth irregular
masses springing from the ventricular bands of either side. On di-
viding it posteriorly in the middle line and exposing the interior
of the larynx, the cartilages of which were ossified, the&e growths
were found to be in contact and to fill up the entire cavity. The
left ventricular band was enormously swollen and the vocal cord
of the same side ulcerated. Extending downward from its in-
ferior border to a point level with the middle of the tracheal
opening and covering the entire laryngeal wall of the left side
was a papillary mass ulcerated on its lower portion. On the
right side the ventricular band was infiltrated, but not to so great
a degree as the left. The vocal cord was thickened, and be-
low it a mass of diseased growth extending nearly to the lower
border of the thyreoid cartilage. Just to the right of the median
line at the base of the cricoid cartilage and above the upper mar-
gin of the tracheal wound was a globular pedunculated tumor
of the size of a large pea. There was no erosion or growth be-
low the level of the tracheotomy wound. The submaxillary
; gland on the left side was enlarged. The specimen was sent to
Dr. R. G. Freeman for examination, who made the following
report :
The specimen shows considerable swelling of the glottis and
upper part of the larynx. Below the vocal cords, on the ante-
rior wall of the trachea, a growth five sixteenths of an inch in
diameter and three sixteenths of an inch in height projects.
Just below this is the artificial opening due to tracheotomy.
The upper lip of the opening is somewhat thickened. The tumor
involves all the upper portion of the larynx and the anterior wall
of the lower portion. Specimens were taken for examination
from the posterior and lateral walls of the glottis, and from the
growth from the anterior wall below the cords.
Microscopic examination showed the tumor to be an epithe-
lioma. The cells are grouped in a reticular arrangement with
a varying amount of stroma. In places they are arranged in
concentric masses, forming epithelial pearls. In some parts
there is an extensive production of spheroidal cells. There
is some necrosis on the surface. The mucous glands are in.
flamed and some of these ducts are occluded by inflammatory
changes.
There are certain points in this case which make it of
special interest. First, the absence for so long a period of
positive signs of malignant disease ; and, secondly, the na-
ture of the irritating cause producing the spasmodic attack
which finally destroyed life.
The first point is accounted for by the fact that the case,
being one of intrinsic cancer, was naturally slow in growth.
There was no external manifestation of the disease, unless
^he slight glandular swelling could be so considered ; nor
was there any evidence of infection of any other organ.
There was a thickening of the mucous membrane of the
ventricular bands with infiltration of the muscles and loss
of motion, which swelling forbade a view of the subglottic
lesion, which, if visible, might probably have revealed its
true nature ; but there was no ulceration, no lancinating
pain in the ear or elsewhere, no reddened base, nor any cer-
tain sign of malignant disease — only swelling and dysphonia ;
and in this case a fragment removed for microscopical in-
vestigation might have proved deceptive, for the sections
taken from the upper portion of the ventricular band showed
evidences of inflammatory action more markedly than of
epithelioma. Even at the last, when the increasing stenosis
rendered operation necessary, there was no absolute proof
of cancer. This could only be deduced from negative data
by clinical experience. Tubercle and syphilis being ex-
cluded, there could be nothing to account for the condition
but malignant disease.
From the point of view well taken by Butlin, that in-
trinsic cancers not only differ essentially from those of ex-
trinsic origin by their limitation to a circumscribed area,
but, being less actively malignant, are less likely to recur,
this case would seem to have been a favorable one for ex-
cision, were it not for the advanced age of the patient war-
ranting the opinion that tracheotomy would afford relief
during the probable term of his natural life. Thyreotomy
was out of the question, as the ossified state of the cartilage
forbade the idea that the larynx could he sufficiently dilated
to permit of a thorough operation being performed. In the
treatment of the case, pyoctanin blue was employed locally
and internally, but without any apparent effect. Taken in-
ternally in doses of three grains, it produced vomiting and
could not be continued.
The cause of the paroxysms of dyspnoea is obscure, un-
less it can be attributed to the globular mass projecting into
the windpipe, producing them as asthma is caused by simi-
lar proliferations into the upper air passages. I attribute
the fatal termination immediately to cardiac weakness, the
result of the grippe with which he was attacked after the
operation.
234
HOPKINS: INTUBATION FOR STENOSIS IN TUBERCULAR LARYNGITIS. [N. Y. Med. Joub.,
INTUBATION FOR THE RELIEF OF
STENOSIS IN TUBERCULAR LARYNGITIS *
By F. E. HOPKINS, M. D.
The following case is presented, not only because of
some points of interest which it may have in itself, hut be-
cause it involves the suggestion of intubation as a substi-
. tute for tracheotomy in stenosis due to tubercular disease
of the larynx :
Mrs. B., American, of German parentage, aged thirty-nine,
seventh in a family of eleven children. Four sisters are living
and all are of the stout Germanic type, their ages ranging from
thirty to forty-five years; all in good health.
A sister died in Germany, aged forty-six; cause unknown.
A brother died of pneumonia in October, 1890, aged thirty-six.
The remaining children died in infancy. The father is living
and in good health at the age of seventy-eight. The mother
died at fifty-three of typhoid fever. The grandparents, both
paternal and maternal, reached a good old age, dying at ages
ranging from seventy-four to eiglity-eight. Of the uncles and
aunts, one, an uncle, died at the age of sixty-five of peritonitis.
A maternal uncle died of " consumption " at the age of twenty-
five. An aunt died at seventy-seven, her twin sister six months
later; causes unknown. An aunt is living and in good health
at the age of sixty-seven.
It is thus seen that the woman's history is exceptionally
good for a hospital patient, and it helps to account for her
powers of resistance against the disease from which she surfers.
Mrs. B. always enjoyed good health till Novemher, 1885,
when she had an attack of pneumonia. The attack was not a
severe one, but was followed by a laryngitis and a cough, which
continued till she came to the Manhattan Hospital in June,
1886. During this interval from November to June she re-
ceived no special treatment, and the syni| toms had increased in
severity.
Through the kindness of Dr. Charles H. Knight, under
whose care this patient was when she first came to the hospital,
I am able to present the following notes of her condition then :
At the time this patient first came to the Manhattan in
188K her general condition was good. She had but little
cough, and that without expectoration. By physical examina-
tion no evidence of pulmonary disease could be discovered.
Her object in coining to the clinic was to get relief from hoarse-
ness, which had annoyed her for several weeks.
On examining the larynx with the mirror the following con-
ditions were seen: The mucous membrane in general was pale.
The vocal bands were somewhat hypersemic and thickened,
and on phonation failed to approximate. The arytenoids and
aryepiglottic folds were normal in appearance. At the poste-
rior commissure, however, in the interarytrenoid space there
was distinct thickening, the mucous membrane being lobnlated
and decidedly pale in color. Two wart-like m isses co Id be
3een projecting into the lumen of the larjnx, no doubt suffi-
cient to interfere with the action of the vocal bands. The
ventricular bands were normal, and there was no ulceration
present.
The diagnosis of laryngeal tuberculosis was based upon the
anemia of the larynx and the post commissural infiltration.
No attempt was made at that time to confirm the diagnosis by
microscopic examination of the sputa or of scrapings from the
larynx. The subjective symptoms gradually subsided under
* Read before the Section iu Laryngology and Rbiliology cf the New
York Academy of Medicine, October 28, 1 H'.t I .
treatment, the voice was restored, but the thickening of the
posterior wall of the larynx persisted. Several applications of
lactic acid were made without any marked effect.
Soon after this, treatment; was suspended and the patient
disappeared, tne correctness of the diagnosis having been seri-
ously questioned, owing to the non-development of pulmonary
symptoms, and the steady improvement of the patient's condi-
tion.
The patient returned to us in June, 1888, just two years
from her first visit. She had improved greatly in appearance,
having gained in strength and weight. She said she had been
well during the period of her absence. She had married in
September, 1887.
I will here remark that the patient had no treatment from
June, 1886, to January, 1891, except that at the Manhattan Hos-
pital.
The query quite naturally arises, Was this a case of primary
tnberculosis of the larynx, and was this cured by the treatment
she received at that time?
When she came for treatment in June, 1888, she was again
suffering from cough and hoarseness, but the larynx at this time
also did not present the characteristic appearance of the tuber-
cular process, although the thickening and infiltration previous-
ly referred to was more marked than on her first visit. There
was, however, evidence of beginning pulmonary disease, there
being a limited area of dullness at the apex of the left lung.
She attended the clinic with some regularity again for a
time, secured relief from the distressing symptoms, and again
disappeared.
Since about the 1st of July, 1890, she has failed steadily,
though up to that time she had regarded herself as well. This
long period of quiescence, covering about three years and a half,
is certainly worthy of remark, and attention is called to it in
connection with the query already suggested.
The last few months have witnessed the familiar decline,
steadily advancing emaciation, increasing cough with expectora-
tion, night sweats, hectic, and loss of strength.
The area of pulmonary involvement has gradually increased,
there being at present dullness on percussion down to the sixth
intercostal space, upon the left side, with a cavity in the upper
lobe.
An examination of the sputa by Dr. Ira Van Gieson, pa-
thologist of the hospital, reveals the presence of tubercle bacilli.
The ulcerative process in the larynx advanced, the larynx
presenting for some months past the typical appearance of this
disease. There was a steady encroachment upon the lumen of
the larynx, due to thickening and infiltration of all the sur-
rounding parts, the interarytsenoid thickening being especially
noticeable, the latter exaggerated condition being seen by refer-
ence to Fig. 1.
This thickening was considered by the members of the
staff, who watched the process going on in this larynx, as an in-
flammatory infiltration rather than an (edema, because of its
slow advance, and because of the firmness and solidity of the
tissues involved.
For three weeks preceding January 30th last, suffocative
attacks came on nightly and increased constantly in severity.
There was also marked dyspnoea on exertion. Her general con-
dition declined more rapidly. She hail no appetite; whs so
weak that her visits to the hospital were serious drafts upon
her strength. Her expression was one of painful anxiety. It
was evident that tracheotomy would soon become nece-sary
because of the steady narrowing of the already dangerously
narrow rima glottidis, and that operation was advised by mem-
bers of the staff".
I resolved to try intubation instead, should it become neces-
Feb. 27, 1892.] HOPKINS: INTUBATION FOR STENOSIS IN TUBERCULAR LARYNGITIS.
235
saiy, and instructed the patient's friends to call upon me in case
of emergency. I was called to the case on the evening of Janu-
ary 30, 1891, and found the woman in great distress from the
dyspnoea. Respiration, 60 ; pulse, 126 ; and temperature,
l 101 -5° F. She was extremely weak, as she had not been able
to sleep for several nights. She had been unable to eat, all her
energy being expended in the effort to secure sufficient air for
existence.
Examination of the larynx revealed a condition which is
illustrated in Fig. 1. The vocal bands were more thickened
than is shown in the drawing, and, because of the infiltration in
the posterior commissure, were fixed in about the position
shown, neither separating nor approximating except in slight
degree.
The interarytaenoid thickening had advanced to such an ex-
tent that the vocal cords were covered for fully a third of their
length.
The ventricular bands were much thickened and appeared
like firm fibrous masses, encroaching upon the rima glottidis
upon either side.
The posterior commissural thickening was doubtless respon-
sible most largely for the stenosis, for, besides being an obstruc-
tion in itself, it interfered with the movement of the cords.
The drawing represents the condition in inspiration, and the
glottis, as shown, is probably slightly larger than the reality.
After cocainizing the pharynx and larynx, the attempt was
made to insert the largest tube in my case — the O'Dvvyer set —
that intended for a child of twelve years.
The patient co operated intelligently and with great cool-
ness, considering her condition.
Three attempts were made to insert this tube, and all the
force was employed that it seemed prudent to use, hut the tube
failed to pass. Even the size smaller met with much resistance
— a resistance due largely, no doubt, to muscular spasm.
Fie. 1. Teia. 2
The presence of the tube excited violent paroxysms of
coughing. After the tube had been in position some minutes,
and after the cord attached to it had been removed, the cough-
ing was less severe. Although the tube was so small, the pa-
, tient breathed much easier than before its insertion, and when
I I left she was comfortable.
The tube was expelled later during an attack of coughing.
, The dyspnoea, however, was relieved and the patient passed a
f better night than for three weeks.
j For twenty-four hours following she suffered considerable
local pain and swallowed with difficulty, although there had
previously been no dysphagia. She also coughed more than
usual, expectorating blood-stained mucus, this and the dysphagia
being due to the traumatism of iutubation.
A reference to Fig. 2, which shows the condition of the
larynx five days after intubation, will show why the dyspnoea
was relieved, although the tube was worn so short a time.
The force exerted upon the tube tore away a portion of the
posterior commissural thickening, and doubtless the remainder
subsided somewhat by contraction, and from relief to the en-
gorgement from the bleeding. This allowed the cords an in-
crease of their limited range of motion. Moreover, the removal
of that thickening reveals a loss of tissue in the vocal bands be-
fore unseen, and which increased slightly the lumen of the
larynx.
With the relief of the dyspnoea the patient's appetite again
improved, and there followed a gain in strength and general con-
dition.
She resumed her visits to the clinic for a short time on Feb-
ruary 17, 1891.
A portion of tissue was removed from the posterior commis-
sural thickening and submitted to Dr. Jonathan Wright for mi-
croscopic examination, with the idea that perhaps tubercle ba-
cilli would be found here also. None was observed, but the re-
port is of interest, since it reveals the condition present in the
process under consideration.
The following is Dr. Wright's report: "Specimen consists of
two or three small masses of tissue about the size of wheat
grains. The largest one, when cut and stained, shows the fol-
lowing microscopie structure: the surface is fairly smooth and
consists of a layer of pavement epithelium cells, in places of
normal thickness, in others considerably proliferated in the
' thorny layer.'
"The basement substance, or body of the mass, is composed
of cedematous, fibrous connective tissue, the fibrillae being sepa-
rated from one another by infiltrations of serum and fibrin and
a fewr white blood-cells.
"The blood-vessels are some of them enormously dilated
and contain granular detritus. There is no glandular structure
to be seen. There are no papillae. The structure is therefore
analogous to that of the so-called nasal mucous polypi, except-
ing that it has, as one would expect in the larynx, an investment
of pavement instead of columnar epithelium. Diagnosis: Poly-
poid degeneration of the mucous membrane of the larynx."
Mrs. B. so far recovered her strength that she not only
helps to take care of herself, but assists in the care of her
husband, who is now confined to the bed, being in the sec-
ond stage of pulmonary tuberculosis.
Here, then, is presented another point of interest. Is
Mr. B.'s case one of infection ?
I will give his history briefly, leaving the question
open.
Mr. B., thirty-three years old, born in Maryland of American
parentage, is the oldest in a family of three children. A sis-
ter died in childhood of diphtheria. A brother is living, aged
twenty-nine, and in good health. The mother died at thirty-
one of some puerperal disease, two days after the birth of this
brother. The father died suddenly, at forty-four, of " heart dis-
ease."
Grandparents, paternal and maternal, reached an advanced
age.
Of the uncles and aunts, so far as known, but two have died
— a paternal uncle, at sixty-three, of consumption, and a pater-
nal aunt, at fifty, cause unknown. Mr. B. is tall and broad-
shouldered, and was apparently a man of more than ordinary
strength.
He has led a seafaring life since the age of sixteen, and for
the latter years was mate of his vessel, a sailing craft. He was
married, as already stated, in September, 1887. He was never
sick until March, 1888, when he was at sea during the memor-
able blizzard. He was much exposed at this time, and con-
230
LOCKWOOD: FUNCTIONAL DISTURBANCES OF THE HEART. [N. Y. Med. Jo
Fig. 3.
tracted a severe cold. He has had frequent "colds" since, but
has never been confined to the house.
The last attack at sea was after prolonged exposure in Au-
gust, 1890, when he gave^up his position and attempted to find
some easier work in the city. Previ-
ous to this time his stays at home
here had been of a week's duration
or less, and at intervals of two or
three months.
From August to November, 1890,
he drove a mail wagon as a "night
extra." He was obliged to give this
up at the latter date because of a
steady loss of strength.
Since that time he has failed
steadily, presenting the familiar symp-
toms of pulmonaryjtuberculosis.
The foregoing was writtenjearly
in March; since then both the pa-
tients have died — Mr. B. on April 14th, and Mrs. B. five
weeks later. Mrs. B. had no suffocative attacks after the in-
tubation. In fact, during the last weeks of her life the lumen
of the larynx, enlarged by the destructive ulceration, was greater
than it had been during any time in the preceding year, as shown
in Fig. 3.
The only record of intubation for the relief of stenosis
in tubercular laryngitis of which I have been able to learn
is that reported in the July number of the Journal of Lar-
yngology and Rhinology. M. Massei is reported as having
intubated in three cases of tubercular laryngitis. He says
of the operation that " stenosis may be got to yield in a
surprisingly short space of time."
At the time this paper was written I learned that the
operation had twice been done in this city — once by Dr.
Dillon Brown ; the patient was dying and intubation was
done for the promotion of euthanasia ; once also by Dr.
D. C. Cox, under like circumstances and for the same pur-
pose.
In the condition under consideration it is not unwar-
rantable to make the assertion that the operation ought al-
ways to be done instead of tracheotomy.
The ease and quickness with which the operation may
be done ; the comparative absence of shock ; the absence
of a wound in tissues predisposed to necrosis ; the fact that
air reaches the lungs through the natural passages ; the pos-
sibility that after a few hours or days the tube may be dis-
pensed with — in fact, all the familiar arguments in favor of
intubation appeal with great force for its use in these cases.
Instead of tardily and reluctantly yielding to the impor-
tunities of friends for relief by tracheotomy — an operation
of doubtful utility — one may early offer intubation with as
much hopeful enthusiasm as can be summoned in so des-
perate a condition, knowing that as large a measure of re-
lief will be gained with the doing of relatively no damage.
To put the question simply : Shall the patient be given
air by a method which adds materially to his suffering, and
rarely prolongs life beyond a narrow limit, or by a method
which allows respiration to go on as freely as after trache-
otomy, adds nothing to the risks of the sufferer, and offers
the possibility of prolonging life to such limit as the gen-
eral condition allows ?
In conclusion, I wish to acknowledge my indebtedness
to Dr. Charles II. Knight for his material assistance, and to
Dr. Van Gieson and Dr. Wright for their kindness in mak-
ing microscopic examinations.
A CONSIDERATION OF
FUNCTIONAL DISTURBANCES QF THE HEART
AND THEIR REMEDIES,
with the. History o f a Case of Functional T rouble
characterized by Irregular Rhythm and Force
and Intermittent Action which has persisted for Two Years*
By C. E. LOCKWOOD, M. D.
Functional disturbances of the heart, as has been often
remarked, comprise the large majority of heart affections
for which physicians are consulted, because, as has been
noted by Dr. Walshe, " the amount of local suffering en-
tailed by disturbance wholly or in the main dynamic is
often greater than that produced by actual organic dis-
ease." The importance of their careful study is therefore
apparent.
The study of the nervous supply of the heart, upon the
derangement of which so many functional irregularities de-
pend, is one surrounded by many difficulties, and our in-
formation on this point is very incomplete. It seems to be
generally admitted that by the cardiac ganglia at the base
of the heart, which are intimately connected with the
sympathetic system of nerves, the rhythmical movements
are carried on, even when the heart is removed from the
body, and that the controlling or inhibitory nerve is the
pneumogastric. It is well known, says Dr. Fothergill, that
excitation of the pneumogastric will slow ventricular con-
traction, and, if powerful enough, arrest it altogether. In
animals the right possesses the inhibitory power more than
the left. In the pneumogastric there are certain fibers
which exert an accelerating action and increase the rapidity
of the heart's action. Irritation of the medulla oblongata
will also produce a similar effect if certain nerve tracts are
uninjured ; so impaired action of the vagus or stimulation
of the accelerating fibers may be the cause of tachycardia.
According to Strieker, says Dr. Austin Flint, there exists in
the medulla oblongata a center the stimulation of which
increases the rapidity of the heart's action, and from this
center fibers descend in the substance of the spinal cord,
pass out with the communicating branches of the lower
cervical and upper dorsal nerves to the sympathetic, and go
to the cardiac plexus. It has been shown that, after division
of the pneumogastric, stimulation of the accelerator fibers
increases the number of beats of the heart. And when we
consider how intimately the heart is connected with the
brain and other organs, through the pneumogastrics and the
sympathetic system, the great wonder is that its functions
are not more frequently disturbed. Such derangement of
the heart functions as can not be shown during life or after
death to be connected with organic lesions we call func-
* Read before the Section in General Medicine of the New York
Academy of Medicine, November 17, 1891.
Feb. 27, 1892.]
LOCKWOOD: FUNCTIONAL DISTURBANCES OF THE HEART.
237
tional, although some lesion of the organ may exist and
not he discoverable by our present methods of examination
during life.
Functional disturbance of the heart, according to
Walslic, is connected more or less constantly with the fol-
lowing conditions : Perverted innervation, as in hysteria ;
the menopause ; uterine and ovarian excitement ; spinal
irritation ; various neuralgias ; sudden fright ; overexertion
of the faculties of the mind ; prolonged mental anxiety ;
chorea; emotion; dyspepsia; gastric catarrh, etc. It is
also caused by : An altered condition of the blood, due to
haemorrhage, anaemia, gout, chronic rheumatism, functional
derangement of the liver, chronic liver disease, or uraemia ;
nervous exhaustion, abuse of the sexual organs, and other
causes ; mechanical interference, as when the stomach or in-
testines are distended with flatus, and in pregnancy, tight
lacing, or pleuritic effusion ; and certain poisonous influences,
such as the use of stimulants, tobacco, etc.
In regard to the actual symptom-producing agent in
tobacco, when smoked in excess, there seems to be some
difference of opinion among authorities, some contending
that nicotine is not present in tobacco smoke. Dr. W. L.
Dudley, of Nashville, Tenn., concluded from his investiga-
tions that carbonic oxide was the most poisonous constituent
of tobacco smoke, derived, of course, from combustion ; and,
further, that more injury resulted from cigarettes than
cigars or pipes, as the smoke was inhaled, poisoning the blood
with carbonic oxide. Nicotine, like prussic acid, is a com-
pound of carbon, nitrogen, and hydrogen ; it contains no
oxygen, the formula being C10H,N. When exposed to
air and light it undergoes a chemical change and acquires a
brown color ; its energy as a poison is thereby reduced.
Bernard says he found the modus operandi of the partially
decomposed poison to be different from that of nicotine.
The functions of the lungs and heart were directly affected
by it, while the pure poison chiefly spent its physiological
action on the capillary circulation. We must therefore
conclude that tobacco smoking or chewing to excess is
especially disturbing to the heart functions. Dr. Fother-
gill says : " The effect of tobacco is to render the heart
action quicker, beat feebler, and to promote liability to
palpitation."
As regards the effects of alcohol upon the heart, it
seems to be well settled that in small quantities its first ef-
fect is to stimulate the heart, causing a slight increase in
frequency and a marked increase in force, accompanying
which is a dilatation of the cutaneous capillaries, and proba-
bly also those of the brain. In poisonous doses, a lessen-
ing of the heart's power by one twentieth and the blood-
pressure by one sixth occurs. Nothnagel explains this as
a reflex result, due partly to the severe irritation of the
vagus, partly to a direct affection of the heart plexus and
pneumogastric center in the brain.
Theine and caffeine are powerful neurotic agents, and
when indulged in to excess have a very decided action on
the cardiac ganglia ; according to Dr. Fothergill, they render
the heart irritable, excited, and arrhythmical in its contrac-
tions. He also says that, " looked at from a chemical point
of view, the principles of coffee and cocoa are closely allied
to tea ; and it seems difficult to explain how symptoms are
relieved by substitution of coffee and cocoa for tea. Still,
clinically, the fact remains. It is said tea contains, besides
theine, a volatile intoxicating oil, and this may make the
difference."
Functional disorders of the heart have been divided
into five groups: Slow, intermittent, irregular, and frequent
pulse, and inordinate vascular pulsation.
"In the variety characterized by infrequency of the
heart's action it may be assumed," says Dr. Flint, " that
the causative agency is exerted through the pneumogas-
trics. The inhibitory function of this nerve is affected in
the same way as by the galvanic current in the experimental
observations on animals in illustration of this function."
This view is corroborated by the frequent association of
this variety of disorder with notable cerebral disturbance.
According to Sir Dyce Duckworth, slow pulse has been
most frequently noticed after acute disease, and has been
found in cases of malarial poisoning, after jaundice, or with
increased arterial tension. Injuries to the head, meningitis, and
cerebral abscess are also causes of this form of pulse. Dr.
Southey, of England, has reported a case where the patient
had fibroid thickening of the upper membranes of the spinal
cord in which the pulse was quicker than normal. In a
paper by Dr. Seymour Taylor, published in the Lancet, for
June 6, 1891, entitled Remarks on the Slow Heart, the
author makes the following observations which he thinks
it well to remember :
" 1. That there is a series of cases in which it is a per-
fectly healthy phenomenon, occurring in tall, muscular men,
and in whom it is quite consistent with health, and even
prolonged life.
" 2. That it is often a manifestation of advanced me-
chanical disease of the heart, or of disease of the aorta and
its primary vessels.
" 3. That it occurs as a result of prolonged anaemia or
other diseased conditions of the blood, including certain
fevers.
" 4. That it may supervene after abuse of tea, coffee,
and tobacco, or the use of various medicinal drugs, as
quinine, cocaine, aconite, nitrate of potash, or as the result
of some poisons, as from snake-bites.
" 5. That it is often a sequel of grave neurotic changes
and disorders, and is thus correlated with derangements of
respiration, digestion, and other functions.
"6. That we find it also in cases of shock from sudden
fright, in epilepsy, and in abdominal injuries or opera-
tions."
In regard to the significance of slow pulse as a symptom
of organic disease, Dr. Russell, of Birmingham, England,
says that he has collected thirty-eight cases of slow pulse,
and in thirty of them organic disease was found to coexist ;
and of three cases in which the pulsations ranged from
26 to 38 a minute, all had been accompanied by organic
disease.
Dr. Austin Flint says that cases of slow heart are very
rare in healthy subjects, and that a persistent slowness can
not be acquired except rarely without some serious impair-
ment of health. This dictum is doubted by Dr. Seymour
238
LOCKWOOD: FUNCTIONAL DISTURBANCES OF THE HEART. [N. Y. Men. Joub.,
Taylor, as he says all departures from normal states tend to
increase the frequency of the heart's action.
Intermittent pulse is generally caused by dyspepsia, the
excessive use of tea, coffee, or tobacco, or gout, sudden
fright, etc.
Dr. Webber, of Boston, has published an account of
two cases of intermittent pulse following sudden fright in
which there were no other symptoms of cardiac disturb-
ance, no murmurs, no enlargement ; he regarded them as
choreic in character, and the patients both recovered under
arsenical treatment.
Irregular pulse is due to about the same causes as men-
tioned under the last head.
Frequent pulse is caused by dyspepsia, disease of the
liver, or by some deep-seated nervous disorder. The
menopause has been assigned as a producing factor of this
form of heart disturbance by Professor Kisch, of Prague,
who locates the cause in hyperplasia of the ovarian
stroma.
Inordinate vascular pulsation is found chiefly in middle
life and in leucocythaemia. Hysteria and gout are both
causes of this form, according to Sir Dyce Duckworth.
Dr. Da Costa has described a number of cases in which
forced work or slight exertion in those whose constitution
had been impaired by poor nutrition or disease seemed to
be productive of this trouble ; he found it to be most
quickly developed in those unaccustomed to fatigue or sub-
ject to readily quickened circulation. The symptoms of
this form of functional heart disorder have been graphically
depicted by Dr. Da Costa, and are great frequency of the
action of the heart, constantly recurring attacks of palpita-
tion and pain in the precordial region, an abrupt, jerky
impulse, sometimes of irregular rhythm, with a short first
sound and a very distinct second sound.
" The disorder is very obstinate, and much exercise is
impossible. The malady often exists when the general
health is perfect."
Dr. Halbert has recorded two interesting cases of this
kind in the College and Clinical Record — one in which
the pulse was forcible and reached 120 a minute; the
other in which the pulse reached 160. In both the im-
pulse was felt over the abdominal and iliac arteries, and
auscultation showed no organic disease in either case ;
treatment by rest in the recumbent posture, restricted diet,
and two drops of tincture of aconite every three hours re-
sulted in cure in one case in three weeks ; in the other case
the same treatment, with the addition of eight grains of
quinine three times a day, effected a cure in six days.
The treatment of functional heart disorders would natu-
rally be such as would be indicated by the evident cause
when that can be ascertained — in those characterized by
perverted innervation, removal of exciting causes, rest, nu-
trition, tonics, etc.
In hysteria, compound spirit of ether, valerian, and
other antispasmodics are useful ; at the menopause, the
bromides and mild systematic purging, with wet applica-
tions to the lower part of the abdomen, combined with
suitable dietetic and hygienic measures, as recommended
by Professor Kisch.
In cases following or accompanying chorea or caused by
sudden fright, arsenic has seemed to be useful.
Where the heart affection is due to dyspepsia, gastric
catarrh, anaemia, gout, rheumatism, or disease of the liver
or kidneys, the treatment appropriate to such complaints
would be indicated.
In nervous exhaustion due to sexual excess, we should
remove the cause and use such measures as will restore nor-
mal nerve tone.
In mechanical interference with the heart, removal of
the cause should be effected, if possible.
Where the trouble is due to the excessive use of alco-
holic stimulants, tea, coffee, or tobacco, discontinuance of
their use and the administration of heart tonics, such as
digitalis, belladonna, and nux vomica, combined with agents
which lessen nervous irritation, such as the bromides, are
to be used.
As regards the medicinal treatment in general, Dr. Da
Costa has found digitalis and digitaline especially useful in
cases characterized by inordinate frequency, tincture of
aconite in very forcible pulsation, and belladonna and
atropine where irregularity was a marked quality.
Dr. Janeway favors the administration of morphine hy-
podermically for cases of tachycardia, and Sir Walter Foster,
of Birmingham, England, recommends quinine in such doses
as ten grains, three times daily, with the use of the continu-
ous current applied to the sympathetic in the neck in " run-
away pulse." Dr. Solis-Cohen speaks well of sulphate of
sparteine in doses of a quarter of a grain, four or five
times a day, in cases needing a remedy of comparatively
rapid action and regulating power — that is, a power (as he
expresses it) to render steady and continuous the previously
unsteady and intermittent heart-beats, and recommends
belladonna in the irritable, irregular, and feeble overacting
heart of some cases of tobacco poisoning.
Case. — T. C, white, aged twenty-four years, born in Ire-
land, a collector, consulted me on February 21, 1888.
Family History. — His father died at the age of sixty-three
years; cause of death, paralysis. His mother died at the age of
sixty years; cause of death unknown. He has three brothers
and three sisters living and well.
Personal History. — He has always been well, except, he says,
that he had a catarrhal throat affection last fall, and that his stom-
ach has not been in a satisfactory condition for two years. lie
appears to be of a nervous temperament. He complains that dur-
ing the past two weeks he has sntfered from a soreness over
the stomach on moving or walking, has had a headache most
of the time, and palpitation occurs on the least exertion ; his
throat is dry, his bowels are constipated, and he has a burning
sensation in the chest.
Physical Examination. — The heart's action is irregular in
force and rhythm, at times intermittent. The number of pulsa-
tions at the wrist is 108, as near as I am able to estimate, the
counting of the pulse at the wrist being attended with much
difficulty, on account of the difference in the force of the beats,
some pulsations being hardly perceptible. The apex-beat is on
the mammary line and somewhat raised, and I am unable to detect
any murmur. On investigation as to the cause of the troubles,
the patient says he thinks his occupation as a collector has been
attended with considerable overexertion, as he has been obliged
to go up and down many flights of stairs daily. I am unable
Feb. 27, 18!>2.J
LOGKWOOD: FUNCTIONAL DISTURBANCES OF THE HEART.
239
to elicit a classical history of dyspepsia. He says he does not
smoke or use tobacco in any form, or tea or coffee to excess;
neither is there any history of prolonged mental exertion, wor-
ry, or sexual excess, lie speaks of having been disappointed in
love. There are no symptoms of gout. He is somewhat anse-
tuic in appearance, and says he has never had syphilis.
The patient's age (twenty-four years) rather precluded athe-
roma of the coronary arteries, and his weight (one hundred and
twenty pounds and three quarters) and the absence of subcutane-
ous fat did not indicate fatty degeneration. In view, therefore, of
the history of overexertion, mental depression due to disappoint-
ment in love, and the evident neurotic temperament of the pa-
tient, I diagnosticated the case as one of heart jteurosis, and
recommended measures to restore the impaired nerve tone and
regulate the action of the heart, with the avoidance of all cir-
cumstances calculated to call upon the heart for increased effort,
moderate exercise in the open air, no emotional excitement;
the drinking of two quarts of milk daily in addition to his
usual diet; cod-liver oil with iron after meals ; buckthorn cor-
dial, from a teaspoonful to a tablespoonful at bed-time, to over-
come constipation; and a mixture of equal parts of tincture
of nux vomica and tincture of digitalis, ten drops three times a
day.
September 18, 1888. — Heart's action the same as when last
seen in February, 1888; same treatment advised, except that
I prescribed ten drops of tincture of digitalis three times a
[ day.
September 11, 1889. — Patient reappears after lapse of one
year; heart's action the same; has lost flesh; same general
treatment advised ; for constipation, aloin, one fifth of a grain ;
strychnine, one sixtieth of a grain ; extract of belladonna, one
eighth of a grain at bed-time.
25th. — Weight, one hundred and twenty-six pounds, a gain
of five pounds since September 11, 1889. Heart's action the
same ; prescribed one thirtv-second of a grain of strychnine and
ten drops of tincture of digitalis three times a day to regulate
heart action ; the application of a belladonna plaster to the
chest over the region of the heart, and continuance of general
measures as to nutrition and hygiene.
October 7th. — Pulse more regular at the wrist; heart action
more regular with the exception of some hesitation, so to speak,
at times; weight, one hundred and twenty-eight pounds, a gain
of seven pounds and a quarter since September 11, 1889; pre-
scribed one twenty-fourth of a grain of strychnine and ten
minims of tincture of digitalis three times a day ; general treat-
ment, continued.
13th. — Heart action more regular, but dicrotic every eight
beats; prescribed a mixture of strychnine, iron, quinine, and
phosphorus, as a general tonic ; and for the constipation, which
still remained obstinate, maltine with cascara, one or two tea-
spoonfuls at bed-time.
December 2d. — Weight, one hundred and thirty-one pounds,
; a gain of ten pounds and a half since September. Heart action
arrhythmical, hesitating, and dicrotic. Treatment unchanged.
January 1G, 1800. — Weight, one hundred and thirty-three
pounds and a quarter. Heart action the same ; prescribed tinct-
I tire of strophanthus, five drops three times a day.
February 10th. — Heart action irregular; prescribed conval-
lamarin, one one hundredth of a grain three times a day.
March 10th. — Heart action the same ; complains of full feel-
ing in region of the epigastrium, probably due to indigestion ;
prescribed tincture of nux vomica, eight drops before each meal
and five grains of bismuth and soda after eating; and, with a
view to regulate heart action, five drops of fluid extract of con-
vallaria three times a day.
20th.— Heart intermits every sixth heat, but in other respects
is more regular; prescribed mixture of bismuth, tincture of nux
vomica; dilute nitro-hydrochloric acid and pepsin before meals
to aid digestion.
April 1st. — Weight, one hundred and thirtv-three pounds.
Heart intermits about every tenth or fifteenth beat, but more
regular in other respects, due perhaps to better action of the
stomach.
11th. — Heart action dicrotic every tenth beat ; prescribed
tincture of digitalis and tincture of strophanthus, equal parts,
ten drops three times a day.
May 7th. — Heart action irregular as to rhythm ; prescribed
sulphate of sparteine, one fourth of a grain three times a day.
June 3d. — Heart action more regular ; intermissions occur
every twenty beats; advised to keep up nutrition and continue
cod-liver oil.
October ll^th. — Weight, one hundred and twenty-three
pounds ; loss in weight since May, 1890, ten pounds. Heart
intermits every ten or fifteen beats ; prescribed cod-liver oil,
iron, and two quarts of milk in addition to regular meals.
30th. — Weight, one hundred and twenty-seven pounds and
five eighths. Pulse, 84 ; no intermission, hut occasionally notice
a double beat; prescribed tincture of digitalis, ten minims, and
one thirty-second of a grain of strychnine three times a day.
December 15th. — Dr. R. C. M. Page, at my request, made a
careful examination of the patient with the following result:
Liver and spleen normal ; apex beat of the heart on the mam-
mary line and somewhat raised ; intermission felt best in the
carotids ; eyesight good ; no enlargement of the thyreoid gland ;
respiratory murmur perfect, except it is wavy, which is peculiar
to nervous people with palpitation; false intermission at the
wrist; anasmic murmur in the pulmonary interspace; venous
hum marked in the neck at the right side.
Dr. Page expressed the opinion that the case was a heart
neurosis with anaemia, and well worth watching for the develop-
ment of exophthalmic goitre. Prescribed a mixture of tincture
of nux vomica, two drachms; powdered rhubarb and sodium
bicarbonate, each one drachm ; water, to two ounces. A tea-
spoonful to be taken before meals and at bedtime.
Dr. Page thought that gastric catarrh, torpid liver, or anje-
mia might produce such a neurosis. Urine examined: reaction
acid; specific gravity, 1-020 ; no sugar; no albumin; some crys-
tals of oxalate of calcium and some urates found.
February 9, 1891. — Heart action the same. Patient was care-
fully examined by Dr. Janeway, who found the heart slightly
enlarged with displacement of the apex to mammary line and
raised; found no adhesions between visceral and parietal layers
of the pericardium; Blight murmurs were heard at the apex,
which he thought due to irregular action of the papillary muscles.
Dr. Janeway thought the hypertrophy was due to the irritable
heart condition and said the murmurs were more audible after
rapid exercise or partial respiration, and expressed the opinion
that the trouble was a heart neurosis choreic in character, and
advised that the patient take a mixture of equal parts of tincture
of strophanthus and tincture of nux vomica, ten drops three
times a day; that he pay careful attention to his general health
and avoid all excitement ; and for stomach symptoms, a mixture
of tincture of nux vomica, bicarbonate of sodium, and rhubarb,
and three grains of salicin three times a day.
March 3d. — Pulse, 84; heart action the same. In view of
the choreic nature of the case, I prescribed Fowler's solution of
arsenic, two drops to be taken after meals, and the dose to be
gradually increased up to ten drops.
May 13th. — Patient has taken Fowler's solution of arsenic
in gradually increasing doses until he reached ten drops three
times a day. Heart action unchanged. Prescribed one sixtieth
of a grain of atropine, to bo taken three times a day, in accord-
240
LEADING ARTICLES.
[N. Y. Med. Joub.
ance wit!) Dr. Da Costa's view that this <lru^ is especially use-
ful in irregular action of the heart.
25th. — Heart action still irregular in force anil rhythm.
The points of interest in this case seem to me to be —
1. The evident neurotic character of the affection, its
persistency, and the very slight annoyance or discomfort
experienced by the patient.
2. The difficulty of assigning a cause for the irregular
heart action.
3. The inefficacy of all medication looking toward regu-
lation of the disturbed heart action.
Bibliography.
Lancet, June 6, 1891. Remarks on the Slow Heart. By
Seymour Taylor, M. D.
Medical Record, September 20, 1890. Report of the Dis-
cussion on Functional Disorders of the Heart before the British
Medical Association.
Mew York Medical Journal, November 29 and December 6,
1890. Therapeutic Principles governing the Selection of Car-
diac Medicaments. By Solomon Solis-Cohen, M. D.
Diseases of the Heart and Great Vessels. By Walter Hayle
Walshe, M. D., London, 1862.
Pepper's System of Medicine. Neuroses of the Heart. By
Austin Flint, M. D.
Reference Hand-book of the Medical Sciences. Alcohol. By
Lewis L. McArthur.
Human Physiology. By Austin Flint, M. D.
Dublin Journal of Medical Science. Practical Observations
on the Diagnosis and Treatment of some Functional Derange-
ments of the Heart. By D. J. Corrigan, M. D.
American Journal of the Medical Sciences, Philadelphia,
1869. On Irritable Heart : a Clinical Study of a Form of Func-
tional Cardiac Disorder and its Consequences. By J. M. Da
Costa, M. D.
Lancet, 1877. Treatment of Neurosal Affections of the
Heart. By F. M. Fothergill, M. D.
College and Clinical Record. Philadelphia, 1883. Certain
Varieties of Cardiac Neurosis. By J. E. Halbert, M. D.
Boston Medical and Surgical Journal, 1880. Cardiac Ir-
regularity as the Only Result of Fright. By S. G. Webber, M. D.
Medical Record, New York, 1880. On Various Forms of
Functional Cardiac Disturbances. By Beverley Robinson, M. D.
Guy's Hospital Reports, London, 1858. On Poisoning by
Nicotina, with Remarks. By A. S. Taylor.
A Bill to restrict the Use of Hypnotism, drafted, it is said, in the
office of the Buffalo Enquirer, has been introduced into the New York
Legislature. The bill is as follows:
An act to prohibit public exhibition of hypnotic experiments and to pro-
hibit hypnotic treatment by any one except duly licenced physicians.
The people of the State of New York represented in Senate and
Assembly do enact as follows :
Section 1. It shall be unlawful for any person except duly licensed
physicians in the course of lectures to medical students or before scien-
tific bodies to give exhibitions of or perform hypnotic demonstrations
in public.
Section 2. It shall be unlawful for any person not a duly licensed
physician to hypnotize another.
Section 3. Any person violating either of the foregoing provisions
of this act shall be guilty of a misdemeanor.
Section 4. This act shall take effect immediately.
The bill is warmly advocated by several Buffalo physicians, and will
doubtless have the support of the medical profession throughout the
State.
THE
NP]W YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by Edited by
D. Appleton & Co. Frank P. Fostkr, M. D.
NEW YORK, SATURDAY. FEBRUARY 27, 1892.
THE BABY STUDENTS' RELIEF BILL.
In our issue for February 13th we spoke of the disgraceful
purport of a bill that was then under consideration by a com-
mittee of the Senate of the State of New York, having for its
object to relieve certain medical students of the necessity of
passing the State examination. We are glad to see that the
committee on legislation of the Medical Society of the State of
New York has since issued a circular, dated February 17th.
calling on the physicians of the State to influence members of
the Assembly to vote against the bill, which has already been
passed in the Senate. The committee very properly says in its
circular that there is no valid argument in favor of the bill, but
that its passage by the Senate has been brought about by per-
sonal solicitation and selfish appeals. Personal effort should
therefore be resorted to against it in the Assembly.
"The law governing the practice of medicine in the State of
New York,-' says the circular, "is being copied all over the
country; it is said by educators to be one of the fairest and
best laws on the statute books of any government in the world;
almost daily requests for a copy of this law are received from
all quarters of the globe, and its praises have been sounded in
congratulatory letters to its projectors by physicians and lay-
men from far and near. Should such an excellent law, passed
after more than twenty years of struggle in legislative halls, be
emasculated year after year because of the lethargy of our pro-
fessional brethren, when those selfishly interested are so ener-
getic and persistent? The answer rests with you and all of us.
If you desire to crush out this yearly cry on the part of the
students against high medical standards, if you desire to pre-
serve intact the excellent law which it is now sought to amend
and practically nullify, write or telegraph your member of As-
sembly at once (delay is now dangerous) that the entire medical
profession, not only of the State but of the country, regardless
of creed or pathy, is opposed to Assembly Bill No. 513 ; that it
is special and selfish legislation calculated to benefit the few to
the detriment of the many, and that it should not prevail. If
you value a higher standard in the profession of medicine, if
you believe in adding to its dignity and worth, you will not put
this letter aside until you have lent your aid toward the defeat
of this proposed legislation."
Besides issuing its circular, the committee has worked dili-
gently by individual correspondence to rouse the profession to
the need of speedy action, and we are informed that a most
gratifying response has been the result. The medical societies
of Fulton, Albany, Kings, Erie, and other counties had delega-
tions present at a hearing held on Wednesday, the 24th inst,
before the Assembly committee on public health, and there
Feb. 27, 1892.]
MINOR PARAGRAPHS.— ITEMS.
241
were also present representative physicians from New York
city, Brooklyn, Buffalo, Elmira, Syracuse, Gloversville, Albany,
and other large places— homoeopathic and eclectic as well as
those of our own "school" — to protest against the proposed
legislation. In addition, several of the more influential of the
newspapers have published editorial articles opposing the bill.
It must not be supposed that all the students who could
take advantage of the proposed law are enlisted in favor of its
enactment; indeed, in one school, that of Niagara University,
of Buffalo, they have passed a resolution declaring that the law
as it stands is good enough for them.
The Legislature should understand that the medical profes-
sion opposes the bill not from any selfish or illiberal motives,
but solely in the interest of the public welfare; all that the
profession asks for itself is not to be deprived of the means of
keeping itself clean.
MINOR PARAGRAPHS.
AN ASYLUM FOR SUPERANNUATED INSTRUMENTS.
According to a London letter to the American Practitioner
and News for January 16th, old and discarded surgical instru-
ments can be put to a good purpose by being sent to mission-
aries in foreign lands. A benevolent member of the Royal Col-
lege of Surgeons has made a suggestion that all old-fashioned
and discarded surgical implements be brought out of their dark
corners and placed in the hands of the secretaries of those soci-
eties which employ medical missionaries. The gentleman who
makes this appeal states that he knows of an instance of a mis-
sionary who bad no other instruments than an ordinary case-
knife and a pair of scissors with which to remove the frozen
foot of a North American Indian in whose case an operation
was so imperative that he proceeded to operate with these.
1 Fortunately the patient survived. A beginning has already
been made by forwarding certain superfluous instruments and
appliances to the Missionary Training College in East London.
Old operating-cases, dental instruments, tourniquets, trocars,
sounds, catheters, etc., may all be welcome and find their best
value in the hands of those lonely pioneers, many of whom are
a hundred miles distant, perhaps more, from any possible as-
sistance.
COMPRESSION OF THE CAROTIDS AS A THERAPEUTIC
MEASURE.
In a recent number of the Gyogydszot Dr. Leopold Roheim,
of Budapest, publishes a case of eclampsia which he had, after
the failure of a large number of remedies, successfully treated
i by compressing the carotids with his fingers. The publication
of this case recalls the fact that the whole subject of carotid
compression in its relation to the treatment of nervous diseases
was thoroughly worked up by Dr. J. Leonard Corning over ten
years ago. Not content with following the ancient practice of
pressing upon the carotids with the fingers, Dr. Corning devised
a number of ingenious instruments by means of which he was
able to compress those arteries and faradize the subjacent sym-
pathetic and pneumogastric nerves at the same time. He has
embodied the results of these researches in a number of papers,
and notably in a little book, Carotid Compression, published in
1882. Dr. Coming's contributions are especially valuable, as
' the conclusions arrived at are based upon a large array of cases
of nervous disease in which the method was given a thorough
trial. Oases of headache, eclampsia, convulsions of children,
epileptic convulsions, and obstinate insomnia as it occurs in the
insane were treated successfully in this way.
MONTHLY BULLETIN OF THE SECRETARY OF THE RHODE
ISLAND STATE BOARD OF HEALTH.
Dr. Charles IT. Fisher, of Providence, has begun again to
publish his little sanitary serial, called the Bulletin of the State
Board of Health. It was discontinued in June, 1891. The
fourth volume opened in January, 1892. It is essentially a vol-
untary publication on the part of Dr. Fisher, whose purpose is
the double one of having a printed record of mortality, meteor-
ology, etc., for the use of health officials and for enlightening
the public and the public schools about the sanitary duties of
boys, girls, teachers, and citizens. The Rhode Island Institute
of Instructors has found this latter feature so well carried out
that it has publicly asked Dr. Fisher to continue the publication
and has promised a liberal advocacy of its objects.
HIGH TEMPERATURE IN INTERMITTENT FEVER.
Dr. Stephen Mackenzie, in the British Medical Journal for
February 13th, reports a case of intermittent fever in which
twice the temperature was 107° F., once 109°, twice 113°, and
once 113-8°. The observations were made with the thermome-
ter in one or the other axilla; sometimes two thermometers
were placed in the axilla and found to correspond. On account
of rigors the temperature could not be taken in the mouth. The
periods of hyperpyrexia were exceedingly brief, sometimes a re-
turn to normal temperature occurring in five minutes. The
patient recovered.
A BENGALI MEDICAL JOURNAL.
The Indian Medical Gazette, of Calcutta, says in its January
number that it has received the first and second issues of
Veshukdorpon (the mirror of medicine), a monthly medical
journal written in simple Bengali, so that it can be read by the
native doctors and civil hospital assistants of all grades and de-
nominations. The character of its contents is commended by
the Gazette.
ITEMS, ETC.
Infectious Diseases in New York. — We are indebted to the Sanitary
Bureau of the Health Department for the following statement of cases
and deaths reported during the two weeks ending February 23, 1892 :
DISEASES.
Week ending Feb. 16.
Week ending Feb. 23.
Cases.
Deaths.
Cases.
Deaths.
Typhus
86
0
16
4
7
6
13
5
225
39
209
31
0
1
0
1
204
10
224
17
123
37
134
35
8
1
7
3
4
0
2
0
18
0
16
0
1
3
2
0
Mumps
0
0
4
0
The County Society Prize. — Members of the Medical Society of the
County of New York are invited to compete for the annual prize of
one hundred dollars or a one-hundred-dollar gold medal, to be awarded
for the best essay on any medical or surgical subject by the society at
its annual October meeting, the award being subject to the following
conditions :
1. The competitor must be a member of this county society in
good and regular standing.
242
ITEMS.
[N. Y. Med. Jors ,
2. The competitor's identity must not be revealed until after the
report of the committee on prize essays has been presented at the
annual October meeting, each essay in competition being designated
simply by a motto and accompanied by a sealed envelope exhibiting the
same motto, and inclosing the author's name.
3. If, in the judgment of the committee, no essay is presented that
is sufficiently meritorious, no award will be made.
All essays competing should be sent to the chairman of the com-
mittee, Dr. E. B. Bronson, No. 123 West Thirty-fourth Street, on or
before the first day of October, 1892.
The Medical Association of Georgia will hold its forty-third annual
meeting in Columbus, on April 20th, 21st, and 22d, under the presi-
dency of Dr. G. W. Mulligan, of Washington.
The Randall's Island Hospitals. — Dr. William J. Morton has been
appointed neurologist on the medical board.
The Pan-American Medical Congress. — The Medical Society of the
County of Kings, N. Y., has appoiuted a committee consisting of Dr.
J. H. Raymond (chairman), Dr. A. J.. C. Skene, and Dr. Alexander
Hutchins to co-operate with the officers of the congress.
The Royal College of Physicians of London. — It is stated that the
recently published list includes 295 fellows, about 50o members, and
about 3,300 licentiates. Only the fellows manage the organization.
Army Intelligence. — Official List of Changes in the Stations and
Duties of Officers serving in the Medical Department, United Statet
Arm;/, from February 7 to February 20, 1892:
Glennan, James D , First Lieutenant and Assistant Surgeon. The
leave of absence granted on surgeon's certificate of disability is ex-
tended fifteen days.
Fisher, Walter W. R., Captain and Assistant Surgeon. The leave of
absence granted is extended fifteen days.
The following-named officers, having been found by army retiring boards
incapacitated for active service on account of disability incident to
the service, are, by direction of the President, retired from active
service this date, under the provision of Section 1251, Revised Stat-
utes: Burton, Henry G., Captain and Assistant Surgeon ; Taylor,
Arthur W., Captain and Assistant Surgeon. February 5, 1892.
Naval Intelligence.— Official List of Changes in the Medical Corps
of the United States Nary for the week ending February 13, 1892 :
Bryant, P. H., Assistant Surgeon. Ordered to the Naval Hospital,
Philadelphia, Pa.
Percy, H. T., Passed Assistant Surgeon. Detached from Coast Survey
Steamer Patterson and granted leave for two months.
Decker, C. J., Passed Assistant Surgeon. Detached from Naval Hos-
pital, Philadelphia, and ordered to Coast Survey Steamer Patterson.
Uric, John F., Passed Assistant Surgeon. Ordered to the Naval Hos-
pital, Portsmouth, N. H.
Wells, Howard, Surgeon. Detached from the Naval Hospital, Ports-
mouth, and to wait orders.
Guthrie, Joseph A., Assistant Surgeon. Ordered to Naval Station,
Port Royal, S. C.
Young, L. L., Assistant Surgeon. Detached from Naval Station, Port
Royal, S. C, and ordered to the Receiving-ship Independence.
Marine-Hospital Service. — Official List of the Changes of Stations
and Duties of Medical Officers of the United States Marine-Hospital
Service for the three weeks ending February 6, 1892:
Pcrviance, George, Surgeon. Detailed as chairman of the Board of
Examiners. February 3, 1892.
Hutton, W. H. H., Surgeon. Detailed as member of the Board of Ex-
aminers. February 3, 1892.
Sawtelle, H. W., Surgeon. Granted leave of absence for ten days.
January 30, 1892.
Irwin, Fairfax, Surgeon. Granted leave of absence for fourteen days.
January 26, 1892.
Mead, F. W., Surgeon. Detailed as recorder of the Board of Ex-
aminers. February 3, 1892.
Carter, II. R., Passed Assistant Surgeon. Granted leave of absence
for seven days. January 20, 1892.
Cabmichakl, D. A., Passed Assistant Surgeon. When relieved, to pro-
ceed to Port Townsend, Washington, and assume command of the
service. January 23, 1892.
Glennan, A. H, Passed Assistant Surgeon. When relieved, to pro-
ceed to South Atlantic Quarantine and assume command of the
station. January 23, 1892.
White, J. H., Passed Assistant Surgeon. Relieved from duty at South
Atlantic Quarantine; to assume command of the senice at Savan-
nah, Ga. January 20, 1892.
Carrington, P. M., Passed Assistant Surgeon. When relieved, to pro-
ceed to Evansville, Md., and assume command of the service.
January 20, 1892.
Magruder, G. M., Passed Assistant Surgeon. Relieved from duty at
New Orleans, La. ; to assume command of the service at Portland,
Oregon. January 23, 1892.
Vaugiian, G. T., Assistant Surgeon. When relieved, to report to the
Supervising Surgeon-General. January 20, 1892.
Cobb, J. O., Assistant Surgeon. Ordered to examination for promo-
tion. February 3, 1892.
Stoner, J. B., Assistant Surgeon. Ordered to examination for promo-
tion. February 3, 1892.
Condict, A. W., Assistant Surgeon. When relieved, to proceed to
Wilmington, N. C, and assume command of the service. January
23, 1892. Ordered to examination for promotion. February 3,
1892.
Gardner, C. H., Assistant Surgeon. Assigned to temporary duty at
Baltimore, Md. January 27, 1892.
Promotions.
Carter, H. R., Surgeon. Commissioned by the President as Surgeon.
January 28, 1892.
Vaugiian, G. T., Passed Assistant Surgeon. Commissioned by the
President as Passed Assistant Surgeon. February 6, 1892.
Appointment.
Gardner, C. H, of Maryland. Commissioned by the President as As-
sistant Surgeon. January 28, 1892.
Society Meetings for the Coming Week :
Monday, February 29th: Medical Society of the County of New York;
Boston Society for Medical Improvement; Lawrence, Mass., Medi-
cal Club (private); Cambridge, Mass., Society for Medical Improve-
ment ; Baltimore Medical Association.
Tuesday, March 1st: New York Obstetrical Society (private); New
York Neurological Society; Elmira Academy of Medicine; Buffalo
Medical and Surgical Association ; Ogdensburgh Medical Associa-
tion ; Hudson, N. J., County Medical Society (Jersey City) ; Andro-
scoggin, Me., County Medical Association (Lewiston) ; Essex, Mass.,
South District Medical Society (annual— Salem) ; Baltimore Acade-
my of Medicine.
Wednesday, March 2d: Society of the Alumni of Bellcvuc Hospital;
Harlem Medical Association of the City of New York; Medical
Microscopical Society of Brooklyn ; Medical Society of the County
of Richmond (Stapleton); Penobscot, Me., County Medical Society
(Bangor); Bridgeport, Conn., Medical Association.
Thursday, March 3d: New York Academy of Medicine; Brooklyn
Surgical Society ; Society of Physicians of the Village of Cauan-
daigua ; Boston Medico-psychological Association; Obstetrical So-
ciety of Philadelphia; United States Naval Medical Society (Wash-
ington).
Friday, March flh: Practitioners' Society of New York (private);
Baltimore Clinical Society.
Saturday, March 5th : Clinical Society of the New York Post-gradu-
ate Medical School and Hospital ; Manhattan Medical and Surgical
Society (private) ; Miller's River, Mass., Medical Society.
Answers to Correspondents :
No. 372. — You do not state what form of electricity you have used.
We should expect a favorable action from local faradization, using a
weak current ; also from the administration of drop doses of tincture
of eantharides hourly for four hours each day.
No. 373.— We think not.
Feb. 27, 1892.]
BOOK NOTICES.
243
$ooh Itoticcs.
Therapeutics: its Principles and Practice. By H. C. Wood,
M. D., LL. I)., Professor of Materia Medica and Therapeutics,
and Clinical Professor of Diseases of the Nervous System, in
the University of Pennsylvania. A work on Medical Agen
cies, Drugs, and Poisons, with special reference to the Rela-
tions between Physiology and Clinical Medicine. Eighth
edition of A Treatise on Therapeutics, rearranged, rewritten,
and enlarged. Philadelphia: J. B. Lippincott Co., 1891.
This oft-reviewed work comes to us in its eigbth edition, en-
larged and improved, but not revolutionized as in its seventh
edition. Its favorable reception and flattering reviews, if in-
deed any praise could flatter it, by the profession of not only
our own, but almost every civilized country, leave little to be
said for it which would not be trite and commonplace. In the
branch of therapeutics, however, so many discoveries and so
much experimentation are being made that a book which was
authority three years ago would be at best a book of reference
to-day. The author must be wide awake and ever on the alert
to study new drugs, new works and conclusions upon old ones,
and new theories and methods of applying them. In this re-
spect, as in others, Dr. Wood has proved himself a man of dili-
gence and careful scrutiny.
No doubt there are many of the newer remedies that he has
failed to notice in his work, but most of them are very new or
have not as yet established their right to a place among the
standard therapeutic agencies. One of the greatest charms in
the study of this work is that the reader is not asked to believe
upon general hearsay. The studies have been made by the au-
thor himself, or his conclusions drawn from competent authori-
ties, which he invariably cites. The facts of experimentation
are presented and the author's conclusions therefrom laid down,
leaving the reader the liberty to draw different ones if the pro-
cesses of reasoning seem imperfect to him. It is not a work of
dogmatic axioms, but one of rationalism in therapeutics, and it
directs the practitioner to a higher plane than that of the older
works, which, teaching from empiricism, told the student that
mercury was good for syphilis, quinine for fever, and opium for
diarrhoea. It would be impossible in our space to point out the
different features worthy of commendation in this work; the
points for criticism are few and far between. The most serious
fault we can find with the book is the meagerness of advice with
regard to the application of remedies in special diseases. If
every reader was a practical physiologist or thorough logician,
this would not be a fault; but such is not the case, and a fuller
list under each drug of the diseases in which it has been success-
fully used would make the work more popular at least.
The arrangement of the drugs in classes, according to their
physiological actions, is to our mind the only scientific and satis-
factory one, both for reference and for study. The division of
the work into two parts will be a novelty to most of Dr. Wood's
older students. Part I, on Remedies, Remedial Measures, and
Remedial Methods which arc not Drugs, comprises a new and
interesting portion of the book. Here are treated not only the
general considerations and miscellaneous remedial measures —
such as massage, metallotherapy, and feeding of the sick—but
also the management of general bodily conditions, including ex-
haustion, obesity, and the gouty diathesis. Divisions are also
made of Heat and Cold and Electricity, all of which are
treated of in the author's clear and convincing manner. On
the whole, this is a work worthy of the high place it has taken
in medical literature and one of which every American should
be proud.
Lessons in the Diagnosis and Treatment of Eye Diseases. By
Casey A. Wood, C. M., M. D., formerly Clinical Assistaut,
Royal London Ophthalmic Hospital (Moorfields), etc. With
numerous Woodcuts. Detroit: George S. Davis, 1891.
Tins little manual is intended to aid the physician to detect
and treat the diseases of the eye which are most frequently
overlooked in the course of general practice. It is subject to
the same criticism which may be made regarding most of the
manuals of this series, that too much is attempted to be told in
a small space.
The Pathology, Diagnosis, and Treatment of Intracranial
Growths. By Philip Coombs Knapp, A. M., M. D. (Har-
vard), Clinical Instructor in Diseases of the Nervous Sys-
tem, Harvard Medical School, etc. Boston: Rockwell &
Churchill, 1891.
Tins is the essay for which was awarded the Fiske prize for
1890. Dr. Knapp wisely decided to present a series of new
cases, even though some of them were defective, rather than to
collect more typical published cases from the great number al-
ready reported. The essay is therefore based on the records of
forty personal cases with autopsies. He has, however, availed
himself freely of the literature of the subject, especially in the
discussion of symptomatology. In the chapter on treatment
also he has given a complete list of all reported cases of opera-
tions.
Of the forty cases collected by the author, eleven were not
uncomplicated cases of brain tumor, but cases in which the
patient died of something else, and the tumor was merely a co-
existing lesion, giving rise during life to no apparent dis-
turbance.
In thirteen cases there were symptoms of some cerebral
trouble, but they were not definite enough to permit of a cor-
rect diagnosis. In only sixteen cases was it possible to make a
diagnosis oi the existence of an intracranial growth, and in eight
of these a correct focal diagnosis was also made. The number
of characteristic cases, when thus analyzed, is so small that the
author could hardly do more than use them in illustration of
facts already established, rather than attempt to add to our ex-
isting knowledge of the subject. He gives, however, a very
clear and complete exposition of this knowledge, especially in
the chapters on symptomatology and diagnosis. His remarks
on treatment also are characterized by a judicious conservatism.
Philadelphia Hospital Beports. Vol. I, 1890. Edited by
Charles K. Mills, M. D., Member of the Neurological Staff.
Philadelphia: Detre & Blackburn. 1891.
This publication should receive a warm welcome from the
medical profession in this country. Those physicians who are
familiar with the reports published by Guy's Hospital and other
institutions abroad have long regretted the regular publication
of similar works in the United States.
A part of this volume is given up to historical sketches and
reminiscences of the Philadelphia Eospital and Almshouse, be-
ginning with their establishment early in the last eentury. The
almshouse was founded in 1742, and the hospital proper in 1753,
and it is but fitting that their ancient origin should receive
recognition in this initial volume.
The main body of the work is made up of twenty-five clini-
cal reports by various members of the medical statff. Neurology
is represented by Dr. Mills, Dr. Dercum, and Dr. Sinkler; sur-
gery, by Dr. Porter and Dr. Deaver; general medicine, by Dr.
Musser, Dr. Henry, and Dr. Solis-Cohen; obstetrics, by Dr.
Hirst and Dr. Davis; and pathology, by Dr. For mad. An in-
teresting experimental study of the Bacillus suhtilis, by Dr. J.
244
BOOK NOTICES.— REPORTS ON
THE PROGRESS OF MEDICINE. [N. Y. Med. Joub.,
Leffingwell Hatch, should also be mentioned. His conclusions
are in agreement with the opinion of Klein that this bacillus
represents a class of non-pathogenic bacilli.
There are other writers \vh03e names are only less well
known than those given above, almost every member of the
large hospital staff having contributed one or more papers.
Philadelphia is to be congratulated on this evidence of medi-
cal enterprise, and we hope that New York will not be tardy in
following her good example.
Guy'' 8 Hospital Reports. Edited by W. Davies-Colley, M. A.,
M. C, and W. Hale White. M. 1). Vol. XL VII, being Vol.
XXXII of the Third Series. London: J. & A.Churchill,
1890.
This volume, in addition to the usual number of valuable
clinical studies, contains a very interesting and discriminating
memoir of the late Sir William Gull. An autotype portrait
completes the impression gathered from the memoir, and gives
one a good idea of the striking presence of that distinguished
physician.
As to the reports themselves, it is difficult to single out any
for special mention. There are two, however, that we have
found unusually instructive — namely, a paper entitled Chiefly
concerning Bruits, by Dr. Goodhart, and another by Dr. W.
Hale White, on The Pathology and Prognosis of Pernicious
Anaemia.
Dr. C. H. Golding-Bird also contributes an interesting study
of Congenital Wryneck and Facial Hemiatrophy, in which he
advances a new and striking theory of the pathology of these
affections when associated in the same individual.
Other reports by various writers combine to make a volume
full of clinical information.
On the Medical and Surgical Uses of Electricity. By George
M. Beard, A. M., M. D., and A. D. Rockwell, A. M., M. D.,
etc. Eighth Edition, with over 200 Illustrations. New
York: William Wood & Co., 1891.
To this edition the surviving author, Dr. Rockwell, brings
broadened views and a richer experience. The vagueness
and uncertainty that formerly occupied some of its pages have
in a large measure been eliminated, and in place of suggestions
we have experiences and positive advice. The chapter upon
dosage in electricity is well-worded and instructive, being a
great improvement upon that in the former editions. The
chapter upon the different physiological and therapeutic effects
of the induced current is new and highly interesting. The cuts,
many of them new, are not of the highest type, but are
generally accurate. In attempting to show the application of
electricity to every form of disease much useless material has
been brought into the book, and this, too, without giving the
negative conclusions which the experiences justify. We do not
depreciate the usefulness of electricity in many conditions, but
it is not well to allege for it curative virtues in every ill that
flesh is heir to. Dr. Rockwell would inspire more confidence
if he told us candidly that there were some infirmities in which
electricity was of no use. Fewer cases with more detail would
give the student a better idea of the methods of applying elec-
tricity and of its ultimate results. On the whole, this work de-
serves its popularity.
BOOKS, ETC., RECEIVED.
A Manual of Operative Surgery. By Frederick Treves, F. R. C. S.,
Surgeon to and Lecturer on Anatomy at the London Hospital, etc.
With Four Hundred and Twenty-two Illustrations. Vol. I. : General
Principles ; Anaesthetics ; Operations upon Arteries and Nerves ; Am-
putations ; Excisions; Operations upon Bones, Joints, and Tendons.
Pp. xvi to 775. Vol. H. : Plastic Surgery; Operations upon the Neck
and Abdomen ; Operations on Hernia; Operations upon the Bladder
Scrotum, Penis, and Rectum ; Operations upon the Head and Spine,
Thorax, and Breast. Pp. xiii to 775. Philadelphia : Lea Brothers &
Co., 1892. [Price, $9.]
A Dictionary of Treatment ; or, Therapeutic Index, including Medi-
cal and Surgical Therapeutics. By William Whitla, M. D., Professor
of Materia Medica and Therapeutics in the Queen's College, Belfast,
etc. Revised and adapted to the Pharmacopoeia of the United States.
Philadelphia: Lea Brothers & Co., 1892. Pp. 9 to 921. [Price, $4.]
Surgical Diseases of the Ovaries and Kalloppian Tubes, including
Pregnancy. By J. Bland Sutton, F. R. C. S., Assistant Surgeon to the
Middlesex Hospital, etc. With One Hundred and Nineteen Engravings
and Five Colored Plates. Philadelphia: Lea Brothers & Co., 1892.
Pp. xvi to 500.
First Lines in Midwifery: a Guide to Attendance on Natural Labor
for Medical Students and Midwives. By G. Ernest Herman, M. B.
Lond., F. R. C. P., Obstetric Physician to the London Hospital and
Lecturer on Midwifery, etc. With Eighty Illustrations. Philadelphia:
Lea Brothers & Co., 1892. [Price, $1.25.]
The New Cure of Consumption by its own Virus. Illustrated by
Numerous Cases. By J. Compton Burnett, M. D. Second Edition,
revised and enlarged. Philadelphia: Boericke & Tafel, 1892. Pp. xi-
13 to 187.
Sleep, Insomnia, and Hypnotics. By E. P. Hurd, M. D., Member of
the Massachusetts Medical Society, etc. Detroit : George S. Davis, 1891.
[The Physicians' Leisure Library.]
Notes on General verms Local Treatment of Catarrhal Inflamma-
tions of the Upper Air-tract. By Beverley Robinson, M. D., New York.
[Reprinted from the Climatologkt.]
Apparatus for collecting Water for Bacteriological Examination.
By Samuel G. Dixon, M. D., Philadelphia. [Reprinted from the Timet
and Register.]
Annual Address before the State Board of Health of Pennsylvania.
By Professor Samuel G. Dixon, M. D. (Read on May 15, 1891, at the
Sanitary Convention at Altoona.)
Injury to the Spine: Invention and Application of Paper Jacket.
By J. Marshall Hawkes, M. D., New York. [Reprinted fron the Medi-
cal X< ii's. \
The Part played by Leucocytes in Inflammation in the Light of Re-
cent Bacteriological Investigations. By William T. Howard, Jr., M. D.,
Baltimore. [Reprinted from the Man/land Medical Journal.]
Pneumonic Fever ; its Mortality, with a Consideration of some of
the Elements of Prognosis. By Edward F. Wells, M. D., Chicago. [Re-
printed from the Journal of the American Medical Association.]
Twenty-first Annual Report of St. Catherine's Hospital, Brooklyn.
Reports on tire progress of ffteoichu.
REPORT ON OPHTHALMOLOGY.
By CHARLES STEDMAN BULL, M. D.
(Continued from pa ye 222.)
Clinical Contributions to the Physiology of the Ophthalmic Gan
glion. — Querenghi (Arch, d'ophthal., xi, 3) draws the following conclu-
sions from his observations : 1. Through the ophthalmic ganglion pass
the nervous fibers by means of which the irritation or impulse is con-
veyed to the muscle of accommodation. 2. The ganglion is also
traversed by the constrictor nervous fibers going to the pupil, which
react to reflex irritation of the same eye. 3. It presides over the par-
ticular sensibility of the cornea. 4. The constrictor nerve fibers of the
pupil, which react to the luminous reflex of the other eye and to the
movements of convergence, come directly from the central organs with
Feb. 27, 1892.J
REPORTS ON THE PROGRESS OF MEDICINE.
245
out the intermediary aid of the ganglion. These fibers probably pass
to the eye with the long ciliary nerves.
The Origin of Tuberculosis of the Uveal Tract. — Valude (Arch,
d'op/ithal., xi, 3) gives the results of his experiments as follows: 1. As
long as the tuberculous deposit remains inclosed with the envelopes of
the eye, and as long as no tuberculous fungi develop, the disease ex-
tends hut little beyond its original deposit. 2. In an infected organ-
ism the wounding of the healthy eye is not followed by any special re-
action. Jt thus seems that the eye behaves toward the tuberculous
infection very differently from the way the subcutaneous cellular
tissue or the bones or articulations behave. 3. The propagation of
the tuberculous germs follows by the lymphatic channels, and not by
the blood-vessels. 4. The eye is well protected against tuberculosis by
propagation or generalization ; ocular tuberculosis of internal origin is
certainly very rare. 5. It is therefore probable that ocular tuberculo-
sis of the uveal tract is of external origin.
Superficial Ciliary Nerves in Man. — Boucheron (Arch, d 'aphtha!.,
xi, 4) considers that our modern methods of microscopical examination
have proved that it is possible to divide and resect the deep ciliary
nerves without destroying the cornea, because the superficial ciliary
nerves suffice to preserve its normal sensibility. After division of the
deep ciliary nerves the corneal sensibility, preserved at the margin, is
merely the normal condition of function of the superficial ciliary nerves.
The observations of Magendie and Bernard have also demonstrated that
i the sensibility of the center of the cornea is of different origin from the
sensibility of the periphery of the cornea and conjunctiva.
Recent Researches into the Physiology of the Movements of the
Eyes. — Landolt (Arch, d'ophthoJ., xi, 5) draws the following conclusions
from his researches : It is proved that the act of reading is the more
fatiguing the smaller the jerks or excursions of the eyes are which it
demands. Experiments as to the smallest angle of excursion rapidly
cause such fatigue that they can not be pursued for any length of time
without a rest. The nearer the eye approaches the type, the greater
become the necessary excursions of the eyes, and this imposes a great
demand on the muscles of convergence and accommodation. The par-
ticular kind of motility of the eyes, and the limitation of their excur-
sions, probably contain the solution of many of the problems of ocular
pathology.
Persistence of the Canal of Cloquet ; Eemains of the Foetal Hyal-
oid System ; Coloboma of the Optic Nerve. — Van Duyse ( Arch, oVophthal.,
xi, 5) gives the following results of his examination of an interesting
case: 1. The canal of Cloquet with the remains of the hyaloid artery
become impermeable to the passage of the blood. 2. A long, white
band of tendinous aspect covers the optic disc with its superior end,
and masks the origin of the retinal vessels. It runs downward and
outward toward the periphery of the fundus, and ends here by a bi-
lobed border with pigmented edge. The lower end resembles strongly
a coloboma of the fundus. 3. There was a coloboma of the sheath of
the optic nerve, which surrounded like a large conus the upper end of
the tendinous band. There were also signs of disseminate chorio-
retinitis in the atrophic stage.
The Shape of the Human Cornea, and its Influence on the Vision.
— Sulzer (Arch, d'ophthal., xi, 5) gives the following results of his in-
vestigations :
1. The central parts of the cornea vary very little from the shape
of a spherical cap or coif.
2. At a certain distance from the point of intersection of the visual
line with the cornea, averaging an angular distance of 15°, the radius
of curvature of the cornea suddenly begins to increase. From this
point the corneal surface presents curvatures resembling those of an
ellipsoid, the eccentricities of which increase as the corneal limbus is
approached.
3. If we pass from the point of intersection of the visual line with
: the cornea, or from the point of greatest curvature, toward the corneal
elements situated at equal distances from the point of departure, the
curvature does not diminish equally along the two principal meridians
nor along the two halves of the same principal ineiidian.
Subconjunctival Injections of Corrosive Sublimate in Ocular Thera-
peutics.— Darier (Arch, d'ophthal., xi, 5) considers this method of
i treatment a valuable acquisition of ocular therapeutics. In all cases
where mercurial medication is indicated, and where it is necessary to
put an immediate stop to the progress of the disea.-e, he thinks no other
method is so easily managed or so satisfactory in its results.
Notes on Glioma Retinae, with a Report of Sixty Cases. — Law ford
and Collins (Roy. Lund. Ophthal. Hosp. Rep., xiii, 1) give some interest-
ing notes on this subject Of the sixty cases, thirty were in males,
twenty-seven were in females, and in three the sex was not given. Of
the sixty cases, the growth occurred simultaneously, or with short in-
tervals, in both eyes in twelve ; in four others there was decided proba-
bility that the disease attacked both eyes ; and in one case the affec-
tion of the second eye may have been glioma. Of those in which the
disea.-e was unilateral, the right eye was affected in sixteen cases, the
left in twenty-seven cases, and in one case it was not stated. The dis-
ease was first noticed by the parents within three months of birth in
nine cases; of these it was noticed at birth in five cases, and during
the first five weeks of life in two cases ; between three and six months
in four cases ; between six and twelve months in nine cases ; during the
second year in thirteen cases; during the third year in seven cases ;
during the fourth year in three cases ; during the fifth year in four
eases: during the sixth year in four cases; during the seventh year in
one case ; age uncertain in six cases. From these figures it appears
that the growth becomes evident with greatest frequency during the first
year. The authors have regarded as permanent recoveries only those
cases in which reliable information was obtained that the patient was
alive and well, and that no return of the disease had occurred three
years after the removal of the eye or eyes. Of the sixty cases reported,
eight may be regarded as permanent recoveries. In these cases the
average time which elapsed between the discovery of the growth and
the removal of the eyeball was four months. In sixteen fatal cases
the average interval was fourteen months. Of twenty-two cases, the
tumor recurred in the orbit in seventeen. In the remaining five,
secondary growths were met with in the cranial bones, throat, palate,
and in one case in the brain and spinal cord.
An Ophthalmoscoptometer with Micrometer. — Leroy (Rev. gen.
d 'ophthal., October 31, 1891) has devised an instrument which contains
within the dimensions of an ordinary ophthalmoscope the properties of
a refraction ophthalmoscope and of an objective and subjective op-
tometer, and which, in addition, enables the observer to measure ob-
jectively the elements of the fundus of the eye which are visible with
the ophthalmoscope. It is composed essentially of two parts. 1.
A refraction ophthalmoscope with three interchangeable mirrors, an
ordinary concave mirror, a concave mirror of short focus inclined at an
angle of 45°, and a plain mirror. 2. A positive eye-piece or ocular,
at the principal focus of which is placed a micrometer, divided into
tenths of a millimetre, photographed on glass. This eye-piece is fur-
nished with a prism of total reflection of 45°, so placed as to reflect
the image of the micrometer in the direction of the optical axis of the
ophthalmoscope or visual line of the observer. A screw with a large
button regulates the displacement of the tube containing the microme-
ter and prism, so as to bring the edge of the latter toward the center
of the pupillary field. Then the eye of the observer receives simulta-
neously the rays from the micrometer and from the fundus of the
patient's eye. The properties of the instrument areas follows: 1. If
the eye-piece is removed, we have a refraction ophthalmoscope. 2.
The eye piece and prism being in place, if the observer, fixing his at-
tention on the micrometer, approaches the glass which enables him to
see at the same time a well-defined image of the fundus, this glass
represents the patient's ametropia. If, during this examination, the
observer accommodates, he is immediately warned of it by an indis-
tinctness in the image of the micrometer, and he must theu fix at-
tentively the latter in order to bring his accommodation to a state of
rest. 3. If the prism is turned 180° so that the rays of the micrometer
are turned toward the patient, the glass which enables the latter to see
the micrometer distinctly under the known existing conditions will be
the glass which corrects his ametropia. 4. The most interesting
property is that of enabling the observer to measure the visible ele-
ments of the fundus. After having arranged the micrometer in the
suitable manner by turning it in its frame, the desired measure is ob-
tained by reading the number of divisions which cover the dimension
sought for. Thus can be measured the caliber of the vessels, the
246
REPORTS ON THE PROGRESS OF MEDICINE.
[N. Y. Med. Joub.,
papillary diameter, the dimensions of a staphyloma, of a hemorrhage,
of an exudation, or of a chorioidal lesion.
Affections of the Vision in Parkinson's Disease. — Galezowski (Ree.
d'o/ihtha/., February, 1891 ) draw s the following conclusions from his ob-
servations : 1. In Parkinson's disease vision is usually intact, and when
it is affected the symptoms are slight and never progressive. 2. Gen-
erally the eyes are fixed, and the excursive movements are but slight.
3. The upper lids of both eyes are generally lowered, and only cover
about half of the eyeballs. 4. The lids, in spite of their immobility,
show a slight trembling which is difficult to recognize, and this same
tremor is at times to be seen in the eyeballs also. 5. Vision is usually
intact, but in rare cases there is a unilateral amblyopia without oph-
thalmoscopic lesion, with a narrowing of the visual field throughout
about three quarters of its extent. 6. The immobility of the head and
eyes renders all work difficult.
The Simplification of the Operation for Extraction of Cataract. —
Dimissas (lice. d'ophthal., March, 1891) recommends the following rules :
1. The easy and more extensive laceration of the capsule with the
knife should replace the employment of the capsulotome, ( 1) because
the operation is thus shortened; (2) because the source of possible
infection is suppressed, as the capsulotome is a difficult instrument
to clean. 2. The extrusion of the lens, following so soon after the
completion of the incision, is easily managed, and the removal of the
cortex is soon accomplished. Hence secondary cataracts are rare. 3.
The procedure thus preventing especially all late inflammatory acci-
dents, the first dressing may be left on the eye for a longer period.
Herpes Corneae in Influenza and its Treatment by Pyoctanin. —
Galezowski (Ree. d'ophthal., April, 1891) thinks that the healing of this
form of keratitis may be facilitated by the following means : Irrigation
of the cornea with a solution of yellow apyonin, and the administra-
tion of large doses of the sulphate or hydrobromide of quinine. He
uses a solution of apyonin or pyoctanin in the strength of one centi-
gramme to the gramme of distilled water, and bathes the cornea with
it five or six times a day. He states that this treatment gives excel-
lent and very rapid results.
Iritic Uveitis. — Grandclement (Ree. d'ophthal., May, 1891) thinks
that this form of inflammation of the uveal tract resembles pulmonary
pleurisy, and deserves a special name. He thinks it is caused by a
special micro-organism, and that it is best treated by excision of a por-
tion of the iris.
The Indications for Suture of the Cornea and Sclerotic. — Galezow-
ski (Ree. d'ophthal., April, 1891) thinks that suture of the cornea or
sclera, or both, should be employed (1) in certain grave accidents fol-
lowing the operation for cataract; (2) in all lacerations and perforating
wounds of the cornea; (3) in all wounds of the sclerotic. He has de-
vised special forceps and special needles fcr performing the opera' ion,
which have no advantage over similar instruments long since devised
and used for the same purpose.
A New Operation for Congenital Ptosis. — Gillet de Grandmont (Ree.
d'o/jhthal., April, 1891) describes his operation as follows : 1. After hav-
ing seized the upper lid with a Snellen's forceps, the skin is cut through
parallel to the free border of the lid, the incision being three or four
millimetres from the border and about two centimetres and a half long.
2. Raise up the two cutaneous flaps and detach and excise the corre-
sponding portion of the orbicular muscle, so as to expose the entire tar-
sus from the ciliary border to and including Sappey's orbito-palpebral
muscle or tendon of the levator palpebra1. 3. Cut through the entire
thickness of the tarsus, for an extent of two centimeties, parallel to the
free border of the lid, and from two to four millimetres from it. 4.
Describe a curvilinear incision, with concavity downward, exteuding
from one end of the first incision of the tarsus to the other. This in-
cision should extend through all the tissues of the lid, including the
conjunctiva. 5. The upper or orbito-palpebral flap should then be
stitched to the lower or tarsal flap by three sutures without touching
the skin.
The Curetting of the Lacrymal Sac. — Despagnet (Ree. d'ophthal.,
April, 1891) draws the following conclusions: 1. Whenever in a given
case epiphora is caused by catarrh of the lacrymal sac, the alteration
of the mucous membrane is the principal factor in the disease, and it
should be modified by probing and astringent injections. 2. If this
treatment fails to produce favorable results, curetting the mucous lin-
ing of the sac is indicated, rather than any other operative procedural
3. If the lacrvmation coexists with an exaggerated dilatation of the
sac, or mucocele, excision of a portion of the anterior wall should pre-
cede the curetting. 4. Curetting is also indicated in phlegmonous in-
flammation of the sac.
Dermoid Cyst of the Internal Wall of the Orbit.— Vignes (Ree.
d'ophthal , July, 1891) gives the following results of a macroscopical
and microscopical examination of a case of this nature: 1. The
seat of the pedicle of the cyst was the piano-frontal suture. 2. The
presence of the cyst could only be explained by the foetal inclusion of
the ectoderm within the fronto-maxillary fissure by the welding or
union of the external nasal bud and the maxillary bud behind the
lacrymal hiatus. 3. Neither fibrous nor any other band connected the
cyst with the skin. 4. The diagnosis of similar cysts might be difficult,
as they might be confounded with a lipoma, a fibroma, and even an
osteoma, h. Cysts develop more frequently on the external side of the
orbit than on the internal.
Tincture of Iodine in Infectious Ulcers of the Cornea. — Chibret
(Ree. d'ophthal., September, 1891) thinks he has found in tincture of
iodine the following necessary properties : 1. A powerful and general
antiseptic action. 2. Energetic dialytic power. 3. Absence of forma-
tion of insoluble salts causing indelible opacities of the cornea. 4.
Non-destructive effect on the cornea. He thinks his belief in the value
of this drug has been fully justified by the results, and he even recom-
mends its use in corneal scars and opacities.
The Visual Field in Epileptics and Mentally Deficient Patients. —
Lombroso (Ree. d'ophthal., August, 1891) draws the following conclu-
sions from his observations : 1. The visual field is remarkably limited
in epileptics and idiots. 2. There is a constant irregularity at the pe-
riphery of the field, and the line of demarkation appears irregular and
sinuous, sometimes forming actual peripheral scotomata of very incon-
stant location. 3. The field is more limited on the right side in the
lower hemisphere, and on the left side in the upper hemisphere, thus
forming a partial hemianopsia to the right below and to the left above.
This he calls a partial heteronymous vertical hemianopsia. 4. In some
cases there was an extreme limitation of the field due to neuro-retinitis.
5. In all, the field for color was limited, its form following constantly
that for white, but more or less regularly. 6. The field for blue and
that for red cross at different peripherical points. 7. In almost all cases
the ophthalmoscopic examination was negative. 8. The visual acuity
was entirely independent of peripheral vision.
Congenital Amblyopia. — Martin (Ann. d'oe., January-February,
1891) thinks that instead of placing the cause of congenital amblyopia
in an anatomical malformation or in the neutralization of a diffuse
image by the sensorium, we should regard it as the consequence of a
special anaesthesia of the retina. The rays which are not focused are
incapable of developing in this membrane the degree of sensibility
necessary for the occasion. In astigmatic amblyopia the visual trouble
is dependent on a partial anaesthesia of the retina. In a large number
of cases of congenital amblyopia the retinal anaesthesia is not the only
existing factor, for the visual defect is often increased by lack of use
(unilateral amblyopia) or by a retinal congestion (bilateral amblyopia).
The amelioration arising from the use of an eye which has been long
inactive is the greater the less pronounced is the visual defect due to
retinal anaesthesia.
The Indications for Simple " Resection of the Optic Nerve.— De
Wecker (Ann. d'oe , March-April, 1891) considers that the most impor-
tant point is the removal, not only of the eye, but of as much as pos-
sible of the optic nerve also, with prolonged and repeated disinfection
of the remains of the nerve and contents of the orbit. The next most
important indication is simple enucleation, without resection or disin-
fection. The third indication, if enucleation is declined by the patient,
is the resection of a large piece of the intra-orbital portion of the nerve,
followed by a disinfecting irrigation prolonged for some minutes.
Finally he considers the subject of simple local disinfection by intro-
ducing a few drops of sublimate solution within the shell of the eye.
He, however, regards the simple resection of the optic nsrve as a cer-
tain means of prevention of the occurrence of migratory ophthalmia.
The Question of Sympathetic Ophthalmia. — Abadie (Aim. d'oe.,
Feb. 27, 1892.]
REPORTS ON THE PROGRESS OF MEDICINE.
247
March-April, 1891) thinks that when an eye has been injured it may,
according to the nature of the infectious agent, become the seat of
phlegmonous inflammation, or it may be destroyed by infectious irido-
chorioiditis ending in atrophy ; or there may result a sympathetic oph-
thalmia. In the first case the cauterization of the wound with the
galvano-cautery is the only method of preventing suppuration. In
traumatic ophthalmia (infectious irido-chorioiditis) the cauterization of
the wound and intra-ocular injections may save the injured eye and
prevent sympathetic ophthalmia. Finally, even when a sympathetic
ophthalmia has recently occurred, if the injured eye is not entirely lost,
cauterizations and intra-ocular injections should be tried. If, in spite
of this treatment, repeated if indicated, the sympathetic ophthalmia
does not recede, enucleation must be done.
The Pathological Anatomy of Buphthahnia. — Kalt (Ann. cj'oc,
May-June, 1891) draws the following conclusions from his investiga-
tions: 1. Buphthalmia is the result of a very chronic irido-chorioiditis,
which causes a progressive obliteration of the vessels of the uveal
tract. 2. There results an intra-ocular supersecretion, the origin of
which is probably not in the cells covering the ciliary processes, as
most of these have been destroyed. 3. The existence of this super-
secretion must be admitted, since the channels of excretion are found
considerably enlarged. Hence we have to deal with glaucoma by re-
tention. 4. Eserine lowers the increased tension to the normal state.
General Considerations on Squint ; the Innervation of Convergence.
— Parinaud (Ann. d'oc, September, 1891) draws attention to the singular
fact that tenotomy has served to establish a theory which is erroneous
— namely, the muscular theory of the causation of squint. Most oph-
thalmologists regard the ocular affection as a physical phenomenon re-
lating solely to the eye and its muscles, without considering the influ-
ence of the brain in the matter. But the influences which produce
strabismus all rise in a disturbance of innervation. This, however,
is a special innervation, that of convergence, and the solution of the
question of strabismus can not be found until this innervation is recog-
nized and demonstrated. He lays down four main propositions, viz. :
1. Concomitant squint should be regarded as a vicious development of
the binocular visual apparatus. 2. Whatever impedes binocular vision
may become a cause of strabismus, and the younger the subject is, the
more likely is this cause to prevail. These causes are of two kinds,
one set being located in the eye and the other in the brain. The ocular
causes are errors of refraction, mechanical obstacles to motility, the
prolonged exclusion of one eye, etc. The cerebral causes are those af-
fections which impede the development of the brain in infancy.
Heredity is also a factor in strabismus. This is not only shown by
transmission of errors of refraction, but also by a defective cerebral
disposition to binocular single vision. 3. All causes of strabismus,
whether peripheral or central, act by modifying the innervation of con-
vergence, which is essentially the innervation of binocular single vision.
All that is attributed to weakness or congenital preponderance of cer-
tain muscles should be attributed to a hereditary defect of con-
vergence. 4. The primary causes of strabismus should be distin-
guished from those modifications which arise later. Parinaud concludes
by affirming that: 1. There is a special innervation of the ocular
, muscles for convergence. 2. The relations between convergence and
accommodation are established by means of this innervation. 3. The
change which should be established between these relations in ame-
tropic subjects, so as to admit of binocular single vision without correc-
tion of the ametropia, is produced by the brain.
The Mode of Development of Cyclopia. — Dareste (Ann. d'oc, Septem-
ber, 1891) concludes that in cyelopic monsters the production of a single
eye, the changes in the structure of the mouth, the atrophy and ab.
j normal situation of the olfactory apparatus, the arrest of development
of the vesicle of the hemispheres, are all the result of arrest of develop-
ment of the anterior cerebral vesicle. Cyclopia may be produced in
two different ways: 1. By a simple arrest of development, which may
affect the anterior cerebral vesicle as well as any other organ. 2. By
the compression exerted by the amnion arrested in its own develop
ment.
Bacteriological Researches in Cataract. — Dubief (Ann. d'oc, Sep-
tember, 1891) formulates the following conclusions from his investiga-
tions: All the surrounding conditions being rendered aseptic, if micro-
organisms exist in cataracts, they are few in number. The laving or
irrigation of the lens enables us to state that if the microbes exist,
they occupy the surface of the organ, and this particular location en-
ables us to assume an accidental contamination. Even the variety of
the micro-organisms found enables us to affirm that their origin is out-
side of the lens, and that they have been gathered there by the lens
itself or by the instruments used in the operation of extraction.
The Anatomy of Chronic Inflammation of the Conjunctiva.— Muter-
milch (Ann. d'oc, October, 1891) concludes from his investigations that
the only constant anatomo-pathological phenomenon accompanying all
cases of chronic inflammation of the conjunctiva, and which at the same
time is the cause of the production of pannus, the only characteristic
sign which should serve as datura for a rational classification, is the
alteration of the epithelium. The pathological process attacks only
the cells nearest the conjunctival surface, while the deeper cells remain
normal throughout the whole duration of the disease. There are three
stages of the process : 1. The stage of proliferation. 2. The stage of
superficial destruction. 3. The stage of total destruction.
The Anomalies of Convergence. — Von Millingen (Ann. e/'oc,
August, 1891 ) offers the following propositions lor consideration : 1.
Paresis of voluntary convergence is that form which is shown dv the
impossibility of converging on a very near point without the produc-
tion of latent divergent squint. Binocular vision exists, though with
somewhat difficult accommodation and accompanied by asthenopia. 2.
Paresis of visual convergence includes those cases in which, in spite of
excellent binocular vision, the power of voluntary convergence on a very
near point being preserved, accommodative convergence as a regular
act during ordinary vision is abolished, and gives rise to crossed diplo-
pia with divergent squint. 3. Paralysis of visual and voluntary con-
vergence is shown by the entire loss of the power of convergence,
whether voluntary or with accommodation. If these propositions are
true, we must conclude : 1. That the centers of convergence are con-
nected with the optical as well as with the cortical region, and that the
communication with one of these centers may be entirely intact, while
that with the other is interrupted. 2. That we must distinguish be-
tween visual and voluntary convergence, and must be able to tell in a
given ease which of the two is paralyzed.
Lymphatism and Trachoma. — True (Ann. d'oc, August, 1891)
draws the following conclusions from his investigations : 1. Lympha-
tism is the "clinical soil " of trachoma. 2. Lymphatism favors the
development and modifies the general appearance of granular ophthal-
mia. 3. Lymphatism, in its different grades, constitutes the various
granular formations which may be classified as lymphoid, fungoid,
sclerosed, or fibroid. 4. Lymphatism is the principal factor of granu-
lar lesions of the cornea. 5. Lymphatism is also the " clinical soil " for
phlyctenular or scrofulous ophthalmia. There are certain morbid
combinations in which granular ophthalmia exists with phlyctenular,
scrofulous, or lymphatic ophthalmia, and forms granulo-lymphatic
ophthalmia. 6. Lymphatism is the " clinical soil " for certain cases of
lacrymal keratitis. There are certain morbid conditions in which
granular ophthalmia, together with lacrymal ophthalmia, unite to
form a granulo-lacryraal ophthalmia. 7. Lymphatism favors the in-
fection and contagion of trachoma in proportion to its degree.
Two Cases of Total Achromatopsia. — Querenghi (Ann. rf'oc, No-
vember, 1891) has revised the histories of three cases published by
Landolt and two of his own, and draws the following conclusions: 1.
In all the five cases of total achromatopsia there was considerable reduc-
tion of visual acuity, which did not exceed one tenth for distance. 2.
In four cases nystagmus was present. 3. There was intense photo-
phobia in three cases. 4. The red of the spectrum and deep red in all
cases appeared as black. The other colors appeared as achromatic
lights of different intensity, according to the tone and degree of satu-
ration. 5. Next to white, yellow gave the most intense luminous sensa-
tion. 6. Those cases which recoguized the entire spectrum as a
source of light, all put the line of greatest brilliancy in the yellow.
Eye Disease of Miasmatic Origin. — Bagot (Ann. d'oc, November,
1891) reports the three following cases : The first was that of a young
man, aged fifteen, a mulatto, who had a severe attack of miasmatic
fever of the congestive type with intestinal complications. Immediately
after the height of this attack the vision became affected, and three
248
WE W INVENTIONS— MISCELLA NY.
[N. Y. Med. Joub.,
months later there was a soft cataract in each eye. These being re-
moved, normal vision was restored. The xecond case was that of a
mulatto woman, aged sixteen, who had a very severe attack of pahidul
fever, with cerebro-spinal symptoms, loss of consciousness, convulsions,
and delirium. The vision became affected, grew steadily worse, and
in nine months there was a fully developed soft cataract in each eye>
which was removed by operation and nor-nal vision was restored. The
third case was that of a young white girl who had an attack of per-
nicious miasmatic fever, with delirium, convulsions, and loss of con-
sciousness. On regaining consciousness, the child saw everything red
for twenty-four hours, and then became rapidly blind from retinal
haemorrhages and atrophy of the optic nerves.
The Introduction of an Artificial Vitreous Humor into the Scleral
Cavity. — Morgan (Arch, of Ophthal., xx, 1) reports six cases in which
he has performed this operation. The opening in the eye was enlarged
horizontally by removing two triangular pieces of the conjunctiva and
sclerotic, thus changing a nearly circular opening into a lozenge. The
haemorrhage continued about an hour and a half, and the "artificial
vitreous humor" was not introduced until it had ceased. A solution
of corrosive sublimate (1 to 5,000) or a hot saturated solution of boric
acid was used as an antiseptic. Some of the patients experienced no
pain, while others had but little pain or discomfort. The wound was
closed with six sutures of fine silk. Some of the patients have worn
their artificial eyes for one or two weeks without removal, and the con-
ditions in all six are satisfactory and appear to be permanent.
(7b be concluded.)
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Laceration of the Cervix Uteri and Pelvic Inflammation. — Emmet's
operation for the repair of laceration of the cervix and his ideas of the
pathogenic features of that injury have been so much decried, espe-
cially in Great Britain, that it may be wholesome if attention is called
to the following article, entitled The Pathogenesis and Treatment of
Oophoritis, by Dr. Robert Bell, senior physician to the Glasgow Hospi-
tal for Diseases peculiar to Women, published in the February number
ot the Edinburgh Medical Journal :
If we carefully look into the history of oophoritis and subsequent
hyperplasia of the ovary, we shall probably be led to the conclusion that
these conditions, as a rule, are secondary to a morbid condition which
has previously existed in the uterus ; that the ovarian mischief, in the
majority of instances, is dependent upon disease which has for some
time before been, and is no . coincident with that in the neighboring
organ. What, however, is of much greater consequence for us to be
assured of is that, if the morbid process has not proceeded too far in
the ovary, the organ can in many instances be re-established in health
pari passu with the recovery of the uterus. The question naturally
arises in these circumstances, What is the modus operandi of the dis-
ease process ? So far experience has distinctly taught me that when
oophoritis exists it has very frequently, if not always, been preceded by
endometritis. However, 1 do not pretend to be in the position to affirm
that the disease may not sometimes arise de novo ; but that the cases
where this occurs are few and far between is a subject on which I can
entertain no doubt, and it is because of this conviction that I have been
encouraged to persevere with the treatment advocated in this paper in
cases which, for a time, seemed to be quite intractable, but which,
though trying one's patience to the utmost, eventual!) yielded and re-
covered. It might possibly be demonstrated that the ovaries are more
frequently affected when the cervix is most seriously involved, but then
we must bear in mind that this portion of the uterine canal is liable to
suffer to a greater extent than the upper portion, as the whole of the
acrid discharges which are secreted there in endometritis must of neces-
sity pass over the cervical mucous membrane, and aggravate the dis-
ease that already affects and has induced hypertrophy, and probably ex-
coriation of it.
The fact, however, which compels me to suggest that endocervicitis
has more influence as a factor in inducing ovarian irritation than dis-
ease of the corpus and fundus uteri is that, on passing the applicator
through that portion of the canal, the pain consequent upon doing so is
generally referred to the affected ovary, demonstrating, I hold, a direct
nervous connection therewith. Then, again, we invariably find that
when oophoritis supervenes upon a laceration of the cervix, that it is
the ovary of the affected side which becomes involved, and the ovarian
disease does not yield to treatment until the laceration is repaired, or
the pendulous portions of the injured cervix removed. This coinci-
dence, however, may be due to the fact that the pathological condition
of the cervix has given rise to disease of the uterus as a whole, and that
the health of this organ can not be restored until the integrity of the
cervix has been re-established.
We are all aware of the intimate relationship of the uterine to the
ovarian circulation, and it is only natural to conclude that if the circu-
lation is interfered with in the uterus, which undoubtedly is the case
when endometritis is present, it must react upon the ovaries, whose
affluent and effluent vessels are continuations of those supplying the
uterus.
There is, however, another factor which plays a most important part
in the pathological process, that being the effect of the uterine irrita-
tion upon the sympathetic nervous apparatus, thus further influencing
the circulation through the medium of the vaso-motor system. Any
pjrsistent morbid process, like that which is present in endometritis,
must necessarily have a marked effect upon the sympathetic ganglia
from whence the vaso-motor filaments supplying the uterus are derived,
and as the ovaries and uterus are supplied from the same source, it
stands to reason that the circulation in the ovaries by reflex influences
must be materially affected. The result is that the hyperaemie condi-
tion of the uterus is reflected to the ovaries, producing a congested con-
dition of these organs. Such being the case, it is only natural to con-
clude that, if the original morbid condition is removed, the secondary
disease will also subside ; and such in point of fact is really what takes
place, provided the disease in the ovaries has not advanced too far. It
is, of course, difficult to decide right off when a case has advanced be-
MISCELLANY.
249
yond the reach of medical treatment and crossed the barrier beyond
which resolution will not be assured.
1 have, however, taken cases in hand when the ovary has been en-
larged to the size of a tennis ball, and have obtained most satisfactory
results after from three to six months' treatment. If cystic degenera-
tion of the organ has commenced, I need hardly say no treatment short
of operation will prove of any avail. The instances of ovarian disease,
however, which we constantly meet with, are, as a rule, so amenable to
the treatment I have adopted that it is hardly fair to the patient not
to give her at least the chance of being relieved by this method, and
thus avoid an operation which, even if it be successful, can not but be
humiliating to her.
With the view of demonstrating that the conclusions I have arrived
at are correctly based upon fact, let me devote a few moments to the
consideration of a lacerated cervix (say on the left side) and its effects.
Why is it, if this has occurred and the ovary becomes affected, that it
is invariably on the side upon which the laceration exists ? How is it
that the right ovary remains intact? In the light of the present day,
surely it is quite unnecessary for me to enter into any explanation on
this point. I have seen a considerable number of instances of ovarian
disease, a vestige of which did not exist prior to a confinement, develop
rapidly after that event, and in each case a laceration of the cervix was
discovered ou the side of the affected organ.
Moreover, notwithstanding what some authorities may assert, the
ovarian affection in every instance disappeared very rapidly after the
rent in the cervix had been repaired, and not till then. There is not
the slightest doubt that injury to the cervix is a fruitful source of dis-
i ease, not only in the uterus itself, but also in the ovary of the affected
side. Repair the cervix, therefore, and restore its health, when, in a
short time, if the disease has not advanced too far, the ovarian mischief
will subside and entirely disappear. If, on the other hand, the disease
of the cervix is idiopathic, the development of symptoms and of sequelae
will not be so rapid, and possibly the ovaries may escape altogether.
If, however, degeneration of the cervical tissue has supervened and
erosion taken place, from which surface a purulent discharge is given
off, then it is probable that the ovaries will become secondarily affected,
and their health will only be restored if the primary disease is first re-
moved. We should also bear in mind that, if cervical disease is per-
mitted to exist, it is not likely to end there, but will sprea^ by con-
tinuity of tissue to the whole extent of the endometrium, and possibly
to the tubes also. The walls of the uterus in consequence will become
hypertrophied and softened. Flexions will thus frequently be induced,
and interference with the venous circulation will arise which will tend
to aggravate the original mischief.
Now, to proceed to the treatment of such cases, it is hardly neces-
sary for me to state that in the event of the endometrium having be-
come affected, it will be essential, before the cervix can be permanently
relieved, that the condition of the former be simultaneously attended
to. Otherwise, as I have before remarked, the acrid discharges, which
invariably have their source in endometritis, would continue to flow
over the cervical mucous membrane and maintain the irritation which
previously existed, and this in spite of all the treatment that might be
applied to it per sc.
To illustrate my method of treating such cases, I will detail two
typical instances of oophoritis — one depending upon laceration of the
cervix, the other upon idiopathic disease. I take these two cases be-
cause both occurred in young women ; and there can be no doubt of
their history, as J have known the patients for over fifteen years, and
have attended them during a period which extends for a considera-
; ble time prior to and after their marriage, both before and after they
\ were the subjects of ovarian disease, and also after .this had been re-
moved.
Mrs. S., after a somewhat tedious labor, was delivered of a boy con-
■ siderably above the average size. She made a good recovery, but some
six months afterward complained of a severe pain in the left side, which
was aggravated on any exertion. There was a feeling of bearing down
' and a copious vaginal discharge of a muco purulent character. Over
the site of the left ovary there was considerable pain on pressure. On
' a vaginal examination being made, the cervix was discovered to be
lacerated on the left side, the rent extending throughout the whole of
the vaginal portion. Endometritis also existed, and the uterus was re-
troflexed and hypertrophied. The course adopted was to treat the en-
dometriiis by the intra-uterine application of iodized phenol and vagi-
nal tampons of the glycerin of alum and boracic acid. When the endo-
metritis had subsided somewhat, trachelorrhaphy was done — with the
result that in three months the uterus had regained its health, while the
ovary returned to its normal size, and all pain and inconvenience had
ceased.
The other case is that of a young married lady, Mrs. H., who had
suffered intensely from dysmenorrhuea and copious leucorrhoea for a
considerable period previous to her marriage. Though I did not make
an examination then, I was convinced that endometritis was present,
this having been induced by attending dancing parties night after
night, quite irrespective of the fact that frequently she was menstruat-
ing at the time. Menorrhagia also existed, which was induced by the
same reckless conduct. After marriage her symptoms became aggra-
vated, and sh° came to me complaining of intense prostration, both
mental and physical, while pain on the least exertion was very acute
over both ovaries and in the back. Defecation was very painful, and
there was a profuse muco-purulent discharge. On examination, both
ovaries were found to be enlarged and hypersensitive to touch. The
uterus was retroflexed, and there was metritis. Dyspareunia also ex-
isted to a prohibitive extent. She was put under treatment, which con-
sisted of the weekly application of iodized phenol to the endometrium,
and each time the uterus was restored to its normal position, and re-
tained there by means of tampons soaked in glycerin of alum and
boracic acid, which were renewed in three days and fresh ones inserted.
In less than four months all trace of discomfort had disappeared ; the
uterus remained in situ, and the ovaries were reduced to their normal
size, and within a year afterward she became pregnant.
There would be no difficulty in citing any number of additional
cases to illustrate what I have endeavored to describe as one of the
most potent factors of oophoritis, and to demonstrate what happy re-
sults can be attained by the employment of suitable measures for the
restoration of the uterus when disease of this organ is concomitant
with oophoritis.
I do not, however, wish it to be inferred that I hold oophorectomy
can always be avoided; but at the same time I can not refrain from
stating as my firm conviction that in many instances it maybe avoided
if the treatment I advocate receives an honest trial.
Laboratories of Hygiene. — On the occasion of the opening of the
new laboratory of hygiene of the University of Pennsylvania, on Mon-
day of this week, an address was delivered by Dr. John S. Billings, of
the army. By the courtesy of the editor of the Medical News, in which
the address is to be published in full, we are enabled to give the follow-
ing extracts :
Laboratories planned and fitted for public use, offering to any one
who is able and willing to pay a moderate fee and to submit to a few
simple regulations, not only opportunities for learning the details
of the processes carried on therein, but facilities and means for mak-
ing special research as he could only obtain otherwise at great expense
and loss of time — such laboratories, I say, are all of comparatively re-
cent date.
It is not yet twenty years since the first separate institution of
this kind was established for Hygiene — and even now there are not
more than a dozen such laboratories, specially built and fitted for their
purpose, in existence throughout the world. Of these the best known
is probably that of the University of Munich, under the direction of
Professor Pettenkofer, while the largest is that of Berlin.
This laboratory is the first structure of its kind erected in the
United States, and it therefore opens a comparatively new field of
work in this country. What is the nature of this field and what are its
boundaries ?
The object of hygiene is to preserve and to improve health, and
there are few matters affecting the physical, intellectual, emotional, and
moral condition of man as an individual, or of men in communities,
that may not come within the scope of its investigations. The de-
struction or avoidance of causes of disease is but a part of its objects —
it is at least equally concerned with the means of making a man bet-
250
MISCELLANY.
[N. Y. Med. Jode..
ter fitted to resist these causes. " That kind of health," says Montes-
quieu, " which can be preserved only by a careful and constant 1 emula-
tion of diet is but a tedious disease." Disease, like health, is a vague
term, including widely different and often very complex conditions,
processes, and results, which must be observed, classified, and de-
scribed in such a way that different men, widely separated in space and
time, may know that they are seeitig the same things, and thus may
have the benefit of each other's experience.
In its scientific aspects, fien — those which relate to definite and
precise knowledge — hygiene rests largely on physiology and pathology,
the third leg of the tripod being formed by vital statistics ; while in its
practical aspects it must rest on chemistry, physics, and the dat i of
sociology and politics.
At any given time, therefore, its scope and practical value must
depend largely upon the breadth and solidity of the foundations which
these various branches of science can provide for it. The opinions of
the medical faculty of Paris as to the causes of the " black death,"
and the advice which they gave as to the means for lessening the
" great mortality," absurd and preposterous as they now appear to
us, were yet fully in accord with the knowledge and opinions of the
time.
At the beginning of this century physicians did not distinguish
with any certainty between typhoid, typhus, and malarial fevers, or
between consumption and various other chronic diseases of the lungs,
and until this was done investigations into the causes of these affec-
tions were necessarily almost fruitless.
When, however, a clew is once given to the student of causes, he
may be able, by detecting differences in these causes, to call the atten-
tion of the pathologist to differences in the results, and thus the
bacteriologist, by proving specific differences in micro-organisms, all
of which produce fever, suppuration, etc., induces closer study of de-
tails of cases by physicians, and the recognition of new and more
clearly defined groups of symptoms and results, or, in other words, of
new diseases.
We live in an age of specialization. Progress in science, as a
whole, depends upon special progress in each of its branches. Our
present knowledge of physiology depends largely upon the perfection
of electrical methods. Pathology and pathological bacteriology are
now waiting for increase of knowledge in organic chemistry. The law
of evolution applies to this as it does to modern industrial progress.
The physician deals with sick men, and his first question is, What
is the matter with this person ? That is, what group of symptoms
does he present, and to what derangement of his mechanism are these
due ? The hygienist deals with two sets of problems — the first relat-
ing to men who are not sick, and how their health and vital resistance
power are to be not only preserved, but improved and strengthened ;
the second relating to sick houses, feverish blocks or wards, infected
localities — where the first questions to be solved are : What are the
causes of this condition of things ? How have they found entrance ?
Are they still acting ?
In the investigation of causes he must consider not only the imme-
diate or exciting, but also the remote or predisposing; not only those
which are preventable, but those which, with our present knowledge,
are unpreventable ; and thus it is that heredity, race, local meteorology,
occupation, and many other circumstances must be studied by him,
as well as the effects of food, clothing, habitation, poisons, and
viruses.
The recent advances in our knowledge as to the action of certain
micro-organisms in the production of disease in animals and man have
been largely made by laboratory methods, and indicate clearly that the
study of bacteria and microzoa, and of their development, products, and
effects, must be an essential part of the work of a hygienic laboratory,
which should provide the peculiar arrangements and apparatus which
are required for this sort of work. In fact, several so-called hygienic
laboratories are simply bacteriological laboratories, the interest in this
particular branch of investigation having, for the time being, over-
shadowed all others.
Our laboratory, however, must provide also the means for chemical
investigations of air, water, food, sewage, secretions and excretions, and
the products of bacterial growth ; for testing the effects of gases, alka-
loids, and albumoses of various kinds upon the animal organism ; for
investigations in the domain of physics pertaining to heating, ventila-
tion, house drainage, clothing, soils, drainage, etc.
Just at present research is being specially directed to certain minute
animal organisms — the microzoa — such as are found in the blood in
malaria and in the skin in certain diseases, and to immunity, especially
to that immunity which may be artificially produced.
Experimental investigation is a slow process, and very uncertain in
its results. An experiment may be conceived which seems as if it
would give important results. The experiment itself would lequire only
a few moments or a few hours if all the apparatus were ready to pro-
duce the required conditions, and to record in terms of weight and meas-
ure the results obtained. But to make this apparatus in the best form,
and to provide the means of recording, may take a year or more, and
in making this preparation a dozen problems will come up to be solved
by other experiments.
You are pretty sure to discover something new, but by no means
sure that it will be what you began to seek. Every discovery opens new
questions and indicates new experiments, and the precise shape in which
the work presents itself varies with place and season.
We can not foresee precisely the demands which will be made upon
us, or which we shall make upon ourselves, but we do know that we
shall want some large rooms in which a dozen or twenty men can be at
one time taught how to investigate, working under the eye of an in-
structor; and also a number of small rooms, each fitted for the work
of one or two men who have attained a certain amount of skill, and are
engaged in original research. In all these rooms we shall at times need
to use microscopes, gas-heating, and steam ; there will be vapors and
fumes produced ; there will be delicate instruments scattered about, and
the rooms must therefore be light, have abundance of gas, steam, and
water, hoods and flues for conveying away fumes, and plenty of fresh
air without dust.
Many of the things that will be seen through the microscopes will
be rapidly changing form, and we shall need pictures as well as descrip-
tions of their different shapes.
The most useful drawings for our purposes are those made by sun-
light, and therefore we want photo-micrographic rooms.
We shall wish to test the merits of various articles of house-equip-
ment, such as different patterns of steam radiators, traps, sinks, closets,
etc., and for this purpose we must have places where they can be fitted
and put into use.
We must know what other investigators in other laboratories, and
many places besides laboratories, have done and discovered, that time
and effort may not be wasted.
We must therefore have the books and journals in which these are
recorded, which are already many, and coming rapidly. A small library
and reading-room is therefore essential.
Much of the apparatus to be used must be either made or specially
fitted and adjusted on the spot to meet special indications which it is
impossible to foresee, and therefore we need a large workshop, with
tools and appliances for working in wood, glass, and metal, and with
power.
After describing the new laboratory, Dr. Billings continued as fol-
lows :
We hope that some increase of knowledge will be made here by the
workers in the laboratory itself ; but the main point to be kept in view
is to provide well-trained, scientific, and practical men for other fields
of labor. Dr. Mitchell has said that the true rate of advance in medi-
cine is not to be tested by the work of single men, but by what the
country doctor is. So, also — and even more so — advance in practical
sanitation is not to be measured by laboratory records, but by what
health officers and sanitary engineers are able to accomplish.
Even now we know much more than we do, and the skilled sani-
tarian too often finds himself in the position of the unhappy daughter
of Priam and Hecuba, who could foretell, hut to no purpose.
This laboratory is fortunate in being closely connected with, and in
the immediate vicinity of, a great medical school, and of great hos-
pitals. As was said before, one of the essential foundations of scien
Feb. 27, 1892.]
MISCELLANY.
251
tific knowledge of the cause* of disease is minute and accurate diag-
nosis and pathology, and we are therefore in constant need of the best
knowledge of leaders in these branches of medical science. The hos-
pital is filled with specimens of the results of such causes, acting on
the human body — from one point of view, Nature's experiments with
poisons cunningly elaborated in the tissues of the body, or with viruses
coming from without, upon blood and bone, muscle and brain. Much
of the work of this new department will be connected with the results
of these experiments.
The laboratory is also fortunate in being located in a great manu-
facturing city, where the effects of different occupations, of trades
dangerous or offensive by reason of dusts, or of vapors, or of waste
products, can be readily observed and the materials for study obtained.
There is an immense field for a sanitary clinic here, and in the habita-
tions, the streets, the water-supply, and the sewers of Philadelphia.
These clinics, however, can not, as a rule, be reported for the press,
either lay or medical, since to do so would, to a great extent, defeat
their object; the great majority of the sick in houses and manufac-
tories must be considered as strictly private patients, and their affairs
held as confidential. In the case of public institutions, or of public
nuisances, a somewhat different rule may apply.
Practical hygiene is to play an important part in municipal govern-
ment, to secure the best form of which is now one of the most urgent
questions of the day. Many of the questions to be decided by city
officials as to water-supplies, sewage disposal, etc., require expert
knowledge to answer.
Of course, the subject of hygiene and the work of a university de-
partment devoted to the increase and diffusion of knowledge in sanitary
science extends far beyond the experiments and demonstrations for
which this laboratory is specifically fitted.
Bacteriology, chemistry, pathology, physics, and medical and vital
statistics give us the foundations, but sociology and jurisprudence
must also be studied in their relations to sanitation to obtain the best
results.
It is in and to the home and the workshop that these results are to
be applied, and he who aspires to be his brother's keeper must know
how his brother lives.
Labor questions, education questions, maritime and inter-State com-
merce questions, and methods of municipal finance and government are
all intimately connected with matters of personal and public hygiene,
and economic consequences, as well as health, must be considered in
the advice and regulations of the sanitarian.
I count it as fortunate, therefore, that there is a law school and a
school of finance and political economy in this University to which the
Department of Hygiene can look for advice and friendly criticism when
these are needed, as they surely will be.
And now a very few words as to the needs of the laboratory. First
of all, it needs men — men thirsting for knowledge, and fitted by pre-
vious training and education to come here and acquire that knowledge,
not merely the knowledge that exists in books or that the teachers in
this laboratory may possess, but that which is vet unknown, the weight
of that which no one has yet put in the balance — the shape, and size,
and powers for good or evil of things whose existence has not yet been
demonstrated — men who will patiently and earnestly seek the answers
to the questions, " What ? " " When ? " and " How ? " in the hope that
thus they may by and by obtain some light upon the more difficult prob-
lems of " whence? " and " whither? " even if they may never be able to
answer " why ? "
There are not many such young men whose tastes will be in the di-
rection of these lines of research, and of these there will be very few
who will have the means to support themselves while engaged in the
work. We need, therefore, the means to help them in the shape of
half a dozen fellowships, paying about five hundred dollars a year each,
and granted only to those who give satisfactory evidence of capacity
and zeal.
The second thing we want is a demand on the part of the public for
really skilled, well-trained sanitary investigators and officials such as
we hope to send out from here ; we want a market for our product; we
want the legislators of this and other States, and of our rapidly grow-
ing municipalities, to be educated to appreciate the importance and
practical value of such health officials, and to give the best of them
employment.
Thirdly, the laboratory wants the co-operation and assistance of
sanitary authorities and inspectors, and especially of those of this city
and State.
It needs to know from time to time what they are interested in and
are working at, to have the opportunity of showing to its students cases
of special interest — sick houses, localized epidemics, special forms of
nuisance.
And, on the same principle and for the same reasons, it desires to
have its attention called to special methods of heating, ventilating, and
draining buildings, and especially public buildings, such as schools,
hospitals, prisons, churches, and theatres, and to matters connected
with the hygiene of manufacturing establishments and special occupa-
tions, methods of disposal of offensive or dangerous waste products, of
protecting workmen against dusts, gases, etc.
In short, we want to know how these things are managed by the
men who have a practical interest in them; and if, in our turn, we can
suggest improvements, we shall be glad to do so.
Fourth, the laboratory wants a reference library as complete as it
can be made, and always up to date. Many of the books and journals
required must be purchased, and for this purpose a special fund is
needed, but many of the works required can only be obtained by gift.
Thus we want all the reports of boards of health — State and muni-
cipal— of municipal engineers, water-works and water commissioners,
park commissioners, etc.
We want the catalogues and circulars of all manufacturers of heat-
ing and ventilating apparatus, of plumbers' supplies and house fixt-
ures, of electric and gas fixtures, of machinery and apparatus connect-
ed with water-supply and sewage disposal.
We want copies of plans and specifications of large buildings of all
kinds.
And these things can only be obtained through the aid and good-
will of manufacturers, engineers, architects, and sanitarians all over the
country ; and this aid I venture to ask, feeling sure it will be granted
by those who know what is wanted.
I will mention but one more special want to-day, and that is of
means for the proper publication of illustrated reports and accounts of
the work done in the laboratory.
In the mean time we must be patient, and not too eager to touch the
fruit of the blossom that is not yet blown.
The Anatomical Lesions of Amoebic Dysentery. — At a meeting of
the Johns Hopkins Hospital Medical Society, held on October 19, 1891,
the proceedings of which are published in the Johns Hopkins Hospital
Bulletin for January and February, 1892, Dr. Councilman exhibited the
colon from a case of amoebic dysentery. The patient, a man, aged
twenty-five, was admitted to the hospital on September 1 1th. Four
weeks before admission he was attacked with pain in the abdomen and
diarrhoea. He had six or seven fluid stools daily without much pain.
The diarrhoea continued up to death, which occurred on September 21st.
Most of the time the stools were of a greenish-yellow colcr, but several
times in the last days of his illness they were almost entirely pure
blood.
The body was that of a slightly built, tolerably well nourished man.
The mucous membranes were very aniemic, the muscles pale and soft.
On opening the peritoneal cavity there was no escape of gas. The parie-
tal peritonaeum was cloudy and covered with a very slight fibrinous exu-
dation ; there were a few eechymoses scattered over it. The intestines
were covered with the adherent omentum. On lifting this there was a
free escape of gas from a cavity between the colon, the adherent omen-
tum, and the coils of small intestine. The walls of the cavity were
covered with a dirty yellowish membrane. It contained a quantity of
putrid pus mixed with faecal matter. Outside of this cavity the coils of
intestine were lightly adherent and there was some exudation, which
was best marked at the line of adhesion. The exudation was fibrinous,
rather gelatinous, and transparent. The mesenteric glands were slightly
enlarged. The liver was firmly adherent to the diaphragm by fresh ad.
hesions. The diaphragm on the right side extended to the fourth inter-
costal space; on the left to the lower border of the fifth rib.
252
In both lungs there were small foci of catarrhal pneumonia. The
heart was normal.
The liver was large, 24 x 19 x 8 ctm., anil weighed 1,892 grammes.
The capsule was smooth. The color was a pale brown and the lobules
were only visible in places. Scattered over the surface there were
numerous small, white, opaque areas which were not surrounded by a
zone of hyperemia and not elevated above the surface. On section,
small areas similar to those on the surface were found scattered through
the organ. They varied in diameter from 1 to 5 mm. A dry caseous-
like material could be squeezed from them, leaving a ragged wall.
The spleen, kidneys, pancreas, and adrenal glands were normal.
The large intestine was generally adherent by fresh adhesions. The
cavity mentioned between it and the adherent loops of small intestine
communicated with the lumen by a ragged opening 1 ctm. in diameter.
The entire intestine was soft and tore easily on attempting to remove
it. Its walls were thickened and it was greatly dilated, the average
circumference being 14 ctm. It contained numerous ulcers and ex-
tensive sloughs from the cecum to the anus. In the cecum there were
numerous round elevations with a small opening on the surface. There
were also large irregular ulcers filled with a grayish, transparent ma-
terial, on removal of which the muscular coat was seen. In the trans-
verse and descending colon and in the rectum there were large irregular
ulcers covered with dark sloughs. On removal of the sloughs the
transverse muscular coat was laid bare, and in places the ulceration had
extended through this to the longitudinal muscular coat or to the peri-
toneum. All the ulcers were greatly undermined. The coats of the
intestine were thickened and cedematous. There were elevated ridges
which often passed from one ulcer to the other, and they contained the
same whitish transparent material as the ulcers. Numerous actively
moving anuebe ivere found in the intestinal ulcers, in the peritoneal
exudation, and in the liver abscesses.
This case, the speaker said, was of interest from a number of points
of view. The history showed a much more acute illness than in the
other cases seen in the hospital, and there was not the inteimittence
which was so marked a feature in some cases. The abscesses of the
liver differed from those in other cases in their great number, their
small size, and their general distribution. Were it not for their size
they might be taken for tubercles, the dry contents being more similar
to the caseous material of a tubercle than to the contents of an abscess.
In this case there could be little doubt that the amcebe must have
reached the liver by the blood-vessels and not by the peritoneum. In
most cases the situation of the abscesses seemed more easily explained
by supposing that the auinebe had passed into the liver from the peri-
toneal cavity.
On examination of the tissues after hardening in alcohol, the liver
abscess contained cell detritus, and at the edges there was a consid-
erable degree of purulent infiltration. There were numerous foci of
necrosis extending from the abscess and scattered through the liver.
There were numerous ama'b;e in the abscess contents.
In the ulcers in the intestine there were numerous ama'be, both in
the material in the ulcer and in the surrounding tissues. The character
of the ulcers was typical of this form of dysentery.
Particular attention was paid to the lymph-glands. Numbers of
those in the mesocolon were examined. Some of these were adherent
to the intestines, and the ulceration had almost extended to them. In
none of them were any amoeba; found. The only alteration consisted
in a slight hyperplasia and a marked increase in the large cells of'the
sinuses.
In the study of the tissues there had been in general the best results
after hardening in alcohol and staining the sections with an aqueous
solution of safranin, although other methods would give some results
not attainable by this. The amtrbii! were better preserved by harden-
ing in Miiller's fluid, but this did not give such good results for the
tissue of the intestine. The safranin stained the nuclei of the amceb'sB
and made their recognition easier. Under any circumstances the
am<eba? might easily be overlooked, or the large swollen cells in the sub-
mucosa and in the sides of the ulcers might be mistaken for them.
They could best be recognized after this staining by the marked vesicu-
lar type of the nucleus. It appeared generally as a bright Stained ring
with small knob-like projections on the inside. The nucleus did not
[N. Y. Med. jOocb.
stain in hematoxylin or carmin or in any of the aniline fluids generally
used. In specimens stained by the Weigert method, here and there a
faintly stained nucleus could be found, but they were nearly all de-
colorized.
The Eush Medcial College, Chicago.— The registrar, Dr. E.
Fletcher Ingals, announces that a concours will be held at the college
beginning on Tuesday evening, March 1st, for the purpose of filling the
positions of lecturer on anatomy and on materia medica and therapeu-
tics in the spring faculty. The spring course begins on March 31st,
directly after the close of the regular term, and continues for two
months with a class of from 250 to 300 students, thus affording an
excellent opportunity to exercise their skill as teachers.
It is the policy of the college, so far as practicable, says Dr. Ingals,
to fill vacancies in the regular faculty from the corps of spring in-
ductors. Nine of the present members of the regular faculty have
been selected in this way.
The concoiirs will consist of twenty-minute lectures by each of the
applicants before the faculty, students, and local profession upon sub-
jects pertaining to their branches, which will be furnished by the pro-
fessors of anatomy and of materia medica and therapeutics a week be-
fore the contest.
To Contributors and Correspondents. — The attention of all who purpose
favoring us with communications is respectfully called to tlee follow,
ing:
Authors of articles intended for publication under l/te head of " original
contributions " are respectfully informed that, in accepting such arti-
cles, we always- do so with the understanding that the following condi-
tions are to be observed: (i) when a manuscript is soil to this jour-
nal, a similar manuscript or any abstract thcrtof must not be or
have been sent to any other periodical, unless we are specially notified
of the fact at the time tlie article is sent to us ; (£) accepted articles
are subject to the customary rules of editorial revision, and will be
published as promptly as our other engagemads will admit of — we
can not engage to publish an article in any specified issue ; (3) any
conditions which an author wishes complied with must be distineff}
stated in a communication accompanying the manuscript, and n<-
new conditions can be considered after the manuscript has been put
into the typesetters'' hands. We are often constrained to decline
articles which, although they mag be creditable to their authors, are
not suitable for publication in this journal, either because they arc
too long, or are loaded with tabular mutter or prolix histories of
cases, or deal with subjects of li/'le interest to the medical profusion
at large. We can not enter info any correspondence concerning our
reasons for declining an article.
All letters, whether intended for publication or not, must contain the
writer's name and address, not necessarily for publication. No at-
tention will be paid to anonymous communication*. Hereafter, cor-
respondents eisking for information that we are capable of giving,
and that can properly be given in this journal, will be answered by
number, a private communication being previously sent to each cor-
respondent informing him under what number the answer to his note
is to be looked for. All communications not i tit ended for publication
under the author's name are treated as strictly confidential. We can
not give advice to laymen us to particular cases or recommend ituli-
vidual practitioners.
Secretaries of medical societies will confer a favor by keeping us in-
formed of the dates of their societies' regular meetings. 'Brief notifi-
cations of matters that are expected to come up at particular meet-
ings will be inserted when they arc received in time.
Newspapers and other publications containing matter which the pjerson
sending them desires to bring to our notice should he marked. Mem-
bers of the pro fession who send us in formation of matters of interest
to our readers will be considered as doing them and us a Javor, and,
if the space at our command admits of it, we shall take pleasure in
inserting the substance of such communications.
All communications intended for the editor should be addressed to him
in care o f the publishers.
All communications relating to the business of the journal should be ad-
dressed to the publishers.
MISCELLANY.
THE NEW YORK MEDICAL JOURNAL, March 5, 1892.
Original Communications.
RESECTION OF THE POSTERIOR BRANCHES
OF THE FIRST THREE CERVICAL NERVES FOR
SPASMODIC WRYNECK ;
WITH REPORT OF A CASK*
By CHARLES A. POWERS, M. D.,
BURGEON TO THE OUT-PATIENT DEPARTMENT, NEW YORK HOSPITAL.
In February, 1891, Mr. R. was sent to me by Dr. R. W.
Amidon, to whom he had been referred a few weeks previous-
ly by Dr. F. Iluber, for an opinion regarding a spasmodic
affection of muscles of t lie neck. The patient was a heavily
built, muscular man, of thirty-seven years. He had never suf-
fered with syphilis, rheumatism, or other constitutional disease.
He had been, from boyhood, excessively "nervous and restless,"
starting violently when suddenly surprised, and trembling at the
slightest injury or fear of danger. His father had always mani-
fested the same nervous conditions, and in a marked degree.
Two years and a half previously he had first noticed a slight
twitching of the muscles of the right side of the neck. This at
that time was confined to a very moderate spasm, which carried
the head to the right side. It was manifested only when he
was suddenly startled or when he was much fatigued. These
spasms gradually increased, however, both in frequency and in
degree, and when lie came under observation they were very
marked. He had been given various drugs, electricity, and the
like, by several different physicians, no measures being attended
by permanent improvement. He was subjected to medical treat-
ment by Dr. Amidon, and, this being without effect, be was re-
ferred to me, as said, for operative procedure.
The patient presented a rather senile look, stooping, and
throwing the head well forward. When left to itself the head
was spasmodically rotated to the right to its fullest extent The
patient could carry it back by pressing the chin over with the
hand, but when the restraining force was removed it was im-
mediately jerked back to its rotated condition. These spasms
were constant during the day, but were worse when the patient
was fatigued, irritated, surprised, or among strangers. The
right hand was constantly upon the chin, and the patient was
unable to use it in work or even at table. The right shoulder
was not elevated, there was no sp;ism of the muscles of the left
side, and the right trapezius, sterno- mastoid, and scalenus anti-
cus seemed free from implication. The patient's neck was large,
thick, and short; it seemed somewhat fuller on the right side,
posteriorly, than on the left.
The spasmodic movement seemed to be a rotation of the
atlas upon the axis. When it took place an increased fullness
could be felt in the region just below the occiput and covered
by the trapezius, although no contraction could be perceived in
that muscle. The patient himself said that he " felt jerks in the
deep muscles at the back of the neck." After very careful ex-
amination Dr. Amid<>n considered the affection to be confined
to the posterior rotators, and recommended division or resec-
tion of the nerves supplying them.
I had but very recently read an article t by Dr. W. W. Keen,
of Philadelphia, in which he described in detail the steps of an
* Read by invitation before the New York Neurological Society j
December 1, 1891.
\ Annals of Surgery, January, 1891. The procedure followed by
me is, in the main, that advised by Keen.
operation formulated by him for the division of the posterior
branches of the first three cervical nerves.
After familiarizing myself with the anatomy of the part by
dissection on the cadaver,* I proceeded upon the patient as fol-
lows: The occipital region was shaved and the parts were pre-
pared in the usual way. The man was anaesthetized and placed
flat upon his abdomen, the head projecting over the end of the
table, and so held that the external occipital protuberance was
in a straight line with the vertebral spinous processes. A three-
inch transverse incision was made at the back of the neck, be-
ginning at the median line an inch and a quarter below the
external occipital protuberance and running forward. This was
subsequently enlarged until it measured four inches and a quar-
ter in length. The parts were divided through the trapezius and
the posterior border of the splenius, until the complexus was
reached and recognized, the trapezius being dissected up from
it. After some difficulty the occipitalis major nerve was found
at the upper part of the complexus and outside of the intra-
muscular aponeurosis of this muscle. Preserving the nerve, the
complexus was divided transversely, after which the nerve was
followed back to the posterior branch of the second cervical be-
fore that nerve gave off the filament to the obliquus inferior.
The inferior oblique muscle was then found, passing from
the tip of the transverse process of the atlas to the spinous pro-
cess of the axis; also the superior oblique and the rectus capitis
posticus major, the three bounding the suboccipital triangle, in
which was discovered the suboccipital nerve lying in close rela-
tion with the vertebral artery. The nerve was followed back
to its exit from the spinal canal, between the occipital bone and
the posterior arch of the atlas.
Following down beneath the complexus, the external branch
of the posterior division of the third cervical was found. This
was followed back to the bifurcation of the main trunk. One
had at command, then, the nerve supply to the inferior oblique,
the rectus capitis posticus major, and the splenius, the three
posterior rotators, the first beinn supplied by the first and sec-
ond cervical, the rectus by the suboccipital from the first cervi-
cal, and the splenius by the second and third cervical.
Each nerve was followed well back to the spine and a half
to three quarters of an inch excised from each of the three.
Buried muscular sutures were inserted, a drainage-tube laid to
the bottom of the wound, and the skin sewed up. A large anti-
septic dressing was applied and the head fixed in moderate ex-
tension by plaster. The operation consumed nearly two hours,
the dissection being necessarily carried on slowly and carefully.
I have already said that the patient's neck was very short and
thick. The deeper muscles seemed enlarged and dense. The
wound was deep, yet the length of the incision gave access to
its bottom, and the light from a window was amply sufficient to
enable one to see clearly. The recognition of the occipitalis
major, running as it does in the direction of the fibers of the
complexus aponeurosis, was not easy. It was only after follow-
ing out several strands of fascia that I found the nerve. The
suboccipital lay deep, yet was found far more easily than the
third nerve, which was beneath the lower part of the com-
plexus. The haemorrhage was slight, yet oozing was at times
troublesome. The abdominal position of the patient made the
administration of the anaesthetic difficult, yet his condition re-
mained at all times good.
On coming out of the anaesthetic the patient had no spasms
of the neck ; the head was in the median line, ami remained
* For this opportunity I am indebted to Dr. L, W. Hotchkiss,
Assistant Demonstrator of Anatomy at the College of Physicians ami
Surgeons, who kindly assisted at the operation.
254-
POWERS: RESECTION OF NERVES FOR SPASMODIC WRYNECK. [N. Y. Med. Jot;
there until the final removal of the dressings. The wound healed
per prima m throughout, the tube was removed on the fifth day,
and all dressings were taken off at the end of ten days. At
tchis time there were a few slight spasms, but they did not per-
sist. Directions were given regarding massage and the like, but
they were disregarded, and the head gradually assumed a posi-
tion of contraction, with the face drawn to the right.
The patient escnped from observation and was not seen until
during the past month, when he was examined by Dr. Amidon
and myself, and, at our request, by Dr. C. L. Dana. The pres-
ent condition is as follows: When the patient stands erect, the
right acromion is on a plane an inch and a half to two inches
above the left. The head is carried in a position of rotation to
the right, and lateral inclination a little downward to the same
side. Voluntary rotation to the right is normal, and when the
head is in this position it can, witli effort, be returned to the
median line by the right sterno-mastoid ; hut effort to carry it
beyond this and to the left is attended with difficulty, and seems
antagonized by deeper muscles of the right side. Extension of
the head is very nearly normal, .and, when it is thus extended,
rotation to either side is free and unrestrained. Flexion of the
head on the chest is nearly normal, but when in position of
flexion, rotation to the left is most difficult. The head can be
drawn toward the shoulders more freely on the right side than
on the left. There seems to be a tonic spasm of the anterior
fibers of the right trapezius, and a hard, tense cord can bo felt
between the trapezius and sterno-mastoid ; this is apparently
the levator anguli scapula. There is a scoliosis of the cervical
vertebrae, the convexity of this being to the left, above. There
is a skin " fold " where it laps over on the rigbt side of the neck,
and beneath this fold lies the cicatrix, the line of which is hardly
noticeable. There is a fairly marked depression at the site of
the outer third of the cicatrix.
From the fact that rotation is free when the head is extend-
ed, it seems probable that there is a tonic spasm or permanent
shortening in the splenitis. The patient has no pain or spas-
modic movements, and, in spite of his present contracted wry-
neck, he expresses himself as feeling that his condition is vastly
better than it was before the operation.*
As stated in the foregoing, the operation for systematic
division of the nerves supplying the posterior rotators was
first formulated by Keen, who, in addition to his painstak-
ing work upon the cadaver, has had a single opportunity to
carry out the procedure upon a living subject.
His patient was a woman, fifty-four years of age, who first
came under the observation of Dr. Francis X. Dercum,t March
27, 1886. She then stated that for two years past she had suf-
fered from involuntary rotation of the head toward the left shoul-
der. The movement frequently recurred during conversation.
The chin turned toward the left, and was slightly elevated. She
had distinct hypertrophy of the sterno-cleido-inastoid muscle
upon the right side. There was some diffuse pain at the back of
the nock, though it could not be determined that this was related
to the spasm. She was operated upon, June 27, 1888, by Dr.
Ashhurst, who removed four inches of the spinal accessory nerve,
both branches being embraced in the operation and extreme
traction being made upon the truuk. Following the operation
the spasms disappeared for a week, but then returned and were
apparently unchanged, the frequency being about the same as
* The condition now, February 24, 1892, is vastly improved; the
deformity is but slight, all movements of the head are quite free, there
has been no return of the spasms, and he is able to attend to his daily
work, which was impossible before the operation.
f Journal of Nervous and Mental Disease, 1 890, p. 830. I
before. Some time afterward she was subjected to operation
by Dr. Keen, practically in the manner indicated in the case
which I have narrated.
The spasms ceased immediately after the operation, but re-
turned at the end of a week, less violently, howwver, than be-
fore. The rotation was not so marked, and the patient could
steady the head with the hand, this being impossible before the
operation.
Dr. Keen saw the patient a year later, and thought the pos-
terior muscles free from implication, with the exception of the
splenitis, some nerves of which had perhaps escaped division.
The patient's condition was, however, markedly improved.
I am able to find but one other reported case in which
the posterior cervical nerves have been excised. This is
reported by Mr. Noble Smith (British Medical Journal,
1891, i, p. 752).* His patient was a lady of forty-one
years, who had suffered for sixteen years with severe spas-
modic wryneck, which commenced a few weeks after a
severe strain.
When the patient was first seen (October 30, 1889) the bead
was bent laterally toward the right, so that the cervical part of
the spine was curved very severely to the left. There was con-
stant and very violent spasmodic action of the left sterno mas-
toid and upper part of the left trapezius muscles, drawing the
face toward the right shoulder. There was also spasmodic
action in the 9plenius capitis and other muscles on the right
side of the neck, these producing the same inclination of the
head as the mus-les of the opposite side already named. For
four months fixation and medicinal remedies were tried. The
effect of a supporting instrument was decidedly beneficial, but
it only partly controlled the spasmodic action. It was then
proposed to stretch the spinal accessory nerve.
On March 6, 1890, this nerve was firmly stretched, the im-
mediate result of which operation was decidedly favorable, but
soon began to wear off, and it became evident in about a week
that further measures were necessary. Excision of a part of the
nerve was then determined upon.
On April 22d a piece of the spinal accessory nerve, a third of
an inch long, was excised. The result of this operation was
complete paralysis of the sterno-mastoid and trapezius, and a
feeling of immense relief to the patient, as the spasms were
very greatly lessened. She was up and about in a week
after the operation, and could turn the head easily to the left
side and control it in that position ; she could hold it for a
short time in any position she liked, hut the spasms on the
tight >ide continued, the splenitis capitis being the greatest of-
fender. After waiting a tew weeks and finding that there was
no further improvement, it was determined to operate upon the
posterior branches of the cervical nerves upon the right side.
On May 28, 1890, an incision was made from the occiput down-
ward for about three inches, parallel to and about an inch to the
right of the spinous processes, through the trapezius down to
the edge of the splenitis, some of the fibers of which muscle
were subsequently divided to enlarge tiie wound ; then through
the complexus, eventually exposing the posterior branches
of the cervical nerves.t The great occipital nerve then came
into view. This was separated from its attachments, drawn
aside, and a piece of its external branch, as well as of the third
and fourth posterior branches, were excised. The splenitis was
separated from the parts beneath it, and nerve filaments passing
* Smith seems to have made his observations without knowledge of
the previous work done by Keen.
f The author does not enumerate the individual nerves.
March 5, 1892."] POWERS: RESECTION OF NERVES FOR SPASMODIC WRYNECK.
255
into it were carefully excised. The same procedure was
adapted with the complexus. The suboccipital nerve was left
intact, as the dissection was a rather deep one and veins inter-
fered. Recovery from the operation was complete, 'he spasms
censed, and at the time of report, eleven month's after operation,
had not returned. The loss of power was very slight, and the
patient expressed freedom from discomfort or disability.
We have, then, three cases in which these posterior cer-
vical nerves have been resected. In Keen's case there was
amelioration, though not complete cessation, of the spasms.
In my own the spasmodic action was stopped, yet the patient
now presents a moderate degree of tonic wryneck, while in
Noble Smith's the cure seems to have been a complete one.
I can but think that Smith was cautious in resecting the
fourth nerve and in cutting out all filaments to the spleni-
us and complexus, and in another case I should be in-
clined to follow this procedure. I am hardly prepared to
express a positive opinion as to just what muscles are now
affected in the patient whom you have seen to-night. There
seems no reason for believing that those of the left side are
■in any way involved. The muscles which rotate the head
to the side on which they themselves are situated are the
inferior oblique, rectus capitis lateralis, rectus capitis pos-
ticus major and minor, trachelo-mastoid, and splenius. It
seems quite probable that more than one of these are af-
fected. There is no tonic extension of the head, yet when
the head is in extension, rotation is free.
If flexion with rotation to the left were difficult, we
could feel assured that the muscles which both extend and
rotate to the right were at fault, and that superextension,
relaxing those muscles, would allow the other rotators to
effect the turn to the opposite side. Again, if only the
simple rotators were implicated, there seems no reason
why rotation should be freer with the head in full exten-
sion. The patient carries the head somewhat inclined
to the right side. This inclination, with rotation to the
same side, could be effected by the trachelo-mastoid and
splenius, especially the anterior fibers of the latter muscle,
and I think that we may assume that extension of the head
would tend to relax the splenius and thus permit of more
easy rotation. These muscles are supplied by the external
branch of the second cervical, which nerve was resected at
its exit from the intervertebral foramen, yet it is quite
possible that they receive additional fibers from lower
nerves. It is also possible that filaments were given off
from the nerves before their section. As I have said, how-
ever, I can only conjecture as to which of the deeper mus-
cles are now affected.
With a view to comparing the relative advantages of
the transverse and longitudinal incisions, I have very re-
cently made further dissection of the parts on the cadaver.
Each procedure — the transverse cut of Keen, and the longi-
tudinal one of Smith — seems to possess advantages. In each
the incision must be a liberal one. Keen's transverse divis-
ion of the trapezius and complexus gives better command of
the suboccipital triangle. It is not as easy in this, however,
to gain access to the third and fourth nerves as when the
cut is longitudinal. Keen did not divide the fourth nerve,
yet, as I have said, I think that I should do this in an-
other case. When the patient is fat, either incision must
be a deep one. In one subject which I dissected, the first,
third, and fourth nerves were exceedingly small, and only
found with much difficulty after long and careful dissection.
I am at present inclined to think that if the patient pre-
sented a long, thin neck, I should make the longitudinal
incision, and that T should employ the transverse cut of
Keen in those people whose necks are short and thick.
It is needless to say that good light and ample retrac-
tion are indispensable. The less of fat the region presents,
the easier will it be to recognize the parts, yet I should feel
that it would always be best to advise the patient, before
operation, of the possibilities of failure. Certainly it is an
operation which I should hesitate to undertake without hav-
ing first become familiar with the region by dissection of
the dead subject.
In my own case the divided muscles were sutured and
seem to have suffered nothing as a consequence of their mu-
tilation.
Hemorrhage is not an important factor in the operation.
Oozing of blood from the divided muscles bothers one
by obscuring the field of work and delays one in point of
time, yet there is little danger of wounding large vessels.
The vertebral artery and vein may come into view in the
suboccipital triangle, and it is needless to say that they are
to be carefully avoided, for they lie very deep and it might
be most difficult to ligate them.
Appropriate after-treatment by confinement of the head,
massage, and the like should receive careful attention.
Regarding the indications for operation in spasmodic
wryneck, I need not speak before this society. It is to be
resorted to when other measures fail. Drugs, gelsemium,
hyoscyamine, and other antispasmodics, atropine injections,
massage, position, electricity, and other means will cure a
certain number of cases, but will leave a certain number un-
cured, and these last must be subjected to surgical proced-
ure. We have seen that in operations upon these posterior
nerves we have few data to guide us. In affections of the
anterior muscles, however, those supplied by the spinal ac-
cessory nerve, we have the experience of many observers.
Here various procedures' have been adopted — myotomy,
nerve ligature, elongation of the nerve, division, and resec-
tion. Of these, the last — the resection of a considerable por-
tion of the nerve, possibly combined with firm stretching of
the proximal fragment — enjoys the best repute ; and while
consideration of the operations upon this accessory nerve is
without the scope of this paper, it may not be out of place
to briefly refer to the investigations of a recent French sur-
geon, Petit, who, in July of this year, published (Traitement
du torticolis spasmodique par la resection du nerf spinal,
L1 Union ftiedica/e, July 9, 1891) the results in twenty -six
cases in which the spinal accessory nerve had been resected
for spasmodic torticollis. Of these twenty-six eases, thir-
teen were cured, in seven the amelioration was marked, in
two the improvement was less marked, in three it was tem-
porary, and in one case deatli resulted from phlegmonous
erysipelas.*
* It is needless to say that under present operative methods Beptfc
piocesses play a very small rule.
256
PILCHER: TUBERCULOSIS OF THE URINARY BLADDER.
[N. Y. Med. Jock.,
Petit says : " Thus, of twenty-six patients, twenty have
been either completely cured, or so ameliorated that they
have been able to resume their occupations. This certainly
justifies those surgeons who have practiced resection of
nerves in the treatment of spasmodic wryneck."
It is to be regretted that the author does not state the
length of time after operation which had elapsed when the
term " cure " was applied.
I have purposely refrained from speaking of the occur-
rence of spasmodic wryneck, of its causes, pathology, or medi-
cal or mechanical treatment, and in conclusion beg to lay
before you this proposition : That in spasmodic affection of
muscles supplied by the posterior branches of the upper
cervical nerves resection of those nerves is a procedure,
practically devoid of danger, which offers many chances for
marked amelioration and a fair prospect of permanent cure.
35 West Thiktt-fifth Street.
NOTES ON
TUBERCULOSIS OF THE URINARY BLADDER,
AND THE VALUE OF SUPRAPUBIC CYSTOTOMY
IN ITS TREATMENT*
By LEWIS S. PIL0I1ER, M. D.,
BROOKLYN.
Observations bearing upon tuberculosis of the urinary
bladder have not yet attained so great a number as to make
the report of individual cases unimportant, uninstructive,
or uninteresting. The suffering which the disease entails,
its intractable nature, and the difficulties which sometimes
attend the diagnosis, constitute conditions that will always
command the earnest attention of surgeons.
It is possible that hereafter tubercular infection may be
demonstrated to be a more frequent cause of intractable
cystitis than has up to the present time been recognized.
Certainly the results of the bacteriological studies of Rov-
sing are very suggestive in this direction. This observer is
reported [Ann. of the Univ. Med. Sci., 1891, vol. i, L, p.
40) to have detected tubercle bacilli in the bladder dis-
charges in three out of thirty cases of cystitis subjected to
examination by him.
Cases of cystitis which develop in the course of the
progress of recognized tubercular disease of other portions
of the genito-urinary tract are not likely to fail of imme-
diate classification as being manifestations of an extending
tuberculosis, without special stress having been laid upon
the identification in the bladder discharges of the specific
micro-organism. But in the more obscure cases, where the
primary lesion is in the bladder wall itself, or, if this is con-
secutive, the primary deposit elsewhere in the genito-
urinary tract has eluded identification, the importance of
bacteriological methods for establishing a diagnosis, and
with the diagnosis a prognosis and therapy, is beyond ques-
tion. In the investigation of a tuberculous bladder the
sound can convey but little positive information ; the cysto-
scopc — if, by rare chance, when it is introduced, the fluid
Read before the New York Surgical Society, December 9, 1891.
contents of the bladder are clear enough to enable its mir-
rors to reflect any portion of the bladder wall — can reveal
but imperfectly and uncertainly the degenerative and in-
flammatory changes that may be present, while direct ocular
inspection and palpation with the finger-tip through a
dilated suprapubic opening still need the confirmation of
the bacteriological test in order to establish beyond ques-
tion the opinions which they may have suggested.
The application of this test, however, in the early stage
of a primary bladder tuberculosis may be so impracticable
as to make it unavailable in establishing the diagnosis ; a
certain amount of breaking down of tissue and of discharge
of infected debris into the interior of the bladder is neces-
sary before the bladder discharges can possibly respond to
the tests that may be applied, so that, for a time at least,
all precise diagnostic measures may remain at fault.
In illustration of this possible difficulty of making a
positive diagnosis in the early history of a case, I cite the
following case, although it is still incomplete, but does not
on that account any the less illustrate the point in question:
Case I. — Alexander M., an active young man of twenty-two'
years. In good health until development of present trouble.
One sister died of carcinoma of the breast at thirty-four years of
age; a second sister died at thirty years, of some bladder dis-
ease, after an illness of four years ; a third sister, younger than
himself, is the subject of tuberculosis of the cervical glands.
His parents are healthy, except a tendency to rheumatism on
the part of the father. Six months before coming under ob-
servation the patient was troubled for a period of two weeks
by frequency of micturition. No pain and no change in quality
of urine noticed. This subsided spontaneously and did not
recur for a period of four months, when it again developed,
and the occasional escape of fibrinous, shreddy material in
the urine was noticed. This again subsided for a brief period,
until, after a prolonged ride upon his bicycle, he was attacked
with hematuria, with acute cystic irritation, which had per-
sisted with steady aggravation, despite intelligent treatment,
for two weeks or more, when I first saw him. At that time
he was urinating every hour, or at less intervals, with pain
and tenesmus; the urine constantly contained much blood
and abundant bladder epithelium and leucocytes. Some flakes
of somewhat consistent material, apparently of organized tis-
sue, were also present in the urine. Examination of the blad-
der with a sound gave negative results; the use of the cysto-
scope was impracticable, owing to the constant hemorrhage;
the rectal touch was negative. The shreddy material, hav-
ing been submitted to a pathologist for examination, was re-
ported to be fibrillated connective tissue inclosing cell ele-
ments, and to be suggestive of the existence of papilloma of
the bladder. The indications for suprapubic cystotomy being
thus well established, the patient was removed to the Methodist
Hospital, where the operation was duly performed. The open-
ing of the bladder and inspection of its interior did not reveal
the hoped-for limited papilloma, but instead thereof, on the
right lateral wall of the bladder, extending upward from the
base, an area of the mucous membrane as large as a silver dollar,
intensely congested, velvety in appearance, raised somewhat
above the surface of the surrounding normal mucous membrane,
as if by infiltration of the submucous tissue, and bleeding freely
when touched. In view of the age and history of the patient,
the most probable opinion that these conditions suggested was
that the lesion was of a tuberculous nature. This diagnosis, how-
ever, needs confirmation. Repeated examinations of the urinary
March 5, 1892.-]
PILCHER: TUBERCULOSIS OF THE URINARY BLADDER.
257
sediment made since the operation have thus far failed to detect
the presence of the bacilli of tuberculosis in it. Inoculation ex-
periments are under way, but it is still too early to obtain any
report therefrom.
Meanwhile the treatment" pursued was moderate curetting
of the diseased surface ; immediate tamponade of the bladder
with iodoform gauze for twenty-four hours; subsequent daily
irrigations through the suprapubic wound, first with boro-sali-
oylic solutions, and later with solutions of nitrate of silver (two
grains to one fluidounce). A steady improvement in both the
local and general condition of the patient has resulted ; pain
has vanished, blood has nearly disappeared from the urine, he
sleeps well, eats with appetite, and has gained in weight.*
Another case (also now under observation in my service
in the same hospital as a patient of my assistant, Dr-
Bogart) will bear citation here in further illustration of the
same point.
Case 11. — John W. F., an athletic young man, twenty-
eight years of age, is admitted for relief of fistulse in ano with
the following history: Several of his father's brothers had died
of pulmonary tuberculosis. He himself had never had any
venereal disease. Eight years previously to admission, when in
otherwise perfect physical health, he began to experience fre-
quent and straining micturition. Never any blood. After
eighteen months the symptoms became more aggravated, the pain
keener, and a slight urethral discharge was noted. The exter-
nal meatus was slit up without relief. Every few months an
acute attack, apparently due to increased prostatic congestion,
with increase of pain and of discharge, would occur. Violent
exercise and constipation were the exciting causes of these at-
tacks. By watchfulness in these respects he finally learned to
prevent these recurrent acute attacks, but the urethral discharge
persisted. The testicles are free from disease. Two years ago
an eminent genito-urinary surgeon of Boston, under whose care
he was at that time, detected enlargement and induration of one
of the seminal vesicles. Bacteriological examination of the se-
men and of the urine failed to show any bacilli of tuberculosis.
The cystoscope was used without any definite findings. Mean-
while, about a year before coming under my own observation,
the presence of pus in the ischio-rectal space was detected, which
after some months was evacuated, leaving two persistent fistu-
lous tracts, one of which communicates with the bowel.
With the evacuation of this abscess the bladder symptoms
have become less urgent, but a sense of discomfort in that vis-
cus, and the need of care to prevent its becoming aggravated, is
rarely absent.
The case well illustrates the difficulties which attend
the coming to a positive diagnosis in a case of primary tu-
berculosis of the bladder. Even at this late date, though
there is but little room for doubt as to the tubercular na-
ture of the prostatic and cystic symptoms that have so
many years tortured this patient, it can not be said to be
settled beyond possible dispute.
Thus much with reference to this point of diagnosis.
The special object of this communication was, however, to
report the effects which had resulted from the performance
of suprapubic cystotomy in a limited number of cases of
tubercular disease of the bladder that have been recently
under my care. My attention was called to the possible
benefits of this procedure by the paper which Guyon, of
* The patient has now, three months since this was written, ap-
parently become perfectly well.
Paris, read before the French Surgical Congress in 1889,
in which he reported three cases of the kind ; two of them
were followed by marked relief to the bladder symptoms,
death occurring one and two years, respectively, later from
renal degeneration. The third patient, a male of twenty-
four years of age, who had been suffering for two years with
symptoms, made an apparently complete recovery, remain-
ing well four years after the operation, having gained in
flesh and strength. Other cases nearly as favorable have
also been reported by other surgeons, but I have made no
effort to collect them.
My first case is as follows :
Case III. — Frank B., an active young man, eighteen years
of age, was admitted to the Methodist Episcopal Hospital in
September, 1889, for relief of hagmaturia and irritable bladder.
The symptoms dated back for two years, during which he had
suffered from unduly frequent micturition, with occasional
hajmaturia. The hasmaturia had been constant for the three
weeks previous to admission. Micturition is painful, especially
when much blood is to be voided. Has frequent temporary re-
tention of urine by blocking up of urethra by clots. Has en-
largement of both epididymides, with consolidation at apex of left
lung. Explorations of bladder by sounds and cystoscope, nega-
tive. Irrigations of bladder with boric acid and hydrastis cana-
densis for two weeks without advantage to patient. Patient
suffers much from occasional blocking of urethra by masses com-
posed of fibrin and phosphatic concretions. Suprapubic cys-
totomy. After the bladder had been opened and its base fully
exposed, there came into view an eroded ulcer, about an inch
in diameter, with overhanging edges. Considerable sabulous
matter and muco-ptis was removed from the bladder, the ulcer
curetted, and the cavity of the bladder filled with iodoform
gauze. Median perineal section with introduction of hard-rub-
ber drainage-lube to base of bladder. This tube, after a few
days, was found to be a source of irritation and was removed,
the suprapubic opening alone being depended upon for drainage.
Systematic antiseptic irrigations of bladder. Gradual improve-
ment in condition of patient. Steady contraction of suprapubic
wound. At the end of a month suprapubic wound nearly
closed. Begins to urinate per urethram. During succeeding
months gradual increase in proportion of urine passed per ure-
thram. At the end of the third month only a very small amount
of urine escapes through the suprapubic opening when bladder
becomes overdistended from failure to empty the bladder during
sleep. Patient retains bis urine from one to two hours during •
the day, and twice that time at night, urinating easier and with-
out pain. General health greatly improved. Discharged. Af-
ter leaving hospital, a steady improvement. This continued,
and, at the end of a year from his entrance to hospital, patient
returned to college, his general health being excellent. Be-
tween 6 a. m. and 10 p. m. he urinates about ten times without
pain, but during the night only twice. There is at irregular in-
tervals an occasional escape of urine through the suprapubic
fistula.
Upon recent examination of this patient, two \ears after the
operation, I find him in apparent robust health. lie is pursu-
ing his college studies, and is especially interested in college
athletics. Has gained much in weight ; the epididymal depos-
its remain in statu quo ; the suprapubic opening is firmly closed,
no urine having escaped through it for more than a year. He
rises twice during the night to relieve his bladder, and during
the day time urinates at intervals of about two hours.
Cask IV. — Nellie J., aged nineteen years, was admitted
into the Methodist Episcopal Hospital in August, 1890, for the
258
PILGHER: TUBERCULOSIS OF THE URINARY BLADDER.
[N. Y. Med. Jouh.,
relief of chronic cystitis. For two years she had been troubled
by frequent and painful micturition, with occasional appear-
ance of blood-clots in the urine. When admitted she was com-
pelled to urinate every hour, the act being attended with a
varying amount of pain. The urine contained abundant pus.
The general health was fairly good.
Bacteriological examination of the urinary deposits revealed
the presence in them of the bacilli of tuberculosis. After a
four weeks' trial of the common remedies for cystitis, without
improvement, September 5, 1890, she was subjected to supra-
pubic cystotomy by my assistant, Dr. Bogart. This revealed the
presence at the base of the bladder, extending upon its left lat-
eral wall, of a large ulcerated surface, with very friable and easily
bleeding granulations. The bladder was cleansed by irrigation
and filled with iodoform gauze. At the end of a week, for the
iodoform gauze dressings daily irrigations with solution of car-
bolic acid were substituted. At the end of four weeks the urine,
a9 it escapes from the suprapubic opening, is quite clear. Her
general condition, however, is not so good, and physical exami-
nation of the chest reveals some deposit in both apices.
A week later considerable pus is again found mixed with
the urine, and irrigations are painful. Irrigations are sus-
pended, and balsam of Peru and cocaine are instilled into the
bladder daily for a time. Finally, however, all intravesical ap-
plications are suspended. For some weeks her condition
varied, but a gradual improvement in strength and appetite
finally became established, and at the end of five months and a
half after the operation, having regained ability to resume
dress and to walk about, she was discharged from the hospital
February 20, 1891. She still had at times much pain in the
bladder, her urine still contained pus, and escaped entirely
through the suprapubic sinus. During the year following her
return home her bladder condition remained unchanged. She
was able to be about and do some housework. The pulmonary
tuberculosis, however, continued to develop, and finally deter-
mined her death in the fifteenth month after the cystotomy had
been done.
Case V. — In June, 1890, Joseph S., some fifty years of age,
was brought to me by his physician, Dr. W. E. Beardsley, for
examination. The case was simple and clear in its character.
Beginning five years before with fistula in ano, he had succes-
sively developed tuberculosis of the larynx, of the lungs, of both
epididymides, of the prostate, seminal vesicles, and base of the
bladder. Micturition was frequent and painful, but the suffer-
ing was not so pronounced as to make a cystotomy seem ad-
visable at the time, especially in view of his generalized tuber-
culosis. During the ensuing summer, however, the bladder
symptoms increased in severity to such a degree that cystotomy
became more urgently indicated. The suprapubic section was
accordingly done in New York city in October, Dr. E. L. Keyes
being the operator. Examination of the interior of the blad-
der failed to reveal any ulcer or special characteristic appear-
ance of tuberculosis other than a diffuse, intense congestion
of the mucosa at the base of the bladder, with many minute
granular elevations dotting the surface. Intravesical iodot'orin-
ized applications were made and suprapubic drainage provided
for. After about three weeks, having been brought back
to his home in Brooklyn, he again came under my care. But
little relief had been secured by the suprapubic section; much
constant pain in the bladder demanded frequent administra-
tion of morphine for its control; a total lack of reparative
power manifested itself in the operative wound; and every ef-
fort to promote repair — involving general hygiene, supporting
and stimulating treatment, and local stimulants — was fruitless to
provoke any tendency to cicatrization or to prevent undermining
of the adjacent connective-tissue planes. He gradually sank,
and died by exhaustion ten weeks after the cystotomy was
done.
Remarks. — Of the four cases now detailed in which
suprapubic cystotomy was resorted to, in two of them very
marked benefit has resulted from the procedure. In the
other two no benefit, but, on the whole, decided disadvan-
tage, I think, was the result.
In the case of the girl the opening of the bladder
above the pubes was a very satisfactory proceeding, as an
aid to the exploration of the bladder and in the help which
it gave us in ascertaining its precise condition, but its after-
care required prolonged confinement to the bed; and the
discomforts attending the constant outflow of the urine
above the pubes could only partially be overcome by the
use of voluminous absorbent pads. I doubt whether any
benefit was derived from the efforts at topical medication
that were made ; indeed, I question whether in any of
these cases any substantial advantage is to be hoped for by
attempts at special topical antitubercular treatment. The
tubercular infiltration is not a superficial infection, to be
arrested or diminished by the powderings, instillations, or
irrigations that are available for use in the interior of the
bladder. The curette and the cautery can not be resorted
to with any such degree of thoroughness as to encourage a
hope that even a considerable portion of presumably in-
fected tissue lias been removed by them. The most that
can be hoped for from treatment is to prevent the collection
of urine in the bladder, to keep the bladder at rest, and to
mollify the effects of the existing infection by relieving
pain, removing debris and irritating secretions, preventing
muscular spasm, and restraining inflammation. If this can
be accomplished, it may possibly be that in certain very fa-
vorable cases an indefinite arrest, even the entire recession,
of the tuberculosis may take place.
The value of the suprapubic incision, therefore, does not
consist so much in any opportunity which it may afford to
give access to the disease itself, but rather in the superior
degree in which it facilitates the accomplishment of these
apparently secondary indications named.
In the male I think there can be no question as to the
superiority of a suprapubic opening to a perineal one in car-
rying on the treatment of this special class of cases. In the
female, however, the relations of the base of the bladder to
the vagina are such as to suggest that by the formation of
a generous vesico- vaginal opening an equally efficient and
much more convenient outlet to the bladder would be fur-
nished than could be had above the pubes. My experience
in the case of the girl in question would suggest to me that
in a similar case again it would be better, after having made
the exploration of the bladder by the suprapubic opening,
to establish a free opening through its base into the vagina
and then suture the suprapubic wound, relying on the vagi-
nal outlet for the after-treatment of the case.
Perineal drainage was tried by me as an accessory in one
man (Case III), but the pain and irritation caused by the
presence of the tube in that location, its vesical end neces-
sarily resting upon the ulcerated surface, made its withdrawal
necessary after a very short time. Further experience and
observation have satisfied me that it can rarely be of any
March 5, 1892.]
ALLEMAN: ESSENTIALS IN~ OPHTHALMOLOGY.
259
added advantage to have a perineal opening as long as the
suprapubic opening remains patent and the contractility of
the bladder walls has not been destroyed.
A device to facilitate drainage and intravesical irriga-
tions which I have employed in my latest case has worked
so well and given so much comfort that I will mention it.
It consists simply of the use of two soft-rubber tubes — large
caliber drainage-tubes, 5 to 1 mm. interior diameter — intro-
duced side by side through the suprapubic opening, pro-
jecting unequally into the bladder, one being carried into
the bladder a sufficient distance to nearly reach its base, the
other being only long enough to fairly reach the cavity of
the bladder. Neither of these should have any lateral open-
ings. Ready drainage is thus secured both from the bot-
tom and the top of the bladder, and by alternately sending
an irrigating current, first through one and then through
the other of the tubes, very thorough and painless washing
out of the organ can be readily done. Both of these tubes
I cut off flush with the surface of the skin. By covering
their orifices with a somewhat voluminous absorbent dress-
ing— bags of sawdust are used by myself — which is replaced
as often as it becomes saturated with urine, the patient is
kept dry and comparatively comfortable.
Two practical questions suggest themselves in connec-
tion with this subject to which, in conclusion, some consid-
eration may be given — viz. :
1. How early in a case of possible bladder tuberculosis
is a suprapubic section desirable ?
2. How long is it desirable to maintain the suprapubic
opening patent ?
The answer to the first of these questions, I take it, is
to be found in a consideration of the indications which the
operation may be accepted as subserving. I have already
expressed my conviction that it is by securing bladder rest
and drainage that the operation is especially useful. The
symptoms that demand attention are those usually of cys-
titis ; if these symptoms — it is unnecessary to recount them
or analyze them here — if, I say, these symptoms do not
readily yield to the well-known accepted constitutional and
local measures of treatment, recourse to cystotomy is indi-
cated and should not be unduly deferred while the general
strength is being sapped by the local suffering, the exten-
sion of disease, and the absorption of deleterious substances
into the circulation.
The second question must also receive an indefinite an-
swer. Case III of the series reported this evening shows
that in the most favorably affected cases a gradual subsi-
dence of the symptoms which had called for operation may
take place ; the ulcers cicatrize, the inflamed mucosa re-
sumes its normal state, the urine becomes bland and
healthy, or at least comparatively unirritating, and the blad-
der becomes again capable of acting as a reservoir for urine,
and of painlessly expelling it at suitable intervals.
When this condition has been secured, the suprapubic
opening may be allowed to close, but a prolonged period of
time, possibly many months, must be expected to be re-
quired to bring about this end.
In other cases it is to be expected that comparative com-
fort only will be enjoyed as long as the bladder is not called
upon to retain the urine for any time, which will necessitate
the indefinite retention of the suprapubic opening and a suit-
able permanent drainage apparatus.
In much the larger proportion of cases, however, and
especially those in which the bladder disease is secondary
to or associated with progressive renal or pulmonary tuber-
culosis, it must be that the fatal termination of the case will
early dispose of any question that might have arisen as to
the permanency of the suprapubic opening, which may have
been made for the purpose of temporarily alleviating the
suffering caused by the condition of the bladder.
ESSENTIALS IN OPHTHALMOLOGY
FOR THE GENERAL PRACTITIONER*
By L. A. W. ALLEMAN, M. A., M. D.,
BIOOKLYN, N . T.
It is with the greatest possible satisfaction that the
physician of to-day recognizes that medicine has at length
become a science — not, it is true, an exact science, but a
pre-eminently progressive one. The few fundamental
branches which once constituted the requirements of a
medical education have now put forth many vigorous off-
shoots. It is no longer possible for the conscientious medi-
cal student to master in the time usually devoted to pre-
paratory study all that is to-day known of medicine, and
then to hold fast to that which is good, but in the very
outset of his education he must exercise his selective fac-
ulty, and too often, later on, he regrets that he was not
better advised as to the most profitable use he could make
of his time.
We are all of us frequently called upon to give such ad-
vice to medical students and to those recent graduates to
whom an unappreciative public allows abundant leisure,
which they wish to devote to rounding out their medical
education. Since this question arises nowhere more fre-
quently than in connection with the study of diseases of
the eye, I have thought it of interest to ask you to discuss
with me what knowledge of this special branch is essential
to a' general medical education.
To the medical student the study of ophthalmology
centers in the ophthalmoscope. It is the " outward and
visible sign," the pre-eminent weapon of the oculist. The
first flickering flame of enthusiasm for eye work in the
breast of the student provokes the inquiries, "Shall I get
an ophthalmoscope ? " " How much does the instrument
cost ? " " Which one is best adapted for student's work ? "
and so on. I always advise against its purchase, unless
the man intends to follow eye work after graduation, and
no doubt often seem most inconsistent. After pointing
out the advantage in many medical cases of an examination
of the eye ground, it is a natural inference that the well-
equipped general practitioner should be able to avail him-
self of its aid, but I am more and more convinced that the
advice is sound, and I doubt not that I could put in evi-
* Road before the Kin^d County Medical Association, November 10.
1891.
♦
260
ALLEMAN: ESSENTIALS IN OPHTHALMOLOGY.
[N. Y. Mku. Jouk.
dence the experience of m;my of the gentlemen present,
who, in moments of enthusiasm, have invested in such in-
struments.
That the ophthalmoscope is not a valuable aid to diag-
nosis in the hands of the average medical man is not be-
cause the data which it gives are valueless, but because the
instrument is only of value to the man who has sufficient
opportunity for its employment to keep himself expert in
its use.
In the first place, it requires some practice to see the
fundus bculi at all ; having mastered this, one must get a
standard of normal. Then there are in health wide varia-
tions in the appearance of the fundus, and some of these so
closely simulate diseased conditions that unless the points
of differential diagnosis between pathological conditions
and physiological variations are most thoroughly impressed
by long practice, they are a very annoying stumbling-block.
Having once gained sufficient experience in the use of
the instrument to profit by its showings, its use can not be
long neglected without serious loss of expertness, and just
here is where our general men find the difficulty. In the
busy rounds of professional work cases requiring its use are
not very frequent, and time does not permit recourse to
the clinic to keep in practice. The cases in which an oph-
thalmoscopic examination is valuable as an aid to diagno
sis are among the most difficult we encounter, and the phy-
sician with a fair working knowledge of the instrument
finds that he falls just short of that absolute confidence in
his findings which is essential to his purpose.
A much less ambitious instrument than the ophthalmo-
scope, and one with the use of which every student should
familiarize himself, is a simple mirror. It is, in fact, an
ophthalmoscope, save that it lacks the lenses, which are
usually placed behind the mirror. This instrument takes
the place of the more elaborate one for nearly every purpose
save the estimation of refraction. With a very little prac-
tice one can learn to illuminate the interior of the eye and
obtain a red reficx through the pupil. This will give much
valuable information. For example, opacities in the lens
can be seen, and a diagnosis of beginning cataract made,
its progress can be watched, and by this simple procedure
many a patient in some remote district would be saved a
disheartening journey to the city for the purpose of under-
going an operation for a cataract which either does not ex-
ist or is not sufficiently mature for operation. By its em-
ployment irregularities of the pupil found in iritis can be
seen, floating vitreous opacities recognized, and, in the hands
of one sufficiently skilled, a fair idea of the condition of the
fundus gained.
As to the diseases of the eye recognizable by the oph-
thalmoscope and due to some constitutional disorder, such
as Bright's disease, diabetes, and the like, it suffices to
point out that such diseases exist, and that, in these cases,
an examination of the fundus bculi is sometimes invaluable
as an aid to diagnosis.
The inspection of the eye to determine the presence of
a foreign body is an important matter — a task frequently
imposed on the general practitioner. A man suffering from
a cinder, for example, which is rasping up the delicate mem-
brane, is not always and altogether reasonable. At any other
time he might admit that his case was one which should
properly be sent to a specialist, but if compelled to wait over
night to see one, the patient may not be altogether chari-
table in his opinion of the doctor who declines to relieve
him of his suffering. It is therefore well for every one to
cultivate what knowledge he can of the removal of foreign
bodies, when they are simply lodged in the conjunctival sac
or cornea, and have not penetrated the eye. Here no
amount of telling will do for the student what a little show-
ing will, nor can it give him manual dexterity, but he
should be advised that if he begins his examination of an
eye irritated by the presence of a foreign body by the instil-
lation of a drop of a four per-cent. solution of hydrochloride
of cocaine the matter will be much simplified ; also warn him
in endeavoring to open the lids to examine the eye, not to
dig the fingers into the eye, making pressure upon the sen-
sitive globe, thus exciting spasm of the lids and increasing
the difficulty of examination ; but, resting one thumb
against the margin of the orbital cavity and the other
upon the malar bone, to make firm traction. In this way
the eye is much more easily opened. A condensing lens of
some sort can usually be obtained, and by it a ray of arti-
ficial light focused upon the eye. A very little practice en-
ables one to evert the lid, and in ordinary cases no difficulty
is experienced in removing the foreign body. When it is
deeply imbedded in the cornea, much caution is required to
avoid adding to the mischief already done by rough manipu-
lation in its removal. These points are so self-evident as to
scarcely require comment.
As to the diseases of the eye against which the student
should be repeatedly warned, I think the one of chiefest
importance is ophthalmia neonatorum. So terrible are the
effects of this disease and so simple a matter is its preven-
tion, and in the beginning its cure when properly managed,
that I feel that we should preach upon its dangers in season
and out of season. When we reflect that nearly a fourth
part of the inmates of blind asylums are victims of this dis-
ease, when we consider the life-long misery which blindness
entails, we must feel that a heavy weight of responsibility
rests upon the man who fails to impress upon those he pre-
sumes to instruct the dangers of this terrible disease and
the precautions necessary for its prevention. Not only does
the prevention of blinduess demand our consideration from
sympathy for these unfortunate victims, which, in all con-
science, is imperative enough, but it is our duty as citizens
to try and relieve the State of a burden which I regret to
say is an increasing one. Most of the blind are not only a
loss to society by being withdrawn from the body of wealth-
makers, but are a direct tax upon the industry of others ;
in this State alone the loss to the community from the
blind population was estimated by Dr. Lucien Howe, who
deserves great credit for arousing interest in this subject,
at twenty-five million dollars in 1887, and would no doubt
be found still greater at the present time. It is not possi-
ble here to enter further into the discussion of the preven-
tion of this disease, but suffice it to say that every student,
every midwife, every nurse, any one, in fact, who may at
any time come into contact with new-born children, should
March 5, J 892.]
ALLEMAN: ESSENTIALS IN OPHTHALMOLOGY.
261
be taught that the dropping into the eye of the child, im-
mediately after birth, of a drop of a two-per-cent. solution of
nitrate of silver gives practical immunity from the disease,
and that rinding a case already developed, the law requires
the notification of some responsible officer. The law reads :
CHAP. XLI. — An Act for the Prevention of Blindness.
Section 1. Should any midwife or nurse having charge of
an infant in this State, notice that one or both eyes of such in-
fant are inflamed or reddened at any time within two weeks
after its birth, it shall be the duty of such midwife or nurse so
having charge of such infant, to report the fact in writing,
within six hours, to the health officer or some legally qualified
practitioner of medicine, of the city, town, or district in which
the parents of the infant reside.
Seo. 2. Any failure to comply with the provisions of this act
shall be punishable by a fine not to exceed one hundred dollars,
or imprisonment not to exceed six months, or both.
Seo. 3. This act shall take effect on the first of September,
eighteen hundred and ninety.
When it is impossible to place the case in other hands,
one can easily refer to the text-books for treatment, which
consists of antiseptic washes, iced compresses, nitrate of
silver, and the like, which I can not here describe in detail.
A disease of similar nature and one which no physician can
ever afford to disregard, alike for his own safety and that
of his patient, is gonorrhoeal ophthalmia.
When an eye is inoculated with gonorrhoeal pus, an
inflammation of frightful intensity follows. In some in-
stances an eye may be lost in twenty-four hours, and, even
with the most careful treatment, there is always grave dan-
ger to vision. This should never be forgotten when a case
of gonorrhoea is treated, and the physician should take the
utmost care to protect himself and should warn his patients.
Cases are not infrequent where innocent persons are infect-
ed with this disease from public towels and the like, and it
is our duty to instruct our clients to avoid such criminal
carelessness as will endanger others, and to decry the inex-
cusable practice of using such dangerous articles in the
toilet as those found in any public place.
Glaucoma, too, is a disease which the student should be
taught to be on the lookout for and against which he should
be warned. Many an attack of acute glaucoma has been
allowed to go on to hopeless blindness without an effort
being made for its relief, because it was believed to be a bil-
ious attack*. It is not always easy to test the tension of an
inflamed eye, but when a patient, who seems to be suffer-
ing from what would ordinarily pass for a bilious attack, is
found to have an inflamed and painful eye, the possibility
of glaucoma should be always kept in mind. It may be
added in this connection that it is, as a rule, dangerous to
use atropine in patients over forty, as it is believed to some-
times precipitate an attack of glaucoma.
We should likewise emphasize the fact that there is
such a disease as sympathetic ophthalmia. We can not
hope to enable every student to recognize the disease, but
we can teach him that when one eye is injured, especially
should that injury affect the ciliary body, or should a for-
eign body be located in the globe, there is always danger
that the fellow-eye will be affected, and that it will often
become the more hopelessly blind of the two. Again, when
the patient has an eye which has been lost through some
previous injury, should this eye, even though reduced to a
mere stump, be tender on pressure, it is a menace to the
sound eye, and it is a safe supposition that any irritation
arising in the sound eye under such conditions is the begin-
ning of sympathetic ophthalmia.
In strumous children eye diseases are of frequent occur-
rence. In these cases it should be remembered that attention
to the general nutrition is of the highest importance. A
strict regulation of diet is imperative. We usually find that
these little sufferers are given pie, cake, candies, tea, and cof-
fee, to the exclusion of more wholesome food. The effects
of such a diet are obvious. They are allowed to spend most
of their time indoors, where, as a rule, the surroundings are
most unhygienic, and, if left to themselves, they will select
the darkest and most unsavory corner of this retreat, where
they will spend the entire day with the head buried in the
pillow. When it is necessary to take them out, as for their
visit to the doctor, the eyes are tightly bandaged, and in
the class of patients which I have in mind — namely, those
seen at the public clinic — the preference is usually given by
the parents to the thickest, wooliest, and dirtiest materia)
at hand for a bandage. The bandages should be removed
and the patient be sent into the fresh air ; this, with a ra-
tional diet and the administration of some tonics — as, for
example, the iodide of iron — will do as much as local treat-
ment, often more, to relieve the patient.
One of the most important points relative to diseases of
the eye which the general practitioner is frequently called
upon to decide is whether, in any given case, some error of
refraction or anomaly of the ocular muscles is the exciting
cause of headache or some reflex nervous symptom. That
such eye defects are a frequent cause of headache and reflex
nervous disturbances no careful observer can deny. We
must not allow our enthusiasm to carry us to the point of
believing that all headaches, all nervous symptoms, and the
majority of other physical disorders, have their origin in
some eye defect ; but it is a safe proposition, and one easily
verified in practice, that, in a very large proportion of head-
aches and in a certain lesser projiortion of nervous disturb-
ances, eye defects are at least a contributing, if not an ex-
citing, cause.
My experience has been that, almost without exception,
in patients suffering with these symptoms, arising from
whatever cause, when an error of refraction or lack of mus-
cular equilibrium was found to be present, the correction of
such defects benefited, if it did not cure, the headache.
I think in some of these cases treatment directed to the
stomach, pelvic organs, nose, or other source of irritation
would likewise have relieved the patient. The nervous
system might be able to struggle along comfortably with an
irritation arising from one of these causes, hut with the two
it could not successfully cope. In many cases none will
deny that the eye defects give origin to most distressing
headaches, and to nervous reflex symptoms, some of which
seem so remote that, unless the case is actually before one,
it is sometimes impossible to believe that any connection
exists ; yet the explanation is simple enough. Let any on©
262
ALLEMAN: ESSENTIALS W OPHTHALMOLOGY.
[N. Y. Mkd. Joub.,
of us place before one eye a prism just strong enough to
give the slightest possible separation of images in the verti-
cal, in a few moments the presence of such a glass becomes
simply intolerable and enables one to more easily under-
stand how such a source of irritation, when present for a
long time, can give rise to a condition of nervous hyper-
aesthesia, which may manifest itself in any of those myriad
ways in which a disordered nervous symptom finds ex-
pression.
Such being the importance of eye defects in the causa-
tion of those diseases with which the general practitioner
has every day to cope, it follows that no careful practitioner
can afford to overlook them.
The question then naturally arises, How far and in what
manner shall we proceed in an examination to determine
the presence of such ocular defects ? The ophthalmoscope,
which is highly recommended by some ophthalmologists
as an easy and reliable method of determining the refrac-
tion, we must exclude on the grounds already given, and
even when used by one perfectly familiar with its employ,
I believe its findings to be only approximate. A test which
any one can make is that of visual acuity. A card of test
letters, such as can be obtained at any optician's, can be
hung on the wall of the office, and the patient, standing at
a distance of twenty feet from the card, be allowed, with
each eye separately, to read the lowest line that he can dis-
cern. Should he be unable to read the line marked XX or
better in a moderate light, it is evident that he has some
visual defect.
Astigmatism may sometimes be detected by the very
simple expedient of allowing the patient to look at a chart
composed of radiating lines, such as are sold for this pur-
pose. Should the lines not appear of uniform distinctness,
but those running in one direction — say horizontally — are
clearer and brighter, as if printed in better ink than those
on the rest of the chart, and if these lines rotate as the
position of the head is changed, the patient undoubtedly has
some astigmatism.
These simple tests are valuable if they serve to discover
some eye defect, which may offer an explanation of the
symptoms. But even should a patient pass both of these
examinations successfully, we can not exclude eye defects.
It is in cases of hypermetropia and hypermetropic astig-
matism that headaches and reflex disturbances are most
frequently found, and these defects are often concealed by
the action of the ciliary muscle. In young subjects it is
rather the rule that they are so masked. The patient sees
well, both at the far and near point, and possibly nothing
save a slight feeling of fatigue after using the eyes, some-
times not even this, points to the eyes as a source of head-
ache. I know of no easy test by which these cases can be
detected. If the patient's time is of no consequence, a
solution of four grains of atropine sulphate to the ounce
may be instilled into the eyes for two days, and then another
test of vision made. If the visual acuity has markedly de-
clined, it is then evident that some refractive error was
covered by the ciliary muscle.
When it is impossible to obtain an examination under
atropine, I know of no means by which the physician can
exclude eye strain as a possible cause of these symptoms.
He must then inquire very carefully into the habits of the
patient and the nature of the headaches — whether they are
apt to occur with greater severity after the eyes have been
put to some unusual strain ; whether the patient is usually
better after a holiday or a Sunday ; if the patient is a child
in school, whether the suffering is aggravated by a return
to work after the vacation ; and from such data must make
up his mind as best he can whether an examination of the
eyes is indicated or not.
These suggestions will apply equally well to muscle
cases.
This subject is one which I always approach with many
misgivings, not because I do not believe that abnormal re-
lations of the ocular muscles are a frequent cause of the
symptoms which we have just been considering, but be-
cause I am so thoroughly impressed with the great diffi-
culty so frequently found at arriving at a correct diagnosis
of these cases. They are by all odds the most difficult and
troublesome cases with which we have to deal ; there are
no simple and ready tests for the detection of muscular de-
fects ; each case requires a careful and personal study ; a
defect which in one person gives rise to no inconvenience
whatever will in another totally incapacitate the patient
from eye work. You may examine a patient again and
again with a perfectly negative result, and finally, when ut-
terly discouraged, find some muscular anomaly, or again
the findings of different examinations may be entirely con-
tradictory.
Having determined what the muscular defect is, one is
then by no means relieved of embarrassment ; patients will
often experience the greatest difficulty in wearing prisms,
and it is a frequent experience to find the glass which cor-
rects the muscular defect, and which, persevered in, cures
the patient, will at first increase his sufferings tenfold. The
operation of tenotomy is highly lauded for the relief of
these troubles, but I believe it should be undertaken with
extreme caution. A very little experience suffices to con-
vince one that the muscular relations are by no means con-
stant ;'it is a very simple matter to change a pair of glasses
when they no longer meet the requirements of a case, but
it is not so easy to undo the results of an operation, aad I
am unwilling to operate until the patient has been under
observation for a sufficiently long time to convince me that
the muscular condition is a constant one.
Of the simpler tests for the detection of muscular de-
fects, perhaps the best is made by placing before one eye
of the patient a prism of say 7°, with the base up or down,
and directing him to look at the flame of a candle twenty
feet distant ; if the two images which he now sees are not
directly one above the other, there is lack of equilibrium
between the internal and external muscles ; again, to test
the superior and inferior, place a prism — 10° will usually
suffice — with the base toward the nose ; the images will now
stand side by side, and should one be higher than the other,
a defect is evident. This test is, as I have said, by no
means final, but it is sometimes sufficient to discover a de-
fect.
The foregoing suggestions do not by any means com-
March 5, 18D2.]
SEABROOK: OPHTHALMOL 0 QIGAL PAP.
263
prise all that a man can with advantage learn of disease of
the eye. Could every student before graduation receive a
course of instruction equivalent to what is now given in a
post- graduate course on diseases of the eye, the advantage
to the public would be incalculably great, but until this is
possible, let us endeavor, so far as we can, to impress upon
our students a few of these facts, ignorance of which will
seriously endanger their patients.
64 Montague Street.
0 PHTRA LMOLOGICAL P AP *
By H. II. SEABROOK, M. D.,
SURGEON TO THE NEW YORK EYE AND EAR INFIRMARY.
My dear friend and brother, the general practitioner,
frequently asks why eye specialists do not try to teach him
how to know what eye diseases to treat without danger to
himself, and he says he wants this given in a simple man-
ner in a treatise that he can understand, not for fine diag-
nosis of eye disease, but merely —
" Distinguishing those that have feathers and bite
From those that have whiskers and scratch."
" For," says he, " I send several patients in succession to
some eye specialist, who return and upbraid me when they
are told that their trouble is an extremely simple one,
which any medical man ought to recognize. Tired of
this, I treat an apparently simple case myself, and the next
thing I hear is that my patient has gone to a specialist
and been told that the man who has used atropine on that
eye with glaucoma ought to be put on ice if he ever has a
chill."
During the next twenty minutes I shall not endeavor to
raise you from your present condition of dense ignorance
to a perfect knowledge of the differential diagnosis of eye
diseases. For any such consummation the general practi-
tioner is referred to some school for post-graduate instruc-
tion. The task I have set myself is, perhaps, more diffi-
cult— viz., to write a paper containing a few general points
about eye diseases in such a manner that the members of
this society can understand it. Consider the price of suc-
cess, gentlemen, and pity me. What manner of treatise
must it be ?
Many patients complain of water running from the
eyes. This may be due to slight conjunctivitis or conges-
tion of the lids; sometimes from improper correction or
lack of correction with glasses. Overflow of tears, due to
trouble with the lacrymal canals, may be diagnosticated
by pressure upon the lacrymal sac, when mucus or pus
will flow back at the inner angle of the eyelids. This latter
condition is usually consequent upon disease of the nose
and stricture of the nasal duct. If the stricture is above
the lacrymal sac, the contents of the sac will empty down-
ward upon pressure. Many of these cases require opera-
tion. There is one class of cases, however, requiring
special mention. There is chronic irritation of the lids,
even inflammation, with a granular condition in certain
* Read before the Lenox Medical and Surgical Society, December
14, 1891.
cases. The correction of the eyes with glasses has been
attended to. The condition of the lids is relieved by local
treatment, but relapses occur. The eye symptoms being
severe, the patient refers the trouble entirely to the eyes,
rebels against treatment of the nose, and is surprised at the
relief to the eyes afforded by such treatment. The trouble
starts in the nose primarily and extends up the lacrymal
canals. This is the way in which the nose affects the eyes,
and it requires a robust imagination at present to conceive
diseases of the nose as causative in any eye diseases except,
quite frequently, in conjunctival inflammations and occa-
sionally in corneal troubles. When the lids are stuck to-
gether upon the patient awakening from sleep, there is con-
junctivitis. You may consider this a diagnostic sign of
acute conjunctival inflammation. In my experience the
general practitioner is, in one way at least, extremely mod-
est. He confesses that he knows little about eye diseases,
but often coyly admits that he knows conjunctivitis. Since,
however, he is apt to call it by another name and use atro-
pine locally in its treatment, it may be well to hint that
while his standpoint may be entirely correct, it differs
slightly from the conventional one which obtains among
ophthalmologists, that in conjunctivitis the lining of the
lids is inflamed and that the quality of the congestion upon
the eyeball is of more diagnostic importance than the quan-
tity : long, tortuous vessels appearing over the white of
the eye in conjunctivitis, short, straight, numerous vessels
being seen at the corneal margin in central inflammation
(of the cornea or iris). Muco-purulent or purulent secre-
tion occurs only in conjunctival inflammations, and it is the
presence of this in front of the pupil, with consequent
haziness of vision and distortion of objects, that causes the
complaint of " poor sight " and " seeing double." This
condition is momentarily relieved after the lids have been,
gently rubbed while closed, as there is no real trouble with
the sight. Patients frequently complain of pain instead of
a smarting or gritty sensation when the conjunctiva is in-
flamed. In the male German who weighs over two hundred
pounds, conjunctivitis appears to cause at times the most
acute suffering, much aggravated when the lids are slightly
touched. However, it is customary to consider a genuine
all-wool pain in the eyeball or forehead as symptomatic of
neuralgia, iritis, or inflammatory glaucoma. In supra-or-
bital neuralgia there is tenderness over the affected nerve,
and the sight of the eye is not affected. In iritis the pupil
is contracted, the iris is sluggish or immovable and dis-
colored, the pupil has a more or less hazy look, and there is
the characteristic injection about the cornea. The sight is
affected more or less. In inflammatory glaucoma the pupil
is dilated, the iris is discolored and immovable, the structures
in front of the pupil are hazy, with a greenish-yellow reflex
from the pupil, and there is the circumcorneal injection with
injection of the veins just over the sclera as well, the iris is
pushed forward toward the cornea, and the sight is very
much impaired. In addition, there is corneal ansesthesia,
and upon pressure ever the center of the eyeball through
the upper lid while the patient looks down, the affected
eye will be found to be harder than the sound one.
Now, glaucoma should be treated by means of eserine oi
264
SEABROOK: OPHTHA LMOL 0 QIC A L PAP.
[N. Y. Med. Jouk.,
an iridectomy. You all remember Artemus Ward's China-
man sailing down the flood in a wash-tub when asked by
the drowning man to throw him a rope. His reply — " No
have got, how can do ? " — has always been considered a valid
excuse for non-performance of duty even in California.
W hen a medical man meets with a case of acute arlaucoma
late at night about five miles out from New Egypt, he knows
that the nearest druggist would not know what eserine was
if he should send for it, he has no instruments for an iridec-
tomy, and does not know how to do one any way. It is
best in such a case for him to give a hypodermic of mor-
phine, apply heat in the form of frequent douching to the
eye, and hope for the best.
The many forms of corneal disease have several signs
in common. Photophobia is the characteristic subjective
symptom. Objectively there are one or more opaque
spots upon the cornea and the pericorneal injection. Co-
caine should not be used indiscriminately in these cases.
Eserine (not stronger than half a grain to an ounce in
a fresh solution) should be used in glaucoma and deep
marginal ulcer of the cornea. It is dangerous in iritis.
Atropine may be used in the other diseases of the eye-
ball. It is a cause of irritation in conjunctivitis, it is
" rank pizen " in glaucoma, and it can not be used in all
eyes without external inflammation, especially in persons
past middle life, without decided injury to some of them.
Heat should be used in diseases of the eyeball, except just
after a burn or other injury and where there is haemorrhage.
Cold is better for conjunctival inflammations, injuries, and
haemorrhages. The subject of injuries of the eyeball is an
extremely complicated one, but in treatment cold and atro-
pine, with antisepsis when the tissues are lacerated, are in-
dicated at first. Subconjunctival ecchymosis in young sub-
jects from injury, coughing, or straining, has usually no un-
pleasant significance. Cold to check it, with heat later to
promote absorption, may be used. The practice of attempt-
ing to wipe off the spot with the corner of a handkerchief
is, so far as I know, indulged in by no one except an occa-
sional medical student. In subjects no longer youthful, sub-
conjunctival haemorrhage may be significant of some gen-
eral circulatory or local ocular disturbance. Excepting
tumors, there are but three other appearances upon the
white of the eyeball needing consideration here : a livid
swelling signifying episcleritis ; a vesicle with more or
less swelling at the base (phlyctenule) ; lastly, a horizontal
more or less triangular thickening of the conjunctiva, usually
on the nasal side of the eyeball, yellowish, and somewhat
vascular, having an apex upon the cornea from which it
spreads peripherally (pterygium).
When the eyeball is inflamed, especially in iritis and in-
juries, it sometimes develops extreme tenderness upon the
lightest pressure just back of the corneal margin. This is
the diagnostic sign of an inflammation of the ciliary body
(ciliary processes and ciliary muscle), and that inflammation
means business.
Many general practitioners possess two cards for test-
ing. One is placed at a given distance and the patient asked
to read the letters marked as being appropriate to that dis-
tance. The other presents in small type a statement to the
effect that if it can not be read at twelve inches glasses are
needed. The further statement that floating spots before
the eyes indicate nervousness is probably put in to fill space,
being both irrelevant and misleading. You all remember
how Captain Cuttle acted when Florence Dombey fainted.
Having a notion that a watch and a physician were in some
way connected, he hung his famous repeater on the hook
that was attached to the stump of his arm and then waited
to see if the watch would not do something. The faith dis-
played by many men in the test cards above mentioned is
as entirely misplaced as Captain Cuttle's in the efficacy of
the watch. Failure of central vision, if recent, is an indi-
cation of ocular disease, but disease may exist in eyes that
see the proper conventional letters at twenty feet. As re-
gards the diagnostic and prognostic significance of the con-
dition of the eye in certain general diseases little need be
said here. Much is written already upon this subject, and
with the increase in the crop of young specialists and con-
sequent struggle for ophthalmological existence more and
more will be heard regarding it. Poor sight for distance
may also mean that glasses are needed, but certain symp-
toms indicate the necessity for ocular treatment just as defi-
nitely. These are a feeling of fatigue or pain in the eyes,
congestion of the lids, especially redness at the edges, dull
ache in the forehead, temporal headache on one or both
sides, pain in the muscles at the nape of the neck extend-
ing sometimes downward along the spine, perhaps combined
with nausea and dizziness.
Double vision — i. e., seeing two distinct images of an ob-
ject either temporarily or permanently — may indicate grave
ocular or cerebral difficulty. Lack of parallelism of the axis
of the eyes in any position, decided inequality of the pupils,
and the drooping of a lid coming on suddenly, are signs
usually of grave import.
Of late years there has been an unusual waste of medi-
cal energy in discussing the influence of the eye upon the
general system. Without entering into the discussion re-
garding eye-strain as a cause of haemorrhoids, or whether
the colic of infants is due to the irregular action of their
ocular muscles, it is absolutely necessary for an ophthal-
mologist to give consideration to the abnormal eye as a
source of irritation to the nervous system. Man is com-
paratively easy of medical comprehension. We know he is
a liar on the authority of David, probably a fool according
to Carlyle, and by the indisputable dictum of Moses and
Sayre that he ought to be circumcised. The cause is some-
where near the effect as regards his symptoms, and when
his brain or spine is affected it is considered good judg-
ment to start off with full doses of iodide of potassium.
With the modern American woman, however, it is some-
what different. Almost any nervous manifestation on her
part may be due to some irritation in any situation in the
body or out of it. Just at present the dress reformers have
had to take a back seat. Who could consider the vulgar
corset as a cause of woe when once hypophoria had been
mentioned in opposition ? So the eyes have the call at
present, and the general practitioner is invited, by means of
various more or less scientific articles in the medical jour-
nals, to bathe his patients with various nervous symptoms in
March 5, 189>2.-] JACOBI, WEY, AND SHERMAN: REPORT ON CAPITAL PUNISHMENT.
■
the ophthalmological font. There is an accepted standard
as to what an eye ought to be, but some people with emi-
nently proper eyes suffer from eye-strain, and other repro-
bates with eyes that ought to give a horse the blind stag-
gers are exasperatingly comfortable. As a rule, of course,
defective eyes cause definite trouble when much used, which
can be more or less relieved by local eye treatment. When
an eye is corrected as nearly as possible up to the scientific
standard, this may or may not be the proper standard for
the individual case, and the correction must accordingly
frequently be more or less modified. As if this were not
troublesome enough, the ocular muscles must be considered,
as so much trouble may arise from their defects. No two
men have as yet agreed as to what the standard muscular
arrangement should be for the standard eye. As to the
modifications suitable for the different variations in refrac-
tion and the different kinds of people, no one has the
slightest idea.
There are many cases with conditions of the ocular
muscles well recognized as abnormal, and definite symp-
toms which can be 'referred to the eyes with certainty.
Usually improvement of the muscular condition causes im-
provement of the symptoms, sometimes the eyes get better
and the symptoms get worse, and occasionally the symp-
toms disappear while the ocular condition gets worse.
The arrangements of modern civilized life are seen to be
entirely inadequate to the situation when we reflect that
the ocular muscles seem to be becoming more and more
peculiar and troublesome, while profanity has made no
advance since Washington fought the battle of Monmouth.
118 East Seventy-second Stkeet.
Note. — Reading the foregoing lias shown the inadequacy of the re-
marks about the local use of cocaine and atropine. Cocaine sometimes
causes superficial ulceration of the cornea. The danger of this may be
avoided to a certain extent if the surface of the globe is kept moist or
covered from the air. Its effect upon the ocular circulation is not
always a desirable one. The danger from the use of atropine in the
eyes in old people is in the production of glaucoma in hyperopic eyes
with shallow anterior chamber, or in the bad effect upon such eyes
when an insidious chronic glaucoma may have already begun to de-
velop.
REPORT ON CAPITAL PUNISHMENT,
BY A COMMITTEE APPOINTED BY
THE MEDICAL SOCIETY OF THE STATE OP NEW YORK
IN ITS SESSION OP 1891.*
Bv A. JACOBI, M. D., Sew Yobk, Chairman;
W. C. WEY, M. D., Elmira;
B. F. SHERMAN, M. D„ Ogdensbuegh.
Capital punishment has engaged the attention of all
classes of men, in and out of office — citizens, lawyers, clergy-
men, legislators, and philanthropists. It has gradually, un-
der ordinary circumstances, been restricted to such persons
as have taken the life of a fellow-being. Those in its favor
allege the propriety of retaliation, which, among so-called
civilized men, becomes the exclusive privilege of the com-
munities, and justify their position by referring to the Bible
and the dictates of religion.
* Read before the Medical Society of the State of New York, Feb-
ruary 8, 1892.
•265
Those opposed proclaim their respect for the sacredness
of human life under all circumstances, deny the right of
the state to destroy it, and protest against the community's
imitating in cold blood the example of the very murderer
whom it execrates for his brutality and cruel cowardice ;
they point to the degrading influence of executions, and
also refer, as their justification, to both the Bible and re-
ligion. Thus capital punishment is both condemned and
authorized by religionists, for the same reason that slavery,
but thirty years ago, was both justified and censured.
The questions engaging the attention of this Medical
Society of the State of New York are always scientific ;
they are practical only so far as they are dependent on and
based upon science. No matter what any of our members
believes or acts upon as a private citizen outside this hall,
and outside the legitimate labors of his professional life ;
no matter what his political party allegiance is, or his creed
and religious belief, here we are neither lawyers, nor legis-
lators, nor retaliationists, nor religionists. Thus your com-
mittee does not propose to ventilate the question of capital
punishment, or its perpetuation or abolition, and the sub-
jects connected therewith — viz., the nature of crime, of re-
sponsibility or irresponsibility, of the cerebral functions
called judgment and will, the existence or non-existence of
a free will and its limitations — from any other but an ana-
tomical and physiological, that is, scientific, point of view.
Your committee holds that no questions but those strictly
scientific and conducive to the hygiene of mankind have
any right before your forum. What we must principally
avoid is the reference to metaphysical speculations such as
that of one of the greatest minds in history, Spinoza. He
maintains that " in the mind there is no such thing as abso-
lute or free will, but the mind is determined to will this or
that by a cause which is determined by another cause, this
by yet another, and so on to infinity." Nor must we allow
ourselves to be swayed by an opposite consideration of
Huxley's, who contests that " theft and murder would be
none the less objectionable were it possible to prove that
they were the result of activity of special theft and murder
cells in the gray pulp." Objectionable ? That they cer-
tainly are, for they are anomalies in themselves and dis-
turbers of the equilibrium of social and moral economy.
Objectionable they were, both the theft of a sixpenny worth
when it was punished on the gallows as late as this very
century and that which is forgiven or mildly reprimanded
by a humane judge of our time. More than merely objec-
tionable is the murder of a fellow-being, whether it is ex-
piated on the gallows, or buried in an insane asylum, or
condoned by wire-pulling powers, or justified on the plea of
self-defense.
Crime is the result of an evil impulse which ought to
have been controlled. The controlling powers .ire the cere-
bral functions of judgment and will. Whoever is held re-
sponsible for their aberrations and his wrongdoings is
termed, and punished as, a criminal. Whoever is considered
irresponsible is no longer a criminal to be punished, but a
lunatic against whose vagaries society takes pains to protect
itself. Indeed, among civilized people, both the punish-
ment of the criminal and the incarceration of the hopelessly
266
insane are, or ought to be, but different modes of self-pres-
ervation. By them the theory of revenge and retaliation
has been given up long ago. Their minds are more bent
upon the preservation of the physical and moral health of
the community than on the spiteful annihilation of the rebel
against the common welfare.
The question of responsibility or irresponsibility is a
very grave one, both theoretically and practically. The as-
sumption of the adage " no free will exists " would explain
and excuse and defend everything either friendly or inimi-
cal to the interests of society and the rights of the individ-
ual. Still, many high in science and literature and philoso-
phy defend it.
Benedict, one of the best known and deservedly famous
physiologists and pathologists of the brain, comes ( On the
Brains of Criminals, Vienna, 1879) to the following con-
clusions :
" The brains of criminals exhibit a deviation from the
normal type, and criminals are to be viewed as an anthro-
pological variety of their species, at least among cultured
races.
" The constitutional criminal is a burdened individual,
and has the same relation to crime as his next-of-blood kin,
the epileptic, and his cousin, the idiot, have to their en-
cephalopathy conditions.
" The essential ground of abnormal action of the brain
is abnormal brain structure.
" The appreciation of these facts is likely to create a veri-
table revelation in ethics, psychology, and jurisprudence."
So it will ; though not every crime be dictated by dis-
ease, and because the interests of the commonwealth re-
quire protecting and saving.
Responsibility and irresponsibility have but uncertain
boundary lines. These can not always be determined.
They depend on a great many factors which may be fixed
or changeable, stationary or transitory. The education of
the young, no matter what his cerebral substance or general
physical constitution, works only by influencing and chang-
ing his brain structure. Disturbances of the health of the
body, and particularly of the brain, may either terminate
in restitution to the normal estate quickly and easily, or
with difficulty and late, or no recovery takes place at all.
This difference in the result may depend on the severity of
the attack, on a congenital disposition which need not as-
sume the significance of a malformation, but shows itself
only in differences in the power of resistance on the part
of the cells or organs in the individual bodies ; in the same
way in which an infectious fever destroys the one, injures
the other, and leaves the third intact and immune.
These varieties of structure, dispositions, and of pow-
ers of endurance and resistance are very interesting. There
are many anomalies in the nervous system which tend, ac-
cording to circumstances, either to recovery or to faulty
development. Such are the predispositions, recognizable
in infancy and childhood, to neuralgia, nervousness, melan-
cholia, misanthropy, eccentricity, dudism, hysteria, hypo-
chondria, inebriety, convulsions ; the tendency to cardiac,
vascular, and vaso- motor irregularities, such as palpitations,
fainting spells, vertigo, sudden congestions to brain and
face. They are neither diseases nor crimes, but they may
lead to both. Favorable or untoward influences determine
the development of a hypochondriac into either a famous
humorist, who makes tens of thousands of sturdy men
smile through tears, or a homicide, who sends a shudder
through men and women ; or a boy suffering from con-
gestive herfdaches may develop either into a heart moving
and soul-stirring poet or a raving maniac. For normal
growth and exaggerated overgrowth are but two different
results of the same vascular action.
The adult man or woman is the result of hereditary and
congenital structure and disposition and a thousand influ-
ences of mental or physical nature. The former are but
nominally different from the latter. Education is but the
shaping of the brain by impressions, the consequences of
which are physical, no matter whether they are permanent
or transitory. When the former, they impress even the
features of the face ; deep must be the delineations in the
nervous center which are permanently photographed out-
side. Thus there are educational crimes like social crimes.
The formation of the earliest habits is the determination of
the character of the man. The dime novel, which spoils
the taste and fires the imagination, is as certainly a source
of infection as the exhalation of a sewer. Paul Aubry
wrote in 1888 on the contagiousness of murder. With him
the great factors in inducing it are heredity and degenera-
tion. The latter, according to him, depends largely on
education — in its widest sense. He charges the public
press with producing crimes by its constant sensational re-
ports which excite the imagination and lead to imitation
by the persistent parading of an example. Thus are
brought about the acts of cruelty during political upheavals,
such as remind one more of insanity than of mere barbar-
ism. His prophylaxis is based upon the same opinions.
The prevention of the contagiousness of murder consists in
a sound moral, individual hygiene, in the moralization of
habits and customs, in proper regulations of the press re-
ports, and in a more logical severity of the courts of
justice.
Many of the physical changes which lead, or can lead,
to criminality are preventable. The servant girl who lets a
baby fall may maim it for life, or may so affect the brain as
to change the current of thoughts and feelings into crimi-
nality. The development of a syphilitic infant into either
a healthy man or an invalid, or the luckless possessor of a
cerebral endarteritis or gumma, with their physical or moral
consequences, depends on the diagnostic knowledge and the
therapeutic agents of the practitioner. It is he who may
be the intellectual father of the criminal. The obstetrician's
clumsy forceps, or improper use of forceps, has frequently
injured both head and brain. The prolongation of asphyxia
in the newly born gives rise to thrombosis, haemorrhages,
and secondary encephalitis, to paralysis, idiocy, epilepsy, or
insanity. Thus a few seconds more or less, thus obstetrical
knowledge and dexterity more or less, may decide the fate
of the newly born, his physical, intellectual, and moral
health or invalidism, and his whole future forever. Or con-
template a few large rhachitical heads a few years old after
the disease has run its full course. Their circumference
Maroh 5, 18!i2J JACOB!, WEY, AND SHERMAN: REPORT ON CAPITAL PUNISHMENT.
267
and shape are probably the same ; ossification has been com-
pleted for some time, and no great alterations will ever take
place. In all of them rhachitis was mostly cranial and cere-
bral. One has attained a normal development, one has de-
veloped an unusual amount of brain in the vacant space, and
the vascular irritation has added to its vitality and evolu-
tion into the growing genius ; the last is a confirmed hy-
drocephalus with its future semiparalysis and idiocy. Why
these differences ? Why — in one case the condition was
recognized in time and treated judiciously ; in the other
some domestic absurdity of diagnosis — difficult teething —
was furnished by the ignorant mother and meekly accepted
by the medical man. Thus the same big head may mean
either perfection or incompetence, and it takes more than a
jury of fellow-citizens to decide what is going on inside.
Psychical diseases or anomalies, both acute and chronic,
are frequent under toxic influences. Infectious diseases in
their acute stages give rise to acute attacks quite often.
Scarlatina, typhoid and puerperal fevers, poison the blood
and impair cerebral action by the mere circulation of the
ptomaine, though there be no complication with meningitis
at all. Even in children, insanity, both maniacal and mel-
ancholic, has often been met with in and after infectious
fever. Many of the child murders during the puerperal
stage were the results of puerperal infection. Opium and
the other narcotics — belladonna, hyoscyamus, stramonium
— have similar results of the depraving both judgment and
will-power. The chairman knew a woman who took at
once a number of doses of cannabis which were given
for medicinal purposes, and in her jocose aberration of
mind was found dancing and singing round the stove on
which she was roasting her baby. Next day the medicinal
mania wore off. It took hard work to save her from the
gallows. Ergot sometimes, more frequently iodoform,
oxide of carbon, and the sulphide of carbon of the India-
rubber works act in the same way. And alcohol ? The
delirium tremens and its many criminal acts fill the records
of both the hospitals and the courts of justice. Still more
dangerous, because more numerous, are its chronic effects.
Its ethical depravation equals its aesthetical ugliness ; men-
dacity, feebleness of will-power as bad as physical tremor,
idiotic torpor, and the delirium of jealousy and violence,
the habit of idleness and tramping, thieving, and outrages
of all kinds — are the mottoes inscribed on its flag. Acute
lead poisoning leads often to the same symptoms as that of
alcohol — sleeplessness, hallucinations, and violence like
those of delirium tremens; and its chronic influence leads
to results resembling those of progressive paralysis. Your
committee merely mentions cocaine, chloroform, chloral,
bromides, to remind you of the many external influences
which may slowly, silently, and surely so alter the cerebral
substance as to result in functional anomalies which, if un-
derstood, if recognized through that mute and hard cranial
shell, as what they are, would be called diseases ; when they
are not they are called crimes.
The anatomy and physiology of the brain arc greatly
under the influence of the heart. Many chronic and some
acute cases of dementia can be explained in this way. It is
always the chronic class which is more dangerous because
it is more difficult to notice and guard against. In many
of them atrophy, hypertrophy, or congenital smallness ; in
others, adiposity or fatty degeneration, or stenosis of the
aorta, with its consecutive cerebral anaemia and ill nutrition,
or the obliteration of the pericardium ; in very many the in-
competent mitral valve, with its retarding influence on the
intracranial circulation — is a cause of insanity or insane ac-
tions. The latter precede the recognition of the former a
long time. A man whose name was prominently mentioned
in connection with the New York dynamite affair was re-
peatedly before the coui'ts for assault and battery and at-
tempts at murder before his condition, appreciated and pre-
dicted by a member of your committee, was finally acknowl-
edged.
The diseases of the brain whose influence on and con-
nection with mental and moral diseases is undoubted are
either local or general. In many no other symptoms could
be discovered, in others the intellectual and moral anomalies
were complicated with other symptoms. To that class be-
long tubercles, which are quite common in demented per-
sons, syphilitic changes, abscesses, either from emboli or
atheromatous degeneration, neoplasms of different nature,
and multiple sclerosis. Very frequent is apoplexy either
from vascular incompetency or traumatic. A boy of eleven
years, under the observation of the chairman of your com-
mittee, fell from a tree and had convulsions which lasted for
hours until hemiplegia set in. While his paralysis was slow-
ly improving, he exhibited furibund attacks of violence with
attempts at murder, and finally epilepsy, all of which im-
proved after several years, leaving a moderate degree of pa-
ralysis.
Of the diffuse affections of the brain we shall only men-
tion inanition from physical causes and from overwork and
anxiety, and exhaustion from excesses, insolation, trauma,
and other causes of hyperemia and meningitis. Here be-
longs periencephalitis, which may begin slowly with physical
symptoms, or with mania and hypochondriasis. Senility is
a frequent cause of mental disturbance. Unfortunately, the
symptoms of most of these conditions may resemble each
other very much ; delirium, mania of all kinds, mainly per-
secution mania, puerility, irascibility, diffidence, misanthro-
py, are just so many symptoms of both acute, subacute, and
chronic forms. Epilepsy is a frequent cause of outbreaks
of unexpected violence. This peculiarity gave it the name
of propulsive epilepsy. Many criminal acts are the posi-
tive results of epilepsy, and many epileptics were cured on
the gallows. At this moment a negro is under trial for a
murder. He is known to have severe attacks of epilepsy.
Experts have sworn he is a criminal. Experts have sworn
he is diseased and not responsible. What does it teach ?
It teaches that there is surely reason for a doubt as to the
causation of the criminal act. It would also teach that so-
ciety as represented by the jury, and that society, represent-
ing the humane spirit of the times, ought to keep a sharp
lookout to its own dignity. Man may blunder, but society
can not afford to be brutally mistaken where it is at the same
time accuser, judge, jury, and executioner.
The malformations of the male sexual organs, mainh
anorchis and diminutive development of the penis and test)-
208
JACOBI, WHY, AND SHERMAN: REPORT ON CAPITAL PUNISHMENT. [NT. Y. Mm>. Jock.,
cles, predispose to mental degeneration, with its conse-
quences. One of your committee knows a man of thirty-six
with infantile organs and no trace of hair on the pubes.
In spite of repeated warnings not to expose himself to utter
failure, he attempted cohabitation. When alone with his
partner he grew moody and desperate, becoming more than
ever aware of his incompetency. In his rage at rendering
himself ridiculous he attempted to strangle the woman ; she
finally succeeded in saving herself and delivering him to
the police, which landed him in a penitentiary. Masturba-
tion and emissions produce melancholia and mania ; in
milder forms depression, despondency, and moral obliquity.
If you wish an example of monomania resulting from mas-
turbation and excessive venery, take that of a man other-
wise gifted and in high esteem for many personal qualities —
Tolstoi. His Kreuzer Sonata, the hero of which is evidently
an autophotograph, is the nastiest and most vulgar glorifi-
cation of male impotence and consequent moral depravity
possible. It is again the class of masturbators which fur-
nishes part of the disgusting tribe addicted to sexual per-
version, such as paederasty, sodomy, and homicidal mania.
Nymphomania I have not mentioned, because its complica-
tion with homicidal mania is but rare. But the influence
of the great developmental periods — puberty and the climac-
teric age — in the production of moral morbidity is well ap-
preciated.
< xi-eat difficulty in deciding the nature of a criminal in-
sult is experienced in cases of periodic insanity. It is these
cases which are received in lunatic asylums, retained for a
short time, and then discharged cured to exhibit favorable
statistics, or are freed by the philanthropoid cranks, who
mistake a hospital for a dungeon. The dangers of such
premature or unauthorized discharges are great indeed ; the
daily press reports from time to time homicides and mur-
ders committed by men who ought to be protected against
themselves and prevented from doing harm to others by
being locked up for life. Intervals between acute attacks
of mania or melancholia may last years ; particularly, cases
connected with epilepsy come suddenly like a flash. Moon
and sun, terrestrial magnetism, and the electrical condition
of the atmosphere, climate, telluric exhalations, intervening
diseases, be it only influenza, wounds, or other debilitating
influences of short duration — are apt to give rise to violent
outbreaks. In such cases the decision as to whether the
accused was a criminal or a sick man when the murder was
committed is very difficult or even impossible. Years after
the occurrence the diagnosis of the case must be attempt-
ed. The history of previous cerebral disease, of petit rnalov
full-grown epilepsy, neuroses and fainting spells, eccentrici-
ties, hallucinations, possible heredity will be told with more
or less significance. These are the very cases which prove
unmistakably that insanity is not always typical and con-
stant in its nature. Doubtful conditions are very frequent.
And in the face of these facts a jury is expected, under the
spur of one attorney and the derision of the other, to find a
verdict of responsibility or irresponsibility. These are also
the facts which have induced the Germans to establish the
principle of a partial responsibility.
When a crime is made the subject of investigation the
perpetrator ought to be subjected to the closest study. The
action of an engine is not estimated or calculated without
considering the shafts and wheels and boiler ; but the
changes of judgment and will are weighed too often by the
so-called common sense of the illiterate or semi-educated.
No matter whether Benedict and Lombroso are right or
wrong, these facts are incontrovertible. You meet too large
heads, too small heads, asymmetrical heads — such as you
find so very often in epilepsy and idiocy — asymmetrical
faces, disproportion between skull and face and their sin-
gle parts ; also disproportion between other parts of the
body, excessive length of extremities, big mouth, over-
grown tongue, the roof of the mouth too much arched or
too flat, and the teeth irregular ; the top of the head or the
occiput flattened, hare-lip and cleft palate, heavy lower lip,
deformed ears, and different colors of iris. There may be the
retracted nasal insertion and the shortened base of the skull of
the cretin or semi-cretin, or early neurotic symptoms — such
as hysteria, chorea, epilepsy, night-terrors, and tachycardia.
Suicidal tendency with the result of repeated at-
tempts at self-destruction is but rarely the result of in-
stantaneous despair or despondency. In many cases the
actors in that drama had an organic disease — among them
leptomeningitis in all its forms, sclerosis, syphilis, embolism,
gray degeneration, adhesions, and cysts. Acute and iso-
lated attacks are often the results of fever, in pnemnonia,
pleurisy, meningitis, typhoid fever, or influenza. And
these are, in part, the cases which are thought worthy not
of the hospital, but of the penitentiary.
Conclusions. — There are many causes of the perversion
of judgment and will.
These causes which are physical are either congenital
or acquired. When acquired, they are so either by the
progressive development of hereditary or congenital dispo-
sition, or by intervening diseases, or by the impairment of
cerebral evolution through bad training, example, and so-
cial influences.
The variety of causes, both anatomical and functional,
is such as to render an exact diagnosis extremely difficult.
The sworn opinions of experts are quite often contradictory.
Cerebral anomalies and lesions are very often not accessible
to our methods of investigation.
When there is any doubt in an individual case of
crime in regard to either responsibility or irresponsibility,
it is safer to take the alleged criminal to be diseased and
morbid than to declare the sick to be a criminal.
In many cases the innocent and the anatomically sick
have been subjected to capital punishment. On the other
hand, dubious cases developed full-grown dementia soon
after the criminal proceedings.
The knowledge of such occurences is part of the rea-
sons why juries are averse to rendering the verdict leading
to a death penalty, and why but a small percentage of
murderers are ever sentenced among us, and why so many
are set free to become permanent dangers to the safety of
the public.
Human society and the state, while they owe protec-
tion and safety to all, must make no mistake unless it be
in the direction of leniency and humanity.
J
March 5, 1892.|
BURY EE: TAENIA AS A
CAUSE OF NEURALGIA.
269
The medical profession must not allow mistakes to be
made which can be prevented. This Medical Society of the
State of New York — having the advantages of physiological
knowledge and being aware of the difficulties of being al-
ways correct, and of the absolute impossibility of making a
positively safe diagnosis in every case of alleged crime or
presumable cerebral disease or anomaly — expresses its op-
position to the perpetuation of capital punishment and its
hope that means will be found to protect the community
by less uncertain and less inhumane methods.
TxENIA
AS A CAUSE OF PERSISTENT INTERCOSTAL NEURALGIA,
ALSO OF THE ERUPTIVE FORM—/. E., HERPES ZOSTER.
By CHARLES C. DURYEE, M. D.,
SCHENECTADY, N. Y.
A little over a .year ago the writer was called to attend A.
W., aged twenty-eight years, tor severe pain over the left side
of the thorax. The pain had appeared about a week previous
to my first visit, and had been growing severer and confined
him to his bed. Tenderness along the seventh and eighth inter-
costal nerves was made evident by pressure. The diagnosis
was intercostal neuralgia, which, perhaps, might be the precur-
sor of herpes zoster. Various remedies were tried with little or
no result. Morphine was administered in sufficient quantity to
render his distress at all bearable. Matters continued thus for
about two weeks, when my patient called my attention to some
segments of tape-worm which he had that morning passed, the
first he had ever observed. Treatment for tape-worm was
promptly given, with the result of dislodging a worm of about
the usual length. The pain in the side rapidly began to subside,
and Mr. W. was soon at his business.
A short time after, a gentleman sent for me who had a severe
and typical herpes zoster. At my suggestion he examined his
stools for a day or two and discovered that he was infested
with taenia. Treatment resulted in a worm being removed
about twenty-eight feet in length, probably a beef-worm.
Since my attention was drawn to the first case related
I have seen eight cases of tape-worm, in which four of the
persons had either severe intercostal neuralgia or undoubted
shingles.
Herpes zoster is an expression of more or less acute
neuritis of the intercostal nerves, as are also many cases of
intercostal neuralgia.
The causes of these severe and ofttimes persistent dis-
eases are obscure and are given as compression, nerve in-
juries, operations, atmospheric changes, etc.
I have never seen the presence of t&mia given as a causa-
tive influence in these troubles, but I am of the opinion
that it is of more or less frequent occurrence, and that those
affections are probably reflex symptoms of the digestive
disturbances occasioned by that parasite. Be that, how-
ever, as it may, the foregoing suggestion may be of practi-
cal utility in some obscure and annoying cases.
Constipation. — " Dr. Platan, of Berlin," says the British and Colo-
nial J)ru<j<iist, "suggests a remedy for inveterate constipation. It
consists in the introduction of a pinch of finely powdered boric acid into
the bowel. The results are declared to he most satisfactory, even in
severe cases, in which mechanical measures had failed to afford relief."
THE
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by Edited by
D. Appleton & Co. Frank P. Foster, M. D.
NEW YORK, SATURDAY, MARCH 5, 1892.
THE LEGAL LIABILITY OF HOSPITALS IN CASES OF
ALLEGED MALPRACTICE.
Following close upon the recent dismissal of a suit against
Dr. "William T. Bull, of New York, for alleged malpractice,
comes another important decision in which Judge Giegerich, of
the Court of Common Pleas, dismisses a suit brought against
the Society of the New York Hospital. A young boy sustained
a simple fracture of the femur and was taken by his father to
the New York Hospital, where splints were applied in the usual
way. Three or four days afterward it was noticed that the
foot had become numb and cold, and this condition went on to
the development of gangrene, which made it necessary to per-
form amputation through the thigh. The boy's father put in
0
a claim for damages in fifty thousand dollars, alleging that the
gangrene was due to gross carelessness on the part of the hos-
pital surgeons in that they had bandaged the limb too tightly.
It was proved by the Society of the New York Hospital that
the hospital was a public charity, that it had used all due care
in the selection of its medical officers, and, consequently, that
it could not be held responsible in the case. The court held
that this proof released the institution from all liability for in-
jury sustained by the plaintiff.
Although in this case it was shown by indisputable evidence
that the gangrene was the result of arterial lesion-; sustained at
the time of the fracture, and that the dressings had been emi-
nently proper, the decision releasing the hospital from liability
on account of its character as a charitable institution is of in-
terest in the way of a precedent. It accords with recent de-
cisions made in Massachusetts and Pennsylvania, as well as in
this State, but it is at variance with a decision made in a suit
brought against the Rhode Island Hospital. So far as we know,
the Rhode Island decision is the only American one of impor-
tance that does not agree with Judge Giegerich's. The subject
is an important one, and it is to be hoped that a definite prin-
ciple in law will be established in regard to it.
In the first number of the new International Medical Maga-
zine the department of Forensic Medicine consists of an article
on this question by Mr. Lorenzo I). Bulette, of the Philadelphia
bar, who alleges that the American decisions that accord with
Judge Giegerich's are based on the precedent of an English de-
cision rendered in 1801, ;md that that decision is no longer re-
garded in English courts as of any weight. Ho cites certain
decisions in England practically overruling that of 1861, and
quotes from the decision of the Supreme Court of Rhode Isl-
and, after which he concludes his article as follows :
"The question, therefore, is, in a certain sense, still an open
270
LEADING ARTICLES.— MINOR PARAGRAPHS.
[N. Y. Med. Jouh.,
one, there being a decision each way. But, in view of the fact
that the single case on which t lie hospitals rely to exempt them
from liability has been emphatically overruled in England, and
that the later disposition of the courts in this country also is to
impose the liability in similar cases, it is easy to predict the re-
sult should the matter again come into litigation.
" Following this tendency, the Supreme Court of Rhode
Island, after mature deliberation, had no hesitancy in saying
that for the neglect of the interne, to send for the visiting sur-
geon, as the urgency of the case and the regulations of the hos-
pital required, the latter was answerable. And the same court,
guided by the later doctrine laid down in Mersey Docks va.
Gibbs, said with equal decision that the income of the charity
fund was the source whence to extract the golden balm for the
healing of this neglect.
" From all of which we may safely conclude that the rela-
tion which exists between a public charitable hospital and its
visiting surgeons, physicians, and nurses is that of master and
servant; and for the failure of such hospital either to exercise
reasonable care in the selection of its servants, or for the neg-
ligence and unskillfulness of the latter within the scope of their
employment, the hospital must respond in damages to the in-
jured patient." ,
THE HEALTH OF NEW YORK STATE IN 1891.
The Summary of Mortality of the State Board of Health for
the past year has been received. It shows that there were
123,878 reported deaths, a total requiring a small correction
on account of late returns and non-reported deaths from out-of-
the-way districts, so that the estimated number was 128,578
deaths. The mortality rate for the year was 21*4 per mille, as
compared with 19-6 in the year 1890. The zymotic causes of
death svere more active than in 1890, but less so than during
the last quinquennial averaged period. Aside from epidemic
influenza, which disease is not reported in a form susceptible of
tabulation, the deaths from zymotic disease numbered 22,000,
or 2,300 in excess of the total in 1890 and about the same as in
the year 1889. Scarlet fever caused 2,254 deaths, against 913 in
1890. Diphtheria also showed an increase of mortality and
was exceptionally active during the summer months, over
three hundred deaths from that disease having been registered
in the month of July. The midsummer mortality by scarlet
fever was high also, July showing 180 deaths. Measles and
whooping-cough were most lethal during the first half-year.
The deaths from influenza are estimated as having been 10,000,
a loss which is double that estimated to have afflicted the State
in 1890. The registrar's remarks indicate that the disease was
uniformly distributed through the State. Small-pox caused five
deaths, or one more than in 1890; this, if true, means less than
one death in a million of population, or one death out of 26,000
deaths from all causes. This is tantamount, almost, to an
eradication of .that disease, a state of things which can not en-
dure many years more in this State, in view of the incoming
masses of ignorant, incorrigible immigrants: the outlook is not
favorable to the publication of so good a statistical showing for
1892 as that which has just been presented for 1891. The
deaths by typhoid fever and by diarrheal diseases were more
numerous than in the year previous, but were not excessive
in number when compared with those of former averaged
periods. The deaths by consumption were 13,445, as compared
with 13,831 in 1890. This is equivalent to 109 deaths in 1,000
deaths from all causes, a ratio decidedly lower than was ob-
served during the last quinquennium. The ratio has been
known, as for example in 1880, to rise to 137 in a thousand
deaths. From respiratory diseases, not tubercular, there was
the enormous loss of 20,697 lives, which was 2,600 above the
loss from that class of causes in the year 1890: and the mor-
tality of each of these latter years has been in excess of that of
previous years — a fact that is chargeable in large measure to
the influenzal mortality being credited among the various
" local " classes. Old age was recorded as the cause of 6,500
deaths. There were 5,028 fatal accidents, or deaths from vio-
lent causes. The number of deaths " not classified " was only
15,300, which is less by 3,000 than in 1890. and indicates an im-
proved manner of dealing with the vital statistics of the State.
MINOR PA RA GRAPHS.
INTUBATION.
There seems to be little doubt that intubation is growing
steadily in favor abroad. In this country, where correct instru-
ments have been used and where instruction has been given so
largely by Dr. O'Dwyer and his pupils, the operation has ob-
tained a firm foothold and is far beyond the stage of probation.
In Enjrland and on the continent of Europe its progress has,
naturally, been slower. Reports that have been made, espe-
cially from France and Germany, seem to show that ill-con-
structed instruments have been used. Failures have been re-
peatedly reported of a character that could not have occurred
with proper tubes. Ranke has recently reported, in the Revue
des maladies de Venfance for December, 1891, a second series of
cases with much more favorable results than had been shown
in his first series. In the first he reported 413 cases of intuba-
tion, with 34 per cent, of recoveries, and 866 cases of trache-
otomy, with 38 per cent, of recoveries. In the series last re-
ported there were 348 cases of intubation, with 41 per cent, of
recoveries, and 237 cases of tracheotomy, with 34 per cent, of
recoveries. Bokai, after treating 109 patients by intubation,
believes that tracheotomy should be abandoned except in a
small number of selected cases.
A COLLECTIVE INVESTIGATION REGARDING ANAESTHETICS.
An exceptionally important inquiry, on a large scale, ac-
cording to the British Medical Journal, is to be made through-
out the hospitals of Great Britain, in the year 1892, regarding
anaesthetics. Eminent surgeons, anaesthetists, and general
practitioners will contribute their clinical experiences, as sup-
plemental to the conflicting results obtained by the experimental
workers. The research will be made under the auspices of the
British Medical Association. An influential and fairly consti-
tuted committee has charge of the plan of the inquiry, and
record books have been prepared for the use of those who are
willing to co-operate. These books have been carefully drawn
March 5, 1892.]
MINOR PARAGRAPHS.— ITEMS.
271
up so as to secure uniformity on the part of the reporters, and
they contain full instructions. Mr. Jonathan Hutchinson heads
the committee, and Dr. Ohilds, of Weymouth, is its secretary.
Among the other names of committeemen are those of Lister,
Annandale, Buchanan, Ohiene, Buxton, Duncan, Hewitt, Mao-
ewen, Croly, Butlin, and Macleod. The subcommittee for Eng-
land and Wales is headed by Mr. Pridgin Teale. Similar sub-
committees will preside over the work in Scotland and Ireland.
THE AMBULANCE SERVICE OF THE NATIONAL OUARD
OF THE STATE OF NEW YORK.
Surgeon- General Bryant has issued orders putting the am-
bulance corps on a somewhat different footing. This corps will
eventually be a body of trained nurses. The men formerly em-
ployed will, so far as possible, be reappointed, with the expec-
tation that at the end of the present year an advanced examina-
tion will be required. The original object was to. have ready at
hand a certain number of men who could in emergency cases of
various kinds, upon the inarch or in active service, render tem-
porary relief to the sick or injured until such time as the surgical
staff could be called upon. This system developed rapidly, and
it was found that the members of the corps, not content with
the comparatively simple duties assigned to them, pressed on-
ward until they became almost as proficient as trained nurses
would be. Some of the Red Cross men joined the classes for
nurse training at the hospitals, and some even took up nursing
as a vocation. A very praiseworthy enthusiasm actuates the
members of the corps.
TRANSPLANTATION OF THE CORNEA.
A case of corneal graft has been reported in the Berlin Jclin-
ische Wochenschrijt by Dr. Ilippel, of Konigsberg. The patient
had a dark-brown central discoloration of the cornea three mil-
limetres in diameter and reaching downward to the membrane
of Descemet, which had been the result of the action of nitrate
of silver. Cocaine was used. The discolored cornea was tre-
phined, down to the membrane of Descemet, with a trephine
the crown of which was four millimetres in diameter, and the
included disc was carefully removed. The surgeon then excised
from the eye of a young rabbit a disc of cornea of the same size
and implanted it in the patient's corneal wound. The coapta-
tion was accurately done and the new cornea was at a level with
the adjacent corneal tissues. Iodoform was used in the dress-
ing of the eye and both eyes were closed with a bandage. A
good recovery was made, and six weeks after the operation the
patient was dismissed with a completely transparent cornea.
THE INTERNATIONAL MEDICAL MAGAZINE.
This is a new monthly journal of general medicine and sur-
gery, edited by Dr. Judson Daland, and published in Philadel-
phia, by the J. B. Lippincott Company. The contents for the
first number, for February, are of a very valuable character, and
the journal makes a good appearance, but the proof-reading
ought to be improved.
NEUROTIC INFLUENZA.
Dr. C. U. Hughes, in a recent paper in the Journal of the
American Medical Association, concludes that the present epi-
demic of influenza is, in its incipiency as well as in its sequelas,
atoxic neurosis, more largely adneural than intraneural; that
the central or peripheral neuropathic lesions are more prone to
recovery than other similar, and apparently as grave, nervous
lesions occurring before the epidemic appeared; that the neuro-
pathic sequelae resemble post-diphtheritic nervous diseases in
their susceptibility to therapeutic measures; and that it brings
into activity latent neuropathic and other organic morbific
tendencies.
ITEMS, ETC.
Infectious Diseases in New York. — We are indebted to the Sanitary
Bureau of the Health Department for the following statement of cases
and deaths reported dining the two weeks ending March 1, 1892:
DISEASES;.
Week ending Feb. 23
Typhus
Typhoid fever
Scarlet fever
Cerebro-spinal meningitis.
Measles
Diphtheria . ...
^mall-pox
Erysipelas
Varicella
Pertussis
Mumps..
Cases, i Diaths.
16
13
209
0
224
134
7
2
16
4
5
31
1
17
35
a
o
o
0
0
Week ending Mar. I.
Cases. Deaths.
32
12
241
1
339
132
4
1
17
1
0
4
13
35
2
18
48
3
0
0
0
0
New Buildings for the Jefferson Medical College of Philadelphia.
— The board of trustees and the faculty of the Jefferson Medical Col-
lege have just completed the purchase of two large lots on Broad
Street, giving them a frontage of about 300 feet and a depth of 150
feet, upon which they will proceed to erect at once a handsome hospi-
tal, lecture-hall, and laboratory building. The estimated cost of the
buildings is $500,000. The hospital will not only be built as a suitable
building in which to care for the sick and injured, but also will be pro-
vided with a large amphitheatre for clinical lectures. The basement of
the hospital building will be given over to the various dispensaries, each
of which will be provided with large waiting and physicians' rooms, as
well as rooms for the direct teaching of students. The buildings will
be absolutely tire-proof, and provided with patent sprinklers in case
their contents catch fire. By the erection of three commodious build-
ings, the laboratories where delicate work with the microscope or ap-
paratus is carried on will be separated from the college hall where
didactic lectures are given, and so will be free from any jarring produced
by the movement of large classes. With the hospital on one side af-
fording clinical facilities and the laboratory on the other side of the
college hall for scientific research and training, the college will be most
favorably situated for giving thorough instruction in medicine. Fur-
ther than this, immediately across the street is the Howard Hospital,
and on the adjoining corner is the Ridgway branch of the Philadelphia
Free Library, which contains all the scientific works belonging to this
wealthy corporation. The new site is even more favorably situated in
regard to the center of the city than the old one at Tenth and Sansom
Streets. The move has been made necessary by the large number of
students who are now being instructed in this institution, and because
ths faculty desire to keep the school and hospital in the foremost rank
of medical education in this country. The buildings will be ready for
occupancy in the session of 1893-'94.
The French Congress of Surgery. — The Union medicale announces
that the sixth session will open in Paris on April 18th. The chief
subjects of discussion will be: The Pathogeny and Treatment of Sur-
gical Gangrene, The Pathogeny of Infectious Accidents Subjects of
Urinary Disease, and Operations on the Biliary Passages.
Professor Virchow in Defense of his Name. — The Deutsche Meduinal-
Zeitung quotes as follows from a letter written by Professor Virchow
to the Vossische Zeitung : Newspapers from Cincinnati contain adver-
tisements that the "great German Physician," Dr. Kurl Virchow
Schick, has arrived from Berlin and is prepared for consultations. It
is alleged that he has made important discoveries in the "germ treat,
ment of chronic diseases," and that his presciiption is being used by
80ti physicians in Europe. Allow me to say that, according to the
272
ITEMS.— OBIT U A RIBS.
[N. Y. Med. Jour.,
official registers, there is not and has not been a physician of this
name in Berlin or in Prussia, and none such is known in any of the other
states of Germany. It is hoped that this notice will induce the Ameri-
can journals to oppose the gentleman's course.
An Alumni Association of the Ex-internes of the Presbyterian Hos-
pital of New York was organized on February 19th. Dr. W. Kt Simp-
son was elected president, and Dr. K. R. Ross secretary and treasurer.
The Chattanooga Medical College will hold its annual commence-
ment exercises on the 15th inst. Addresses will be delivered by Dr.
Robert Battey, of Rome, Georgia, and by Dr. N. C. Steele, of the
faculty.
The Brooklyn Surgical Society. — The special order for the meeting
of Thursday evening, the 3d inst., was a paper on Myoma Uteri com-
plicating Pregnancy, by Dr. Pilcher.
The Harvard Medical Society of New York. — At the meeting of
March 5th Dr. Coe is to read a paper on The Difficulties in the Diagno-
sis of Pregnancy.
Influenza and Life Insurance. — It is stated in the Mcrcredi medical
that fiom 1890 to 1891 an English insurance company had to pay over
a quarter of a million dollars on deaths caused by influenza. This is
two and a half times as much as cholera had cost that company in
forty-five years.
Starch in a Fungus. — " It is a well-known fact that, generally
speaking, starch is not found in fungi and those plants which are
without chlorophyll ; one or two instances have been noted of its occur-
rence, however, in special cases, and lately M. E. Bourquelot has dem-
onstrated its presence in Boletus pachypus. Immediately on touching a
section of the boletus with an aqueous solution of iodine and potassium
iodide it gives a line blue tint. The reaction takes place throughout
the whole pseudo-parenchyme, but does not occur in the cells of the
hymenium or in the sub-hymenial tissues." — British and Colonial
Druggist.
The Death of Dr. Charles R. Vanderberg, of Columbus, Ohio, oc-
curred on February 22d. He was a graduate of the Starling Medical
College, of the class of 1885, and lecturer on pathology in that institu-
tion for several years before his death, which took place in his thirty-
fourth year.
•
Naval Intelligence. — Official List of Changes in the Medical Corps
of the United States Navy for the week ending February 27, 1892 :
Means, V. C. B., Passed Assistant Surgeon. Detached from the Naval
Hospital, New York, and ordered to the Navy Yard, New York.
Lane, George A., Assistant Surgeon. Detached from the Navy Yard,
New York, and ordered to the Naval Hospital, New York.
Marsteller, E. H., Passed Assistant Surgeon. Detached from the
Marine Rendezvous, Baltimore, and to wait orders.
Cordeiro, F. J. B., Passed Assistant Surgeon. Detached from the
Marine Rendezvous, Boston, and ordered to the U. S. Steamer
Adams.
Marine-Hospital Service. — Official List of the Changes of Stations
and Duties of Medical Officers of the United States Marine- Hospital
Servici for the three weeks ending February 27, 1892 :
Pbrviance, George, Surgeon. Detailed as chairman of the Board of
Examiners. February 20, 1892.
Hamilton, J. B., Surgeon. Detailed for special duty. February 18,
1 892.
Stonkr, G. W., Surgeon. Detailed as member of the Board of Exam-
iners. February 20, 1892.
Irwin, Fairfax, Surgeon. Ordered to Norfolk, Va., for temporary
duty. February 16, 1892. Granted leave of absence for seven days.
February 24, 1892.
Carter, H. R., Surgeon. Detailed as recorder of the Board of Ex-
aminers. February 20, 1892.
Wheeler, W. A., Passed Assistant Surgeon. Ordered to examination
for promotion. February 16, 1892.
Vaughan, G. T., Passed Assistant Surgeon. Detailed as executive
officer, Supervising Surgeon-General's Office. February 27, 1892.
Society Meetings for the Coming Week :
Monday, March 7th: New York Academy of Sciences (Section in
Biology) ; (Jerinan Medical Society of the City of New York ; Mor-
risania Medical Society (private); Brooklyn Anatomical and Sur-
gical Society (private); Utica Medical Library Association ; Corn-
ing, N. Y., Academy of Medicine ; Boston Society for Medical Ob-
servation; St. Albans, Vt., Medical Association: Providence, R. I.,
Medical Association (annual); Hartford, Conn., Medical Society;
Chicago Medical Society.
Tuhsdat, March 8th : New York Medical Union (private) ; Medical So-
cieties of the Counties of Chemung (quarterly Elmira), Rensselaer,
and Ulster (quarterly), N. Y. ; Kings Count Medical Association;
Newark, N. J., and Trenton (private), N. J-, Medical Associations;
Baltimore Gynaecological and Obstetrical Si.iety.
Wednesday, March 9th : New York Surg.cal Society ; New York
Pathological Society ; Metropolitan Medical Society (private); Ameri-
can Microscopical Society of the City of New York ; Medical So-
cieties of the Counties of Albany and Montgomery (quarterly), N. Y. ;
Pittsfield, Mass., Medical Association (private) ; Worcester, Mass.,
District Medical Society (Worcester); Philadelphia County Medical
Society.
Thursday, March 10th : New York Academy of Medicine (Section in
Paediatrics) ; New York Academy of Medicine (Section in Genito-
urinary Surgery); Society of Medical Jurisprudence and State Medi-
cine; Brooklyn Pathological Society; Medical Society of the County
of Cayuga, N. Y. ; South Boston, Mass., Medical Club (private);
Pathological Society of Philadelphia.
Friday, March 11th : Yorkville Medical Association (private) ; Ger-
man Medical Society of Brooklyn ; Medical Society of the Town of
Saugerties.
Saturday, March lilh : Obstetrical Society of Boston (private).
(Obituarits.
BUCKMINSTER BROWN, M. D., OF BOSTON.
In the death of Dr. Buckminster Brown the profession loses
the man who developed and first practiced the specialty of
orthopaedic surgery in this country.
He was the grandson of Dr. John Warren, the patriot, orator,
and Revolutionary surgeon, and the son of Dr. John Ball Brown ;
he thus had special advantages of both birth and training. When
fourteen years old lie suffered a fall upon the ice and for eight
years was an invalid. This it was that appears to have shaped
the course of his work. The lack of any surgeon possessing an
orthopaedic training led his father to study the subject thor-
oughly and to become recognized as an authority ; and the son,
during the long years in bed, studied his profession, and be-
cause of his infirmity had his thoughts and studies constantly
turned to orthopaedics. Receiving his degree in 1844, he went
abroad and followed the practice of the masters, Little, Stro-
meyer, and Guerin, for two years. On his return he naturally
inherited the orthopaedic part of his father's practice. This was
nearly fifteen years before Davis, Sayre, and Taylor came promi-
nently to the front in New York. Jn 1861 Dr. Brown was ap-
pointed to the charge of a ward in the Home of the Good
Samaritan, devoted to the treatment of deformities. This was
two years before the New York Hospital for the Ruptured and
Crippled was opened, and five years before the founding of the
New York Orthopaedic Dispensary.
Two examples may be cited which well illustrate Dr. Brown
in his relations to the profession and to his patients: During the
March 5, 1892.J LETTERS TO THE EDITOR.— REPORTS ON THE PROGRESS OF MEDICINE.
273
quarter of a century which followed the first writings of Davis,
Sayre, and Taylor upon the treatment of chronic joint disease,
he who questioned the value of the "motion-without-friction"
treatment, or ventured to neglect the use of apparatus for porta-
tive traction, risked his professional reputation, his honorable
appointments, and even his good name. Yet during all this
time Dr. Brown continued to treat joint disease by prolonged
rest ; unmoved and apparently unconscious of the epidemic de-
lirium, he did not feel it uecessary either to write in defense of
his own position or to point out the absurdities and inconsist-
ences of those who felt the sting of his neglect. One can under-
stand that a man the courage of whose convictions was so well
founded could undertake and pursue for two years the treat-
ment by traction and recumbency of a case of congenital dislo-
cation at both hip joints, but to gain and hold the perfect con-
fidence and co-operation of both mother and child so that the
traction was not once relaxed and the position of the patient
not once changed, evidences a man having as marvelous an in-
fluence over others as he had control over himself. Men are
few who can pursue a new line of treatment in an individual
case for two years without once relaxing their self confidence,
but they are fewer still who, without either precedent to cite or
objective progress to show, can retain the confidence of the pa-
tient and the support of the family for so long a period. Such
a man was Buckminster Brown, typical of all that is best in the
orthopaedic surgeon : positive conviction, untiring patience, un-
flagging interest, fertile in expedients, careful in the details of
his work, and possessed of that inestimable birthright — that
something which makes the man loved and trusted by children.
John Ridlon.
fetters to tbe OEbitor.
ASHEVILLE AS A WINTER RESORT.
Alexandria, Egypt, December 18, 1891.
To the Editor of the New York Medical Journal :
Sir: I learn from your issue of November 21st that Dr. Karl
von Ruck, proprietor of the Winyah Sanitarium for Consump-
tives, at Asheville, N. O, is also the observer of the United
States Signal-Service Station in that city. His letter on the
subject of the Asheville climate, while written in his capacity
as a Government officer, seems to me to be sadly tinctured with
the knowledge of the presence of another sanatorium than his
own in Asheville. I hope that physicians who do not reside in
Asheville, who may have spent in past years or may spend in
coming years the months of January, February, and March in
that resort, will come forward with their testimony as to the
value of Asheville as a winter resort during those three months.
Frederick Peterson, M. D.
Reports on tjje jprorjress of Mebirine.
REPORT ON OPHTHALMOLOGY.
By CHARLES STEDMAN BULL, M. D.
(Concluded from page 21(8.)
A Case of Intracranial Neoplasm with Localizing Eye Symptoms.
— Oliver (Arch, of Ophthal., xx, 1) reports the following case: A
man, aged thirty-nine years, had for two years suffered from vertigo,
headaches, and momentary blindness. There was no history of trau-
matism, or abuse of tobacco or alcohol, or syphilis. In April, 1889,
his right foot became stiff, numb, and weak. In August, 1889, some
curious motor symptoms developed themselves. The right arm was
adducted to the trunk, the forearm was flexed on the arm and the
hand on the forearm, while the fingers remained extended. The
seizures lasted from one to several minutes. These attacks became
increasingly frequent, and during the attack the right leg was ex-
tended. The right grip was weak, and the right patellar tendon re-
flex exaggerated. Right ankle clonus was always present, and the
knee clonus at times. No evidence of any mental impairment. Tem-
perature, pressure, and muscular sense all markedly diminished on right
side. Right lateral hemianopsia. On February 26, 1890, some head-
ache and marked diminution of sight in remaining half-fields of vision.
The vision was reduced to -45,r. Direct vision for color lowered. Wer-
nicke's hemiopic pupillary reaction sign plainly manifest on both sides.
All the symptoms pointed to some disturbance in the sensory motor arc
of the ocular apparatus at the base of the brain in the left optic tract,
anterior to the corpora quadrigemina and posterior to the optic com-
missure. Retinal arteries and veins engorged on the right side. Large
haemorrhage on right optic disc. The patient died comatose on March
21st. At the autopsy the left hemisphere bulged. On horizontal sec-
tion, the left lateral ventricle was .shallower than the right. The left
optic thalamus was indurated and swollen. Perpendicular section of
the hardened mass revealed a neoplasm, involving the external portion
of the left optic thalamus and corpus striatum, pinkish in color and
resisting. The capsule was not invaded. The left optic tract as far
as the chiasm was markedly flattened and pressed. The tumor was a
glioma, with beginning sarcomatous degeneration.
Bilateral Hemianopsia. — Schweigger (Arch, of Ophthal., xx, 1) re-
ports a case of this rare affection. A man, aged seventy-five years,
was suddenly attacked in September, 1888, with a hemiopic defect
in both lei t halves of the visual fields, without the occurrence of
any other symptom. The central vision was unchanged, and the oph-
thalmoscopic appearances were normal. In August, 1889, the right
halves of the visual fields failed suddenly, as the left had done, but a
small central field of vision was preserved, of twenty-two minutes in
diameter. In the region of the hemiopic defects the movements of the
hand were perceived eccentrically.
The Pathological Anatomy of Panophthalmitis. — Schobl (Arch,
of Ophthal., xx, 1) reports a large number of cases, and summarizes
as follows : A general oversight of the entire process of panoph-
thalmitis justifies the assertion that, whether the disease be of trau-
matic, secondary, or metastatic origin, it commences constantly with
a fulminating purulent retinitis or chorioiditis, or both together. To
this is soon added a scleritis and inflammation of the capsule of Tenon,
and, it' the cornea has not been previously destroyed, a keratitis in-
ducta interstitialis follows, which later assumes a suppurative charac-
ter. Following this come the carnifying and hyperplastic inflamma-
tions of the various parts of the eye. The original purulent masses
are gradually replaced by granulation tissue, from which later young
connective tissue develops. Finally, the new-formed connective-tissue
masses may undergo a cicatricial shrinking, and retrograde metamor-
phoses take place.
Insufficiency of the Oblique Muscles. — Savage (Arch, of Ophthal.,
xx, 1) calls attention to the well-known function of the oblique mus-
cles to keep the naturally vertical meridians of the two cornea) parallel
even when not vertical. If there is perfect equilibrium of the obliques,
this parallelism of the vertical meridians is preserved without trouble;
but, if the superior oblique of either eye be too strong for its inferior,
or vice versa, the parallelism of the vertical meridians is preserved and
double vision prevented only by excessive work on the part of the
weaker muscle. This brings on, at longer or shorter intervals, a train
of nervous symptoms, for which at present there seems to be no hope
of prevention or cure.
The Development and Course of the Medullated Fibers in the
Chiasm of the Optic Nerves. — Iiernheimer {Arch. »f Ophthal., xx, 2)
h is been impressed l>y the fact that in the optic nerve, some millimetres
distant from the lamina cribrosa, the libers appear as simple axis cvlin
REPORTS ON THE PROGRESS OF MEDICINE.
[N. Y. Med. Jour.,
ders without a medullary shoath. This led him to study the develop,
raeut of the medullary sheath of the nerve fibers in the chiasm by
means of Weigert's method of staining. Tlie chiasm of the new-born
infant is to be considered a nervous organ incompletely provided with
medullated fibers; and the formation of medullary substance does not
exteud to the lamina cribrosa. No trace of medullary substance can be
found in the chiasm, or in its roots and processes, before the twenty-
ninth week of embryonic life. In the chiasm j>f the infant of the sec-
ond or third week all the axis cylinders possess a medullary sheath in
their whole extent. Careful examination of serial sections of the chiasm
at this early stage will show that there are fibers in the upper hall of
the chiasm which pass directly from one tract to the nerve of the same
side. The fact that the lower half of the chiasm contains only fibers
which cross, and that the upper half contains both sorts mixed together,
warrants us in assuming that the number of crossed fibers is consider-
ably greater than the number of direct ones The question as to
whether the fibers run in a compact bundle must be answered in the
negative.
Circumvasculitis Retinae. — Sheffels [Arch, of Ophthal., xx, 2)
reports the case of a young blacksmith, aged eighteen, in whom con-
genital syphilis first manifested itself in the form of circumvasculitis of
the retina of both eyes, attacking only the veins with the exception of
the left v. tempor. super., leading to partial occlusion of the caliber of
the vessels, enormous dilatation and very peculiar tortuosity of the
terminal veins, and extensive haemorrhages. Under the inunction
treatment the haemorrhages and perivascular patches are rapidly ab-
sorbed, leaving only the curious tortuosity of the veins.
The Action of Prismospheres and Decentred Lenses. — Percival
(Arch, of Ophthal., xx, 2) takes up the subject of the unsatisfactory
action of prisms in the relief of muscular defects of the eye, and thinks
this is due partly to the difficulty found in determining exactly the rela-
tive strength of the ocular muscles, and partly to a want of recognition
of the precise action of prisms. In all cases in which errors of refrac-
tion exist these must first be corrected by proper lenses. Then the
absolute minimum of convergence is determined by providing the pa-
tient with glasses which enable him to define some distant object with-
out exerting his accommodation. While his attention is now concen-
trated on it, abducting prisms are placed before the glasses, and the
strongest prism compatible with single vision enables one to discover
the minimum of convergence. The exact determination of the abso-
lute maximum of convergence is more difficult. After the examination
of the refraction and the accommodation of the eyes, glasses should
be given such that the near point of accommodation becomes one third
of a metre. The strongest adducting prisms compatible with single
vision must now be found. The position of the near point of con-
vergence can then be determined, either by the help of the tables
or by means of a simple calculation. Prisms are sometimes chosen
at ritndom and ordered to be worn in the hope that they will relieve
certain symptoms. Failure very often attends such unscientific treat-
ment. There should in every case be granted a fair trial of prismo-
spheres.
A Prism-measure or Lens-centering Instrument. — Smith (Arch, of
Ophthal., xx, 2) describes a new instrument devised for the purpose of
centering lenses, and also for measuring the degree of a prism or prisms
in lenses combined with spherical or cylindrical surfaces. The instru-
ment consists of a bed plate, upon the front of which is fixed a degree
circle, and hinged to the bed plate is an upper plate thrown up by a
spring. An upright face plate stands at right angles to the upper plate.
On the top of the upright face plate is a degree circle. The index finger
is made of steel, and pivoted at a point to swing easily over any portion
of the dill plate. In using, the lens is placed on the lower points of
the surface of the bed plate. The upper plate is pressed down until its
two points touch the lens, and if the lens u of the same thickness at
the two points, the index finger will point to zero on the degree circle
of the upright face plate. In measuring prisms, the position of the
index finger will be governed by the difference of the thickness of the
lens at the two points of the upper plate, and the degree of the prism
will be indicated on the degree circle.
The Proposed Methods for numbering Prisms. — Duane (Arch, of
OphihcU., xx, 3) has calculated a table for the purpose of determining
whether the difference between the values of the deviation produced in
the three different positions of the prism is sufficiently great to be of
practical moment. He deduces the following facts from this table: 1.
Prismatic numeration, according to the angle of minimum deviation, is
sufficiently accurate when a single prism is used. 2. When, however,
as in testing the a lduetive capacity, an aggregation of prisms whose
collective refracting angle exceeds 20° is employed, tfe resulting de-
viation will be more than th» sum of the original deviations produced
by the component prisms, and must be computed by referring once
more to the refracting angles of the latter. 3. When an object viewed
through a converging prism, arranged in the postero-normal position,
is approached to the eye, the incident ray is no longer normal to the
posterior face, but becomes more nearly normal to the anterior face of
the prism. Hence the deviation produced by the prism, although its
position remains the same, is greater in proportion as the object ap-
proaches the eye, and when an aggregation of prisms of total refract-
ing angle in excess of 20° is employed, and the object is brought very
near the eye, the true convergence would be quite in excess of that cal-
culated upon the assumption that the prism has remained in the pos-
tero-normal position, and still more in excess of the value deduced
from the minimum deviating power of the prism.
Disseminated Sclerosis, presenting the Clinical Aspect of Primary
Spastic Paraplegia, with Atrophy of both Optic Nerves.— Zimmer-
inann (Arch, of Ophthal, xx, 3), in reviewing the complications of the
clinical features of primary spastic paraplegia exhibited by his case,
calls attention to the inferior importance of all of them in comparison
with the aff^tion of the optic nerves. Atrophy of the optic nerve,
when associated with the symptoms of primary spastic paraplegia, is
the most valuable and reliable guide in the diagnosis of disseminated
sclerosis. When observed early, before any striking appearance of
other symptoms, its peculiarities will give us a hint to be on the lookout
for other signs, thus enabling us to make an early and distinct diag-
nosis.
Anomalies of the Ocular Muscles ; an Examination of von Graefe's
Doctrine of "Antipathy to Single Vision." — Stevens [Arch, of Oph-
thal., xx, 3) sets forth a view of the causation of this anomaly as fol-
lows : The condition of antipathy to single vision, as described by von
(iraefe and by subsequent authors, depends not upon lesion of the brain
or faulty projection of the images of the retina;, but upon unequal ten-
sion of corresponding ocular muscles under the influence of correspond-
ing nerve impulses directed to them. The causation of this supposed
antipathy exists mainly in two conditions. The first of these is acquired
as the result of the squint operation, and consists in the fact that by
unequal setting back of the inseition of the corresponding tendons,
there are induced irregular responses to the impulses directed to these
corresponding muscles. A second causative influence, and one which
acts as an element in nearly all cases, is the difference in relative ten-
sion of muscles which act in the vertical direction.
Report of Four Hundred and Fifty Simple Extractions of Senile
Cataract. — Greef (Arch, of Ophthal., xx, 3) gives a resume of the eases
of cataract treated in Schweigger's clinic. One group of cases was op-
erated upon with the Sell weigger-Forster capsular forceps. Baer's
broad knife, which at a distance of 30 mm. from the point is 4 mm. high,
was soon supplanted with one 5 mm. hi^rh, anil later still with one 7 mm.
high. The section in the cornea was made upward in 1 17 cases. Twen-
ty-five cases were operated on with the downward section. In the 142
cases there was perfect success in 104 cases, or 73"3 per cent., and 8
cases of Ions, or ;V6 per cent. Two of these losses should be excluded,
as the cases* were complicated with irregular astigmatism from old cor-
neal leucomata, and with chorioiditis at the macula. In the remaining
six cases the loss was due as follows : In one case to hemorrhage into
the anterior chamber immediately after the operation ; in two cases to
irido-chorioiditis, secondary cataract, posterior synechia', and thicken-
ing of the iris ; in one case to prolapse of iris, followed by itido-cyclitis ;
in three cases to infectious infiltration of the lips of the wound. Pro-
lapse of the iris occurred in nine cases, and in eight of them the iiis was
cut off. Prolapse of vitreous is one of the chief anatomical conditions
after which prolapse of iris may be expected ; therefore, wherever this
accident is probable, as in high degrees of myopia, fluidity of the vit-
reous, etc., it is best to perform the operation with iridectomy. From
/
March 5, 1892.]
REPORTS ON TEE PROGRESS OF MEDICINE.
275
his own records, neither Schweigger nor his assistant, Greef, can fur-
nish any satisfactory statistics as to whether prolapse of the iris is oftener
seen after the upward or downward section. As regards the technique
of the simple operation, much more care is needed in the first few
hours than after the old operation, and most operators are agreed in
avoiding the least movement of the patient after the extraction of the
lens. The patient must be comfortably put to bed, and remain there
a? quietly as possible for three full days. The bandage is renewed on
the second day, but the eye is not to be inspected till the third or fourth
day. Atropine may be dropped into the inner corner of the closed lids
as long as may be necessary.
Glaucoma and Affections of the Optic Nerve. — Schweigger (Arch,
of Ophthal., xx, 4) has here a general " critique " on the subject of glau-
coma. He considers that it is now conceded by every one that cases of
excavation reaching to the margin of the disc are not uncommon where
the skilled touch has been unable to detect any trace of increased ten-
sion. The candid observer must admit that increase of intra-ocular
pressure must be carefully considered in the light of other diagnostic
evidence. Augmented tension and glaucoma are by no means identical
conditions. Increase of tension may be doubtful or altogether absent
in cases where glaucoma was certainly present. There is no such thing
as a standard of hardness by which the tension of all eyes can be deter-
mined. There are eyes that are physiologically hard and eyes that are
physiologically soft. If we inquire into the conditions under which ex-
cavations occur in glaucoma, we must begin with a study of the physio-
logical excavation. Our knowledge of the physiological leads us to an
appreciation of the pathological. Schweigger defines the term "physio-
logical excavation " to be one which includes more than one third of the
disc surface, and whose floor is formed by the lamina cribrosa. There
may be slight variations in breadth and depth. When there is joined to
this pre-existing physiological excavation an optic-nerve atrophy, the
difficulties of diagnosis are greatly increased. He feels convinced that
all cases described as glaucoma simplex fulminans are really instances
of atrophic degeneration of the optic nerve occurring with physiological
cupping of the disc. If this is true, there is no such thing as a typical
excavation due to intra-ocular pressure. Leaving the questions of ten-
sion and excavation of the disc and coming to a consideration of other
symptoms, he considers the cloudy cornea as an inflammatory cedema,
but without anything characteristic about it. As regards the condition
of the pupil, he believes that glaucoma may progress to complete loss
of sight, without any interference with the mobility of the iris. The
dilatation of the iris in glaucoma with inflammatory symptoms he re-
gards as of the greatest diagnostic value. It rarely happens that the
pupil is enlarged and at the same time round and perfectly movable.
In most cases this enlargement of the pupil may be regarded merely as
a ciliary paralysis from pressure. The arterial pulsation so often met
with is the result of a disproportion between the intravascular pressure
in the arteria centralis and the vitreous pressure. Usually the cause of
the phenomenon lies in increased intra-ocular tension, but this is not al-
ways the case. He considers arterial tension alone as insufficient evi-
dence of glaucoma. In Sehweigger's opinion, the diagnostic value of
the halo glaucomatosus is very small. He considers that the course of
the disease is marked by distinct attacks of increased tension that come
on and again subside. A most important consideration is that the in-
flammatory symptoms of glaucoma are not the cause but the results of
increased tension. The ciliary body is undoubtedly the locality in which
the sympathetic secretion of glaucoma takes place. The only road to
success in diagnosis lies in continued observation. As soon as the ex-
istence of glaucoma has been demonstrated, iridectomy should be per-
formed at the earliest opportunity. When glaucoma malignum attacks
one eye, it follows hidectomy on the other eye, even when the second
eye is not affected for years after the first. In all cases of chronic
glaucoma affecting both eyes it is advisable to operate first of all upon
the worse eye, even if it be absolutely blind. Should this be followed
by the normal healing process, the second eye may be operated without
the least apprehension. As soon as an iridectomy has been performed
on a genuine case of glaucoma, we may regard it as certain that the
disease has been brought to a standstill. The instances in which
this is not true are so extremely rare that they do not carry much
weight.
Papilloma of the Conjunctiva. — S. Fuchs (Arch, of Ophthal., xx, 4)
thinks that a better name for this disease would be " fibroma papil-
lare," for in many cases the epidermoid or epithelial strata make up no
small part of the tumor, particularly in those papillary fibromata which
develop as a plate or skin-like mass of connective tissue. A study of
the genesis of these tumors always shows that they really belong to the
class of fibrous growths, and that the small amount of fibrous tissue
present is due to the fact that there has been a retrograde metamor-
phosis or an atrophy, caused by the excessive development of the epi-
thelial constituent. In the initial stage all these papillary growths
appear as a small, round knot due to excessive development of the
superficial tissue ; vessels push into the connective-tissue center of the
little bud, and at the same time the epithelial layer grows thicker. New
sprouts appear on the bud and become vascular, forming finally a
branched papilla. The papillomata which spring from the tarsal con-
junctiva often assume a cauliflower appearance, with a wide base.
Similar forms of less extent are seen on the plica semilunaris. Those
developing on the ocular conjunctiva and in the fornix are, on the con-
trary, branched pedunculated vegetations with a papillary surface.
Fibroma papillare of the sclera-corneal border, in its initial stage, can
hardly be distinguished clinically from epithelioma ; but, when it has
reached a certain development and overlaps the cornea, the infiltration
or non-mfiltration of the substance of the cornea is a diagnostic sign
of great value, for a papilloma which overlaps the cornea may be lifted
up and pushed back to the conjunctiva, but an epithelioma will infil-
trate the corneal substance and rest immovably on it. Another valua-
ble point is the enlargement of the neighboring lymphatic glands, which
never occurs in papilloma. The papillomata of the limbus are distin-
guished from so-called ''spring catarrh " by their softness and their
papillary surface. Papillomata are benign, although inclined to recur
if not radically removed.
Pulsating Exophthalmia. — Wing (Arch, of Ophthal., xx, 4) re-
ports the case of a man, aged twenty-two, who, in August, 1889, fell
some distance, striking on his head, and was carried in an uncon-
scious condition to a hospital. He remained unconscious for twenty-
four hours, and was discharged in ten days apparently well. In De-
cember, 1889, the right eye began to protrude, and continued to do so
till June, 1890. At that time the lids could scarcely be closed over it.
Vision was ^oV- There was a distinctly pulsating tumor at the upper
and inner angle of the orbit. There had never been any pain. By press-
ure the eye could be made to partly recede. Pressure on the common
carotid artery caused the pulsations to cease. There had probably been
a fracture at the base, passing across the cavernous sinus and causing
a communication between it and the internal carotid artery, thereby
forcing arterial blood into the ophthalmic veins, causing the great dis-
tention and strong pulsation. The common carotid was ligated, and
the pulsations ceased at once and have never returned. Fourteen
months later there was scarcely a trace of the exophthalmia, and vision
was |0 + .
The Shapes and Development of the Pigment Cells of the Chorioid.
Rieke (Archiv fur Ophthal., xxxvii, 1) draws the following conclusions
from his investigations:
1. All the pigment is formed within the cells.
2. The shape of the pigment cells is manifold, ranging from almost
round to those with many processes. The latter are the most frequent
in the anterior parts of the chorioid.
3. The arrangement of the cells, as a rule, corresponds to the course
of the blood-vessels.
4. The clumps of pigment are perhaps to be regarded partly as per-
manent processes, partly as the remains of disintegrated cells.
5. The diffused pigment granules seem to owe their minute subdi-
vision to the disintegration of former pigment cells.
ti. In many animals the newly born show a marked pigmentation of
the stroma cells of the chorioid.
7. The earliest appearance of pigmentation in the human chorioid
occurs in the seventh month of foetal life.
8. The pigment cells of the chorioid do not originate in the
pigmented wandering cells, but rather in the fixed connective-tissue
cells.
Sarcoma of the Uveal Tract. — Freudenthal (Arch, fiir Ophthal.,
276
NEW INVENTIONS.— MISCELLANY.
[N. Y. Med. Joi;k.,
xxxvii, 1) lays down the following propositions in regard to the develop-
ment and growth o!' sarcoma of the uveal tract: There are four stages,
viz. : 1. The stage of amblyopia or of the Don-irritating course of the
disease, where there is more or less disturbance of vision and slight
changes in the fundus, but no symptoms of inflammation. 2. The
glaucomatous or inflammatory stage. Here the intra-ocular tension is
increased, and there are symptoms of internal and external irritation.
3. The stage of formation of fungous or episcleral nodules. The
tumor lias here perforated the capsule of the eyeball, and developed
externally to it. 4. The stage of so-called constitutional generalization,
or appearance of metastatic growths in other organs of the body.
Primary New Development of Hairs on the Intermarginal Edge of
the Eyelids as the Usual Cause of Trichiasis. — Raehlmann {Arch,
fur Ophthal., xxxvii, 2) has concluded, from clinical observation and
microscopical examination, that long-continued hyperemia of the blood-
vessels of the edge of the lid causes a proliferation of the epithelial
stratum (stratum Malpighii), which, after it has reached a certain
height, often causes the development or new formation of hairs and
sebaceous glands on the edge of the eyelid.
Septic Keratitis. — Silvestri (Arch, fur Ophthal., xxxvii, 2), in his
investigations, has never been able to observe and demonstrate the
entrance of cocci or of leucocytes containing cocci into the anterior
chamber. In well-marked cases of induced panophthalmitis he has
never been able to demonstrate the exit of any cocci beyond the im-
mediate zone of inoculation. He has also satisfied himself that the
cocci, even when inclosed within the white blood-cor-
puscles, are still living and capable of active prolifera-
tion.
The Infection and Disinfection of Collyria. — Franke
(Arch, fur Opldhal., xxxvii, 2) draws the following
conclusions from his investigations: Chemical disin-
fection of collyria is generally a better means of sterili-
zation than that by boiling. For this purpose he recom-
mends sublimate solutions (1 to 5,000 and 1 to 10,000) ;
cyanide of mercury (1 to 1,000 and 1 to 5,000) ; resor-
cin, 1 per cent. ; carbolic acid, 0-5 ; boric acid, 4 per
cent, in carbolic acid 1 per cent. ; Panas's solution ; and
thymol. It is not possible to produce an antiseptic
effect with the antiseptics under discussion in a solution
of the strength which can be used in the eye. A solu-
tion of sublimate (1 to 10,000) will in half an hour,
however, render a solution of atropine or cocaine aseptic. For eserine,
an addition of resorein is preferable.
The Channels of Exit of the Aqueous Humor. — Staderini (Arch, fur
Ophthal., xxxvii, 3) formulates his conclusions as follows: 1. The aque-
ous humor comes from the posterior chamber, and enters the anterior
chamber through the pupil. 2. The current of the aqueous humors
extends slowly and homogeneously from the pupil toward the angle of
the anterior chamber in a radiating manner. Rotary phenomena in
this current never occur. 3. We find in the canal of Fontana the ana-
tomical and physical conditions which facilitate the exit of the aqueous
humor through filtration into the venous channels at the sclero-corneal
region. An open communication between the anterior chamber and
the vascular system does not exist. 4. From the canal of Fontana fine
rifts or channels extend into the tissue of the sclera, which partly
follow the course of the deeper veins at the sclero-corneal region, and
partly lose themselves in the lymphatic system of the sclera. Similar
rifts extend from the canal of Fontana into the connective tissue
stroma of the ciliary body and root cf the iris. 5. It can not be
doubted that the iris participates in the absorption of corpuscular ele-
ments from the anterior chamber. The anatomical structure of the
anterior layer of the iris tissue is fully capable of active absorption. 6.
Physostigmine hastens and atropine retards in a very marked degree
the absorption from the anterior chamber.
The Anatomy of Pinguecula. — Fuchs (Arch, fur Ophthal, xxxvii,
3) gives the following results of his investigations: A Pinguecula con-
sists of a thickening of the conjunctiva, accompanied by a hyaline de-
generation of the tissue elements, and the deposit of free hyaline.
The cause of this degeneration is found in the senile changes of the
tissue, to which must be added the influence of external irritation.
The same conditions lead in the cornea to similar hyaline degeneration
(arcus senilis, band-shaped corneal opacity, yellow patches in corneal
scars). Another important change of the conjunctiva at the site of the
Pinguecula consists in an enormous increase in size and number of the
elastic fibers, for which there is no analogy in any other organ in the
body.
Befco fnbentions, etc.
PRESENTATION OF INSTRUMENTS AT THE THIRTEENTH
MEETING OF THE AMERICAN LARYNGOLOU1CAL
ASSOCIATION.
A laryngeal forceps was exhibited by Dr. Mulhall. " The instru-
ment is the well-known forceps of Morell Mackenzie, modified to meet
certain contingencies. The case for which it was designed was one of
laryngeal papillomata attached to the lower surface of the vocal cords,
in a deeply situated larynx, requiring the use of long blades. It was
found that when the blades, from the angle to the laryngeal ends, were
made of the requisite length — three inches and three quarters to four
inches — the cutting lips could not be made to approximate accurately.
To overcome this, a joint was made in each blade, half an inch from the
Snare presented by Dr. Asch
angle, and the result I show you is an instrument whose lips approxi-
mate perfectly. The instrument will be made, on order, by Holekamp,
Grady, & Moore, 915 Olive Street, St. Louis, Mo."
A snare, combining many of the features of instruments already
well known, was presented by Dr. Morris J. Asch.
iscelluni)
Recent Investigations regarding Favus. — Dr. Ge.rge D. Holsten,
of Brooklyn, contributes the following on this subject:
In the New York Medical Journal for July 11, 1891, a resume was
given of the results of investigation on the fungus of favus up to that
time. Since then further studies have been made.
Louis P. Frank (Monatshffte f. peak. Dermatol., March 15, 1891),
working in Unna's laboratory in Hamburg, has applied all the re-
sources of modern bacteriological technique to determine the following
questions: 1. Is the favus of animals and man the same? 2. Are
there different forms of human favus fungus; also of animal favus
fungus ? 3. Should it be proved that different forms of favus fungi
exist, which of them is to be regarded as the true form, and are the
others separate forms or only varieties?
He examined four pure cultures of favus from the human being
and two cultures of mouse favus. As the mouse favus is not so well
known as the human favus, he describes it. " The entire head from
snout to neck was covered with thick, dirty gray-white crusts, the eye
March 5, 18921.]-
of one mouse being completely overgrown. There were several isolated
scutella in the neighborhood of the shoulders and some small ones on
the back. The shoulder blades were not invaded by the disease, as
they are said to be in many cases." He excised skin and crusts,
hardened in alcohol, and prepared sections.
From these six cultures three forms were isolated, whose character-
istics are brieHy described as follows: 1. Both mouse favi. Growth,
which begins on the second or third day, is superficial and feathery
white, the border of the colonies radiating, the under surface dark
gray, with a yellowish shimmer. The diameter of the mycelia measured
1*8 to 4 ix, running in long strife and terminating in sharp tips. 2.
Fungi of cultures Nos. 2 and 4 (known as Form II) of human favus,
which macroscopically and microscopically seemed identical, showed a
markedly slower growth, did not extend in so superficial a manner as
the first, but rather grew in depth. Colonies, especially the older ones,
in chalk-like masses, were, on the lower surface, of a deep golden
color, with shading toward brown. Mycelia measured 2 0 to 5'0 fx ;
branches short and at right angles, terminations clubbed, pear-shaped
and branched, or chandelier-like. This he considers identical with
Quincke's y favus. 3. Fuugi of cultures Nos. 1 and 3 (known as Form
III) were likewise identical. Growth slower than that of mouse
favus, but more rapid than Form II; border rather cloud-like than
radiating ; superficially mealy, under surface deep golden. Diameter
of mycelia 2'5 to 5-0 fx, and microscopically resembling the mouse
favus.
Culture I inoculated on hi sarm was followed twenty-six days after
by a patch resembliug that of herpes tonsurans ; the periphery was
dark red and covered with small vesicles, which, drying intosero-yellow
crusts, were generally situated around the mouths of hair follicles.
Mycelium and spores were found microscopically in the hairs and
crusts. After two months the favus patch spontaneously passed
away.
Recultures from this gave a positive result on one black mouse ;
negative results on three white mice. The experimental cycle was as
follows : Favus from a mouse was cultivated on agar, then inocu-
lated on his arm, producing a " favus herpeticus " ; from the hairs and
crusts cultures were again made, and these inoculated on a black mouse
gave positive results.
Culture I was also inoculated directly on several white and gray
mice ; after five days a beautifully formed yellow scutellum of the
size of a small pea developed on one white mouse ; the rest negative.
Culture II on mice and himself gave negative results.
Culture III on himself showed appearances very similar to the
mouse favus, except that the patch did not attain so great a size, nor
was the periphery so clearly marked. Examination of hairs gave the
same results.
The forms discovered are then compared with those of other in-
vestigators. Form II agreed with Quincke's y fungus and the mouse
favus with the a fungus, but none of Quincke's descriptions agreed
with Form III.
Grawitz's description corresponds with Frank's II and with
Quincke's y, and seems to be the one most often met with. Grawitz
describes the colonies as growing in herds of lentil size, round, becom-
ing later on dry, with a whitish or straw-yellow center, and thereby
becoming very similar to the scutellum as seen on the skin.
Fabry, in his interesting experiments, employed a fungus which he
declared to be identical with the y fungus. Some of the specimens
placed at the disposal of Fiank proved to be the same as Form II.
Miinnich's cultures correspond with Grawitz's. Microscopically,
Frank found them like Quincke's y and his own Form II.
Jadassohn, in his demonstration of favus cultures, showed that they
were identical with Quincke's y form, and also with the one described
by Grawitz.
Verujski, in photographs taken on the seventeenth and forty-
second day of cultivation, showed a fungus identical with Form II.
Elsenberg's Variety 1 resembles Quincke's a fungus, especially the
macroconidia ; Variety 2 is like the y fungus in growth.
The fungus of Krai, which Pick considers the achorion, did not cor-
respond to any of Frank's. If this be proved also to be a true favus
fungus, then there are three, possibly four forms : 1 . Quincke's y fungus,
277
identical with Frank's II, the fungus found by all the recent investiga-
tors (Quincke, Grawitz, Fabry, Miinuich, Jadassohn, Verujski, Elsen-
berg, Unna, and v. Sehlen), and from which by inoculation Quincke,
Grawitz, and Fabry obtained positive results, but Frank only negative.
2. Form I (or mouse) favus of Frank, with positive inoculation results.
3. The III fungus with positive results. 4. Krai's achorion, from
which Pick obtained positive results.
Frank thinks there are different forms of fungi for animals and
man, still it remains for further investigators to prove if one or the
other form predominates. The possibility of the conveyance of mouse
favus to human beings he thinks can not be doubted, a matter of great
interest from a hygienic point of view.
Kaposi (Internat. klin. Rundschau, 1891, Nos. 13 and 15) reiterates
his former opinion that there is a difference between the fungus of
favus and herpes tonsurans, but does not accept the views of recent
investigators that different forms of favus fungi may exist.
V. Mibelli (La Riforma rned., 1891, Nos. 69 and 79, quoted in
Monatsch. f. prak. Derm., September 1, 1891) gives the results of his
studies on favus in Sardinia, where the disease is very prevalent and
severe. He arrives at the following conclusions: 1. Only one single
species of fungus can produce favus. 2. This fungus produces the
common as well as the herpetic favus. 3. The different appearances
of colonies and the morphological differences of cultures are dependent
on age and on culture media, and various other causes. 4. The variety
of ways in which cultures develop depends upon the stage of growth
and source of the original seed from which the new vegetation arises.
5. To such differences in origin and development are probably at-
tributable the various pictures of favus herpeticus and favus vulgaris,
as well as other transitional forms.
To the third of the questions which Frank propounded — should it be
proved that different forms of favus fungi exist, which of them is to be
regarded as the true form, and are the others separate forms or only
varieties? — no answer could be made, for the reason that, clinically,
only one favus disease has so far been recognized. Further investiga-
tions will have to consider if there may not be more than one form of
the disease, and this question Dr. P. Unna considers in a paper entitled
Three Forms of Favus, read before the Dermatological Section of the
Society of German Scientists and Physicians, in Halle, September 24,
1891, and published in the Monaishefte f. prak. Derm., January 1,
1892.
During the past summer Unna studied in his laboratory, in company
with Dr. Frank, the three forms of favus fungi which the latter iso-
lated and cultivated. He also experimented with some ten samples of
material, two of which he received from Scotland, two from Holland,
and one from Italy, and expresses the opinion that there may be more
different forms of favus than were ever thought could exist, but con-
fines the results of his experiments to Frank's three forms alone.
In order to establish positively which is the true favus fungus, it
will be necessary to produce on animals and man scutella which shall
correspond to the disease as developed spontaneously ; and also that it
shall run a subacute or chronic course.
Frank inoculated on his arm cultures of Form I (mouse favus), and
obtained a beautiful, scaly, strongly reddened ring, with small vesicles
and yellow points around the hair follicles. That these were true favus
growths was proved by recultivating on proper media and reinoculating
on a black mouse, when typical scutella resulted. That this favus
herpeticus was not a traumatic dermatitis was shown by the fact that
the symptoms did not appear until three weeks after inoculatiou.
Inoculations with Form III also produced on Frank a red, scaly
patch, in the scales and hairs of which favus fungi were visible, but re-
cultivations were not successful. Therefore further experiments were
made on Dr. Williams, who inoculated Cultures I and III on his right
leg. Inflammatory reaction appeared on the third day on Culture I; on
the fourth several very small vesicles appeared, and on the fifth swell-
ing and pain were strongly marked. On the sixth day thick yellow
crusts began to form, pain became very severe, and locomotion was im-
possible. Form III ran a similar, but much slower and milder, course,
the inflammation beginning on the fourth day.
On the ninth day both cultures were nearly the same, except that in
Form I the crusts were much thicker. Removal of crusts revealed thin,
MISCELLANY.
»
278
MISCELLANY.
[N. Y. Med. Jouh.,
shining, red epidermis ; no more vesieulation. Extraction of hairs very
painful ; crusts contained many spores but little mycelium, a few spores
in extracted hairs.
On the ninth day all crusts were washed off with hot water, where-
upon pain subsided. Small yellow points, generally but not always
around the hair follicles, remained. Thin scales then began to form
which in the course of three weeks became typical scutella of pepper-
corn to pea size.
It was now of interest to note that these two favus patches lying
close to each other on the same region of the skin on the same indi-
viduil should be unlike each other and remain so. These differences are
as follows : 1. Scutella of I less numerous and less concentric than III ;
some scutella of I being a half ring, while III shows a disposition to
assume the full, round, saucer-like form. 2. Favus 1 is of gray-yellow
color, while III is a dark sulphur color. The first resembles the gray-
yellow color of mouse favus. 3. Scutella of I much softer and more
friable than III. The latter permitted of being removed in toto, while
the former would break in pieces. 4. Scutella I more firmly attached
to the horny layer than III, which also increased the difficulty of re-
moval. Adding to these, 5, the more rapid development of reaction ;
6, the greater inflammatory symptoms, especially at the beginning; and
7, the greater amount of pain in Favus I, then the differences between
the two become sufficiently great to clinically separate them.
These two forms, I and III, are illustrated by a beautiful chromo-
lithograph.
Favus II was also iuoculated on Dr. Williams, but, owing to an acci-
dent, did not develop.
Later Dr. Douglas inoculated Favus II and some Scotch favus re-
ceived from Edinburgh. The II developed some ring-shaped, faintly
reddened patches, which remained six weeks, scaled, and then spontane-
ously disappeared. Cultures were not obtained.
Dr. Leslie Roberts was the fifth and Unna the sixth person to in-
oculate themselves with F'avus II.
This Favus II, with thick, short, septatedjmycelia, forked chandelier-
like terminations, clubbed ends and spores, resembles Quincke's y favus,
the favus of Grawitz, Fabry, Verujski, Jadassohn, Mibelli, and the sec-
ond variety of Elsenberg.
Inoculations were made on white and black mice, on rats, guinea-
pigs, rabbits, cats, and chickens, with the three forms of favus. Good
scutella were never developed on white mice and rats, black rats, and
chickens. The best success was obtained on rabbits and guinea-pigs ;
in a second degree on black mice and cats ; at the same time there is a
difference in the vulnerability of different animals to the three forms
of favus. Form I develops best on mice and rabbits ; form II on
guinea-pigs ; and III again on rabbits.
The scutella were then examined microscopically. They were com-
posed mainly of the fungus with some of the epidermic cells intermixed ;
resting on the basal horny membrane, at the beginning they were cov-
ered above and at the sides with the superficial and middle layers of the
horny epidermis, but later on were free. They did not, as some inves-
tigators have said, invade the entire epidermis and cutis. The lower
portion of the scutella grows rapidly, the sides less so, while the upper
portion not at all or but very little. As the lower portion in growing
meets with the resistance of the epidermis, it is compelled to push out
at the sides, while above, the suspension of growth tends to draw the
sides toward the center, causing the characteristic cup-shape. This is
true whether the giowth occurs around a hair follicle, on non-hairy sur-
faces, or on culture media, and also occurs with other fungi which have
a similar growth.
Favus I on rabbits and mice showed a very rich and regular inser-
tion of the root ends of the mycelia into the horny layer, where they
did not branch, but were straight. Here the mycelia were parallel, very
little branched, grew strongly upward, and formed voluminous scutella.
The proliferation of oidium spores was very rich and regular, becom-
nig with age thicker and larger in the center.
Favus II on guinea-pigs showed a less regular and rich insertion of
the root ends. They were often forked on implantation, and bent into
a hooked form. The further development of the mycelia was a less
parallel one than in Favus I ; more bent, more often branched, and
grew less strongly in height, whereby the scutella became less volu-
minous. On the other hand, the deeper mycelia showed a desire when
around a hair to reach the depths of the follicle. Proliferation of
oidium spores not so abundant and regular as in Favus I.
Favus J II on rabbits showed a great upward growth from the
horny layer, but it whs not straight as in I, nor in such rounded bent
lines as in II, but rather in peculiar knotty branches with many sharp
corners. The very small amount of spore formation also distinguished
this from Favus I. Branching in the depths of hair follicles took place,
but not so regularly as in F\tvus II.
A division of favus into scutella and herpes favus, as Quincke pro-
posed, seems to Unna not feasible; then each form of favus can give a
variety of pictures, according to the skin on which it grows, to sur-
rounding circumstances, as foreign fungi which hinder the growth, for-
mation of crusts and scales, erythema, vesicles, and from the reaction
of the skin it may be destroyed.
As a result of these investigations, Unna believes he has demon-
strated three characteristic species of fungi, which are capable of de-
veloping typical favus scutella on animals anil man.
He proposes for the fungus of Favus I the name Aclwrion euthy-
thrix (meaning with straight or parallel filaments) ; and for the disease
produced by this fungus the name Favus grisetts, from the gray-yellow
color of the scutella. {Urinous — apothecary's Latin; Favus ravus —
gray-yellow — would be more classical, but not so well understood.)
Fungus II he names Achorion dikroon (not dichroon), on account of the
forked terminations ; and the disease Favus sulfureus tardus, from the
sulphur-yellow color and the slow growth. Fungus III he proposes to
call Achorion atakton, on account of the irregular mycelia processes;
and its disease, Favus sulfureus celerior, from the yellow color of the
scutella and its somewhat rapid growth.
That other investigators have reached results differing from the
foregoing due to their not having inoculated apparently different forms
side by side, either on skin or on culture plates. The best culture me-
dium Unna considers one composed of agar, four per cent. ; peptone, one
per cent. ; levulose, five per cent. ; salt, one half per cent.
In a postscript to the above-mentioned article the results of further
inoculations with the II form (Favus sulfureus tardus) are given. On
non-hairy human skin, after eight inoculations, only erythematous pap-
ules were produced; therefore Unna considers that this form is only
capable of producing on non-hairy adult skin a short-lived superficial
disease, a so-called favus herpeticus. Nevertheless, it is a true favus for
human beings ; then it was bred from the scutellum from a child's head.
On the mouse, on the other hand, good results were achieved. Differ-
ing from the gray-yellow, rough scutellum of Favus cjrkeus and the
small, dish-shaped ochre-yellow of Favus sulfureus celerioi-, this scutel-
lum is of a white-yellow or cream-color, has a smooth, finely folded up-
per surface, and a leather-like shine. Small particles of this scutellum
<*ave on cultures the Favus sulfureus tardus.
Noticing that scutella were mo*t often seen around the muzzle of
captured mice, Unna discontinued artificial inoculations and fed the
mice with the old agar-peptone-levulose cultures, and in this manner
arrived at better results.
The different diagnostic appearances of scutella on the backs of the
gray mouse are as follows :
Favus griseus.
Favus sulfureus
tardus.
Favus sulfureus
celerior.
Scutella of medium Scutellum becomes Scutellum remains
size (lentil); thick; on very large and covers small, about size of
upper surface flat or the entire back ; is pepper-corn ; on upper
raised, not saucer- thick; on upper sur- surface cup -shaped,
shaped; gray -yellow, face hollowed out into smooth, but without
like old wash leather, cup shape; surface cov- shine; around the pe-
without shine and ered with small studs, riphery light-ochre col-
smooth; piercedallover folded, yellow-white or or, toward the center
by tine hair and spurs cream - colored ; of more whitish, on the
of hairs. leather - like smooth- curled-up edge horny-
ness, in places shining ; like brown ; pushes the
hairs are pressed down ; small hairs back, while
do not pierce the crust, the spurs of hairs
pierce through.
[
March 5, 1898.1
These three forms of favus, when inoculated on mice, will give their
•characteristic scutella, and two of them have been found spontaneously
on captured mice.
A Case of Malignant Disease of the Stomach in which Gastro-
enterostomy was considered. — At a meeting of the Philadelphia County
Medical Society, held on February loth, Dr. John B. Roberts read the
following paper :
I desire to briefly report the result of a case in which 1 was only
deterred from making preparation for gastroenterostomy by the de-
bilitated condition of the patient, but in which the post-mortem find-
ings showed the inutility of such an operation. The delay which
prevented me from subjecting the patient to the expense and anxiety
of so serious an abdominal operation is so justified by the pathologi-
cal conditions that it has caused me to present the specimen for ex-
amination.
Upon being summoned to another State for surgical consultation, I
found a man about fifty-two years of age suffering from great pain in
the epigastrium. He was vomiting large amounts of fluid. The
temperature was normal, but the muscular weakness was great, and
sleeplessness pronounced. The abdomen was distended with gas, and
there was a. marked prominence in the neighborhood of the left hypo-
gastrium. The patient had suffered for about four years with dyspep-
tic symptoms, during which time he had been under the care of many
physicians. He had recently been treated by lavage, which relieved
the pain temporarily, and he had suffered with such obstinate consti-
pation as made the attending physician think that there was some ob-
struction in the alimentary tract. It was this as well as the excessive
pain that induced him to call in surgical aid.
The character of the vomiting, the situation of the prominence in
the left hypogastrium, and the general aspect of the case made it
very evident to me that it was one of dilatation of the stomach. I
gave an opinion that it was very possible that there was malignant
disease in the neighborhood of the pylorus ; but it was impossible to
determine the question because of the distended abdomen, and the
diagnosis was hence left undecided. The administration of food by
the mouth was stopped entirely, and enemata of peptonized milk
combined with whisky were given every two hours night and day.
Lavage was continued to empty the stomach and relieve pain. This
line of treatment was continued for about three weeks. The patient's
discomfort was relieved, the pain disappeared, the vomiting discon-
tinued, and the consequent reduction of tympany rendered it possible
to detect a hard mass below the liver in the median line. The bowels
in the mean time had become regular by the occasional administration
of cascara. This for two weeks, however, was not needed, because of
spontaneous evacuation of the bowels, probably due to the enemata.
Microscopic examination of the vomited matter showed me that blood
was present in the ejecta, and I now made a diagnosis of malignant
disease.
At the end of three weeks small amounts of nourishment were
given by the stomach. We commenced with a drachm of peptonized
milk with a few drops of whisky every two hours, and daily diminished
the amount of food administered by the rectum. Gradually the amount
of food taken into the stomach was increased until it reached three
ounces every two hours. The prolonged rest duiing the period above
mentioned seemed to have been beneficial to the stomach, so that the
small amounts of food given at frequent intervals were digested with-
out pain ; there was no vomiting, though the tympany became more or
less prominent.
At the time he began to take food by the mouth I told the patient
that he had malignant disease of the stomach, and that exploratory
examination was proper with a view of determining whether an arti-
ficial opening could be made between the stomach and intestine, or the
growth removed. This was deferred until the strength of the patient
should be somewhat improved under gastric alimentation. The patient,
however, continued to lose ground, and died about a month after my
first visit. When the food given by the stomach reached three ounces
and a half he began to have pain.
The autopsy showed, as the specimen makes clear, malignant (lis.
ease infiltrating about one fourth of the long diameter of the stomach
279
with several nodular masses at the pylorus. The pylorus, however, is
sufficiently patulous to admit readily the introduction of a finger-tip.
There was, therefore, no marked obstruction. The cardia is much
thinned, while the middle portion of the stomach presents the normal
thickness and characteristics. An adhesion has taken place between
the stomach and the liver at the point where the growth is most
marked.
Gastric dilatation had occurred secondarily to malignant disease of
the pylorus. The only time at which it seems to me gastroenterostomy
would have been wise was previous to his coming under the care of Dr.
H. A. Stout, who called upon me for assistance; and it is very doubtful
if at any time the operation would have been beneficial. The pylorus,
as shown at the autopsy, must have had an opening as large as would
probably have been made had the operation in question been performed ;
and the infiltration of the wall of the stomach for one third of its length
would have made the area for an opening between the stomach and in-
testine limited. An opening would have had to be made between the
thinned and dilated portion of the stomach at the cardiac extremity and
the large area infiltrated with malignant growth toward the pyloiic end.
This, of course, could have been done, but prolongation of life would
probably not have been gained.
The facts that the man was walking about and attending to busi-
ness and that the tumor presented no external manifestations make it
extremely probable that an operation would not have been suggested
previously to the time he came under the care of the physician who
consulted me, except by an enthusiast.
I present the case partly because of the interesting character of the
specimen, and partly as a contribution to a branch of abdominal surgery
which is assuming increased importance.
The recent series of cases reported by Dr. N. Senn have been read
by me with great interest ; but the conclusion has almost been forced
upon me that mauy of them were cases that scarcely justified operative
procedure. Perhaps I am too conservative ; but may it not be that he
is too enthusiastic ?
The United States Marine-Hospital Service. — The surgeon-general,
Dr. Walter YVyman, has issued the following notice, dated February 23,
1892 : A boaid of officers will be convened in Washington on May 2,
1892, for the purpose of examining applicants for admission to the
grade of assistant surgeon in the U. S. Marine-Hospital Service. Can-
didates must be between twenty-one and thirty years of age and gradu-
ates of a respectable medical college, and must furnish testimonials
from responsible persons as to character.
The following is the usual order of the examination : 1. Physical.
2. Written. 3. Oral. 4. Clinical. In addition to the physical examina-
tion, candidhtes are reqniied to certify that they believe themselves free
from any ailment which would disqualify for service in any climate.
The examinations are chiefly in writing and begin with a short
autobiography by the candidate. The remainder of the written ex-
ercise consists in examinations in the various branches of medicine,
surgery, and hygiene. The oral examination includes subjects of
preliminary education, history, literature, and the natural sciences.
The clinical examination is conducted at a hospital, and, when prac-
ticable, candidates are required to perform surgical operations on the
cadaver.
Successful candidates will be numbered according to their attain-
ments on examination, and will be commissioned in the same order as
vacancies occur. Upon appointment, the young officers are, as a rule,
first assigned to duty at one of the large marine hospitals, as at Bos-
ton, New York, New Orleans, Chicago, or San Francisco. After four
years' service, assistant surgeons are entitled to examination for promo-
tion to the grade of passed assistant surgeor. Promotion to the grade
of surgeon is made according to seniority and after due examination as
vacancies occur in that grade. Assistant surgeons receive sixteen bun-
dled dollars, passed assistant surgeons eighteen hundred dollar-, and
surgeous twenty-five hundred dollars a year. When quarters are not
provided, commutation at the rate of thirty, forty, or tiltx dollars a
month, according to grade, is allowed. All grades above that of as-
sistant surgeon receive longevity pay, ten per centum in addition to the
legular salary for every live years' service up to forty per centum after
MISCELLANY.
280
MISCELLANY.
[N. Y. Med. Jocr.
twenty years' service. The tenure of office is permanent. Officers
traveling under orders are allowed actual expenses. For further infor-
mation or for invitation to appear before the board of examiners, ad-
dress Walter Wyman, M. D., Supervising Surgeon-General, M.-H. S.
The New York Academy of Medicine. — The special order for the
meeting of Thursday evening, the 3d inst., was the reading of a paper
on Cases of Appendicitis illustrating Different Forms of the Disease,
with Remarks, by Dr. Charles McBurney.
At the next meeting of the Section in Genito-urinary Surgery, on
Thursday evening, the 10th inst., Dr. J. E. Kelly is to read a paper on
The Anatomy of the Bladder, and the chairman, Dr. E. L. Keyes, will
open a discussion of the question Pus in the Urine — how to discover
its Source ?
At the next meeting of the Section in Paediatrics, on the same even-
ing, there is to be a discussion on Empyema, by Dr. H. Koplik, Dr. J.
W. Brannan, Dr. J. H. Ripley, and Dr. J. \V. Roosevelt.
At the next meeting of the Section in General Surgery, on Monday
evening, the 14th inst., a paper on Multiple Tendon and Nerve Suture
with Perfect Recovery in Spite of Suppuration will be read by Dr. H.
Lilieuthal, and one on Fibrous Mammary Tumors by Dr. C. N. Dowd.
Mortality in Cities in the United States. — The following table
represents the mortality in the cities named, as reported to Dr. Walter
Wyman, Surgeon-General of the Marine-Hospital Service, and pub-
lished in the Abstract of Sanitary Reports for February 26th :
CITIES.
L
•3
1
Population, U. S.
Consul ot 1890.
S
£ «
o =
90H
ic-
DEATHS FROST-
'S -
— --
- o
1 I
2. S
- s
4
i-
>
_*
■/.
Q
3
3
~ —
— u.
-= £
■s
6
1
2
2
17
New York, N. Y
Feb. 20.
Feb. 20.
Feb. 20.
Feb. 20.
Feb. 13.
Feb. l'J.
Feb. 6.
Feb. 13.
Feb. 20.
Feb. 20.
Feb. 20.
Feb. 20.
Feb. 6.
Feb. 13.
Feb. 20.
Feb. 13.
Feb. 20.
Feb. 13.
Feb. 20.
Feb. 19.
Feb. 20.
Feb. 20.
Feb. 19.
Feb. 20.
Feb. 80.
Feb 20.
Feb. 5.
Feb. 12.
Feb. 20.
Feb. 13.
1,515,301
451. 770
129
24
22
27
2
2
2
1
39
1
7
'.'ii
2
1
2.;
l
9
13
111
13
3
5
Boston, Mass
448,477 200
431.439 233
3
4
2
San Francisco, Cal . . .
298,997
296,908
242,039
242.11311
205,870
on
8
19
14
189
162
82
•
New Orleans, La ...
1
5
1
1
10
Detroit. Mich
Minneapolis, Minn. .
Louisville, Ky
Rochester, N. Y
Kansas City, Mo. —
Kansas City. Mo
Providence, R I
1
in
1
1
101,129
133.890
132,710
132.716
132. 146
60
49
27
38
51
10
3
3
7
3
1
1
2
4
2
4
!
1
1
1
2
106.713 : 32
5
6
'
106,713
105,436
105,136
81,434
81.388
76.168
74,398
36,425
35.005
31.076
29.084
29.081
25,858
11.750
21
33
43
25
41
in
46
17
20
15
17
11
11
Indianapolis, Ind
Indianapolis, Ind
Toledo, Ohio
"
i
8
....
5
9
2
4
Fall River, Mass
1
Portland, Me
Bin^hamton, N Y...
2
4
Galveston, Texas
Galveston, Texas
Auburn, N. Y . »
1
1
1
I 1
The Prophylaxis and Treatment of Influenza. — In the February
number of the Satellite of the Annual of the Universal Medical Sciences
we find the following abstract of the teachings on these subjects in Dr.
Cyrus Edson's book on La Grippe and its Treatment: Three indica-
tions are to be fulfilled : (1) Means must be taken to assist the system
to rid itself of the poison to which the attack is due; (2) pain must be
relieved; and (3), not the least important, depression must be counter-
acted. The first indication is obtained by means of castor oil or two
compound rhubarb pills. Three or four three-grain powders of phen-
acetin are usually sufficient to relieve headache and muscular pains.
Salol, two grains and a half to each dose, may be added to the phen-
acetin with advantage. He deprecates antipyrine and its congeners,
which serve to augment the depression, and recommends instead Hoff-
man's anodvne, which is diaphoretic, diuretic, and stimulant. To over-
come depression during and after the disease, he recommends the free
use of tonics. He repeats Professor Laffont's (of Lille) recommenda-
tion of coca preparations, those of Mariani being given the preference.
During the disease a hot grog, one third Mariani wine of coca and two
thirds sweetened water, is administered, taken very hot, several times
a day, the slight diaphoresis induced being a valuable addition to the
tonic action. (The editor, in the coming issue of the Annual, recom-
mends'the exhibition of coca in the early stages of the disease, with a
view to counteract the impending asthenia and curtail the disease. Hx
grains of blue mass are first ordered, and, as soon as a couple of move-
ments have been obtained, two tablespoonfuls of Mariani coca-wine are
given every two hours ; lozenges, each containing two grains of coca
leaves and one twelfth of a grain of cocaine, contribute greatly toward
off the pharvngo-larvngeal complications. A six-per-eent. solution of
cocaine, applied occasionally to the nasal mucous membrane, directing
the cotton-covered probe toward the roof of the nose and anteriorly,
reduces markedly the pain caused by involvement of the frontal sinus.
He fully agrees with the author as regards the eontra-indkation of anti-
pyrine.) Edson considers champagne, generous wines, tonic doses of
quinine, iron, and strychnine also of value. The catarrhal irritation of
the air passages is best allayed by inhalations of compound tincture of
benzoin. Chloroform liniment is recommended as a rubefacient : opium
and carbonate of ammonium for the cough. The treatment of pneu-
monic grippe is essentially the same as that of uncomplicated pneu-
monia, the author emphasizing the advisability of preserving the
strength of the patients.
To Contributors and Correspondents. — The attention o f all who purpose
favoring us with communications is respectfully called to the follow-
ing :
Authors of articles mti-nded for publication under t/ie head of " original
contributions " are respectfully informed tlu/t, in accepting such arti-
cles, we always do so with the understating that the following condi-
tions are to be observed: (i) when a manuscript is sent to this jour-
nal, a similar manuscript or any abstract lliercof must not be or
have been sent to any oilier periodica1, unless we are specially notified
Of the fact at the time the article is sent to ns ; (2\ accepted articles
are subject to the customary rules of editorial revision, and will be
publislied as promptly as our other engagements will admit of — we
can not engage to publish an article in any specified issue ; [3) any
conditions which an author wishes complied with must be distinctly-
stated in a communication accoinpani/ing the manuscript, and no
new conditions can be considered after the manuscript has been put
into the type-setters' hands. We are often constrained to decline
articles which, although t/iey may be ireditable to their authors, are
not suitable for publication in this journal, either because they are
too long, or are loaded with tabular matter or prolix histories of
cases, or dial with subjects of little interest to tlic medical profession
at large. We can not enter into any correspondince concerning our
reasons for declining an article.
All letters, whether intended for publication or not, must contain the
writer's name and addr ss, not necessarily for publication. Ao at-
tention will be paid to anonymous communications. Hereafter, cor-
respondents asking for information that we are capable of giving,
and that can proprrly be given in this journal, will be answered by
number, a private communication being previously sent to each cor-
responded informing him under what number the answer to his note
is to be looked for. AH communications not intended for publication
under the author's name are treated as strictly confidential. We can
not give advice to laymen as to particular cases or recommend indi-
vidual practitioners.
Secretaries of medical societies will confer a favor by keeping us in-
formed of the dates o f their societies'1 regular meetings. Brief notifi-
cations of matters that are erpected to come up at particular meet-
ings will be inserted when they are received in time. ,
Newspapers and other publications containing matter which the person
sending them desires to bring to our notice should be marked. Mem-
bers of the profession who send us information of matters of interest
to our readers will be considereit as doing them and us a favor, and,
if the space at our command admits of it, we shall lake pleasure in
inserting the substance of such communications.
All communications intended for t/ie editor should be addressed to him
in care of the publishers.
All communications relating to the business of the journal should be ad-
dressed to the publishers.
THE NEW YORK MEDICAL JOURNAL, March 12, 1892.
(Original Communications.
A REVIEW OF
FIVE YEARS OF DERMATOLOGICAL PRACTICE
IN NEW ORLEANS*
By HENRY WILLIAM BLANC. B. S., M. D.,
HEALTH OFFICER, UNIVERSITY OF THE SOUTH, SEWANEE. TENNESSEE ;
FORMERLY DERMATOLOGIST TO THE CHARITY HOSPITAL, NEW ORLEANS ;
LECTURER ON DISEASES OF THB SKIN. TULANE UNIVERSITY OF LOUISIANA;
INSTRUCTOR IN SKIN DISEASES AND SYPHILIS, NEW ORLEANS POLYCLINIC ;
CHIEF SANITARY INSPECTOR FOR THE CITY OF NEW ORLEANS, ETC.
Having found it necessary to change my residence from
Louisiana to the more bracing climate of Tennessee, it seems
right and proper that I should give an account of my stew-
ardship in the field that I have surrendered, and more espe-
cially so as no full statement has ever before been made, so
far as I am aware, of any systematic dermatological work
performed in the Gulf States.
Reports of skin diseases observed in the South have oc-
casionally appeared in our journals, but the writers have
only pointed out the presence rather than the prevalence of
these affections in their section, and have failed to convey
any idea of their relations to race and climate.
We are familiar with the class of diseases commonly ob-
served in Chicago, New York, and Boston, but the derma-
tological practice of New Orleans and other large Southern
cities has up to this time been an unknown quantity.
The writer took charge of and organized the depart-
ment for skin diseases in the great Charity Hospital of New
Orleans in October, 1885, and surrendered it in July, 1891,
after a period of nearly five years, and was the first derma-
tologist ever appointed by the administrators of that insti-
tution.
This paper records cases observed during this period
both at the hospital and in private practice, and of every
one here referred to careful notes have been taken. A
number of cases seen in public and private practice were not
recorded, owing to a variety of causes, and of course they
can not figure in these statistics.
With the exception of syphilis, the venereal diseases are
all excluded, and also the eruptive fevers, including vaccinia,
as these would be out of place in the present analysis. Oth-
erwise the last-mentioned affections would occupy a con-
spicuous portion of this report, as the writer's position of
chief sanitary inspector of the Louisiana State Board of
Health has given him unusual opportunities for observing
the eruptive fevers, while it also made him the head of the
bureau of vaccination during his tenure of office.
The following table, representing some seventy-five va-
rieties of skin disease, is arranged to show sex and color,
but it must be admitted that the record of colored cases is
quite incomplete, due to the fact that negroes are not treated
in the same department of the hospital as the whites, there-
by causing some confusion in the records. It may he safely
said that one half of the cases of skin disease in negroes
* Read before the Tri-State Medical Society of Alabama, Georgia,
and Tennessee, October 29, 1891.
who applied for treatment at the hospital are not recorded
here at all :
Table I.
Diseases arranged in Alphabetical Order.
Disease.
Abseessus
Acne
Albinismus
Alopecia areata
Alopecia pnematura. . . .
Anthrax
Cancer en cuirasse
Cellulitis
Chloasma
Cystoma
Dermatitis
" herpetiformis.
Dysidrosis
Ecthyma
Eczema
Elephantiasis Arabum.. .
Epithelioma (rodent ulcer). .
Erysipelas
Erysipeloid
Erythema
Favus
Furunculus
Herpes simplex
'* zoster
Hydroa
H\ penesthesia
Hyperidrosis
Hypertrichosis
Ichthyosis
Impetigo
Impetigo contagiosa
Keloid
Keratosis
Lentigo
Lepra
Lichen planus
"* scrofulosorum
" tropicus
Lupus erythematosus
" vulgaris
Molluscum fibrosum
" epitheliale
Moiphopa
Myoma
Mycosis fungoides
I Naevus pigmentosus
] " unius lateris
j " vasculosus
( " hypertrophicus . . . .
( >nychia
Papilloma
Paronychia
Pemphigus .
I Pediculosis capitis
« " corporis
/ " pubis
Pernio
Pityriasis rosea
I'ompholyx
Prurigo
Pruritus
Psoriasis
Purpura
Sarcoma
Scabies
Scleroderma
Scrofuloderma
Seborrhea
Sycosis (non-parasitic)
Syphiloderma
Teleangiectasis
Tinea favosa
{Tinea trichophytina barbae
" " capitis
" " corporis
" " cruris
White.
Color'd.
Male.
Female.
Total.
2
1
1
2
103
5
42
66
108
1
1
2
2
4
3
1
4
2
2
2
1
i
2
2
1
1
1
4
i
4
1
5
13
6
1
18
19
5
4
1
5
101
3
81
23
104
4
1
3
4
8
5
3
8
■18
1
15
4
19
481
39
301
219
520
1
1
2
2
53
15
38
53
14
1
6
9
15
6
1
5
6
41
2
21
25
46
1
1
1
35
26
9
35
■1
5
2
1
31
3
25
9
34
4
4
4
3
1
3
5
4
i
5
10
10
10
3
i
3
1
4
18
l
8
11
19
11
l
3
9
12
1
l
1
1
2*
5
2
3
5
1 2
2
2
70
13
49
34
83
8
1
5
4
9
1 1
, JL
1
4
3
1
3
1
2
2
4
1
3
3
1
4
1
3
3
1
4
1
1
1
3
1
2
3
1
1
1
1
3
1
3
1
3
1
1
1
i
2
6
3
'A
6
1
1
1
3
i
2
2
4
2
2
2
4
i
4
1
5
6
5
1
6
2!)
i
6
24
30
50
i
48
3
51
11
11
11
1
1
1
1
1
T
2
1
1
2
5
2
3
5
57
"a
31
30
61
37
25
12
37
1 1
5
6
11
3
1
2
3
104
6
85
25
110
6
1
4
3
7
8
1
6
3
9
35
1
24
12
36
17
17
17
236
23
163
96
259
5
1
4
5
1
1
1
7
2
9
9
7
1
6
7
15
2
9
8
17
26
20
5
25
'282
II LANG : DERMA TOL 0 GICAL PRACTICE IN NEW ORLEANS.
[NT. Y. Med. Jock.,
Disease.
White.
Color'd.
Male
Ferosle.
Total .
fid
l\r.
W 1
31
5
26
10
36
1 1.
19
1
14
6
20
72.
m
1
2
1 1
13
73.
3
1
2
3
74.
Vitiligo
5
3
4
4
8
75.
Unclassified
13
1
6
8
14
Total
1,878
145
1,205
818
2,023
Acne. — This disease constituted 5-33 per cent, of all the
diseases treated. A large majority of the cases of acne were
seen in private practice and among the better class of peo-
ple. Acne is quite common among the lower orders, but
for obvious reasons an affection that produces so little pain
and inconvenience is not apt to be brought to a hospital for
treatment until increasing disfigurement causes its possessor
to look about for a remedy. Negroes are not so subject to
acne as the whites, and when they have it it is usually of
the papular variety, seldom becoming pustular, and is ac-
companied by a mild seborrhcea oleosa. Under this head-
ing are included a number of cases of rosacea, associated
almost invariably with some of the papules of acne. The
remaining cases were varieties of acne vulgaris, with the ex-
ception of two cases of acne atrophica, to which I prefer ap-
plying the title of acne rodens, in order to avoid confusion
with certain atrophic conditions sometimes noted in stru-
mous persons following the resolution of the pustule of acne
vulgaris, or common acne.
The clinical history of these cases of acne rodens will be
reported elsewhere.
Chloasma. — Out of nineteen of these cases there were
eighteen in females, and six were negroes. Most of them
were women between twenty and forty years of age, and all
of them had passed the age of puberty when the disease
began. The majority had some disorder of the menstrual
function, and several were, or had recently been, pregnant.
Two young women (unmarried) who had no evidences of
menstrual disorder were exceedingly anaemic.
Chloasma gestationis is, perhaps, more common in Lou-
isiana among negro women than among white women. The
pathology of this disease being a displacement of pigment,
we find that in brown and black negroes, and to a less ex-
tent in the mulattoes, the skin turns lighter, instead of darker
as in the case of the whites. The intensity of the shade de-
pends upon the natural color of the negro, being darker in
darkest skins. The edges of chloasma patches in negroes
are not so clear-cut and well-defined as in cases of albinism
and vitiligo, and the light patches have more pigment in
chloasma.
Dermatitis. — The class of eruptions usually placed under
this heading are burns and scalds (d. ambustionis), inflam-
mations due to injuries, such as excoriations, contusions,
and the like (d. traumatica), and inflammations due to ex-
ternal irritants.
Seven eases were due to mosquito bites, four out of the
seven being in persons who had just come to the city from
a foreign country. Not using mosquito-bars, as is the cus-
tom in New Orleans in the summer season, they were de-
voured by these little pests, in several cases, from head to
foot. The scratching that ensued set up considerable in-
flammation, witli the formation of pustules, and medical aid
was sought. An interesting case was that of a young Rus-
sian who had acquired malarial fever in Costa Rica. On
his way up the river to the city he was stung by mosquitoes
from top to toe and then deposited in the hospital while de-
lirious from fever. Arriving in my absence, the ambulance
surgeon was much concerned as to how to dispose of a case
which looked like an early stage of small-pox, and the pa-
tient's not speaking the language made the case all the more
perplexing. When he was seen by me a little later, the
diagnosis was made by noting the presence of minute hae-
morrhagic puncta in the center of the pinkish papules, this
being the point where the proboscis of the insect had been
inserted. Under this heading are included forty-one cases
of dermatitis venenata, thirty-five being in males and six in
females. The cause of this eruption was usually ascertained
to be the Rhus toxicodendron, though several cases were due
to irritation from dyes.
Dermatitis Herpetiformis. — Of this affection, sometimes
known as Duhring's disease because of the special study
which this writer has given to it, there were four cases, all
white, three being females. One of the cases is the im-
petigo herpetiformis of llebra ; but, as it evidently belongs
to the group of cases described by Duhring, a brief recital
of its clinical history is here appended :
E. L., aged twenty-niue years, native of Mississippi. Has
five children, and when first seen had been pregnant five months
and a half. History of having caught cold while carrying her
fourth child, but had no eruption, only great itching of body
during the week following its birth. With the fifth child an
eruption appeared when quickening was felt, and lasted till her
baby was three weeks old. She is now pregnant with her sixth
child, the eruption having appeared one day before quickening
was felt. The lesions appeared as circular, erythematous patchest
well marked on the chest, back, and arms, but not clearly de-
fined elsewhere, though occurring all over the body except the
head. These patches were deeper in color at the periphery,
giving them a ringed appearance. On the rings were vesicles,
blebs, and pustules in all stages of development. They were
not numerous, however, some rings having but three or four
of these lesions. She stated that when the eruption first ap-
peared the blebs were very numerous.
Patient's reason for applying for treatment was the incessant
and intolerable itching, worse at night. This caused her to
greatly aggravate the eruption, as she was unable to desist from
scratching. Constant regulation of the diet and bowels and a
carbolic salve ( 3 ss. to ? j) ameliorated, but did not cure, the
itching. She was not seen after her child was born.
Dysidrosis. — Without pausing to give my reasons for
separating this affection from pompholyx, a disease with
which some writers have attempted to identify it, I will
give briefly two cases of the disease classed under this
heading :
Case I. — Mr. A. B., aged fifty-six years, native and resident
of New Orleans. Has been at times a hard drinker. Is suffer-
ing with a rodent ulcer on bridge of nose. Is corpulent, and
has enlarged capillaries in skin of face, giving it a ruddy ap-
pearance.
On the bridge of the nose, on the temples near the eyes, and
on the forehead here and there are little sago-grain appear-
\
March 12, l^«.»t>. ]
anccs, which are quite tense when pressed, but which emit when
broken a watery liquid, acid in reaction. These do not itch and
cause no inconvenience. It was noticed that some of tbem,
after being incised witli a small knife, remained dark for ten or
fifteen days thereafter, on account of the venous blood that
passed into them after the incision. They then healed and did
not reappear, so far as I am aware.
Case II. — Mrs. M. E., aged forty-eight years, native of Ger-
many. Has also ringworm of the thighs, which has spread on
to the abdomen. General health good. Passed the climacteric
period four years ago. Was formerly a wine-drinker, but bas
been taking a good deal of beer for the past two years. Is stunt
and plethoric, having dilated blood-vessels on the face.
Has noticed that during the past three summers a little sago-
grain eruption would appear on her face and d:sappear in
winter.
This eruption consists of vesicles of the size of a small pea,
slightly raised above the skin, but also quite deep beneath the
surface. They do not itch, and are located on the forehead,
temples, nose, cheeks, and chin, being most numerous on the
temples. After puncture, a hemorrhage takes place' in them,
as in Case I. The liquid in them caused litmus paper to turn
red. They all disappeared after incision.
Of the eight cases recorded, two were affected on the
face alone, two on the hands alone, two on the toes alone,
and two on hands and toes.
Eczema. — This affection, the commonest of all the dis-
eases of the skin, has a fair share numerically among the
diseases mentioned in this report, though it is not as com-
mon in New Orleans as it is in certain other localities. For
example, the five hundred and twenty cases of eczema here
reported are 25*7 per cent, of the total number of cases re-
corded in a period of five years. This is a lower percent-
age than that of the combined returns of the American
Dermatological Association for the ten years between 1878
and 1887, for, out of 123,746 cases of skin disease recorded
during that time, 37,661 cases were eczema, a percentage of
30-43 *
In my cases, as in those referred to, the eruptions pro-
duced by the Acarus scabiei and the Pediculus are classed
as scabies and pediculosis, and are enumerated elsewhere.
The following table illustrates the ages of patients suf-
fering with eczema :
Table II.
Ayes of Patients with Eczema.
Under one year 32
" two years 14
" three years 12
" four years 7
" five years 10
Between five and ten years 34
" ten and fifteen 23
" fifteen and twenty 43
" twenty and thirty 86
" thirty and forty 80
forty and fifty 75
" fifty and sixty 57
* In an analysis of 8,000 cases of skin disease Bulkley found 2,(179
cases of eczema, or 33-48 per cent. See Archives of Dermatology,
vol. viii, No. 4, October, 1882.
283
Between sixty and seventy 38
" seventy and eighty 9
Total 520
There were seventy-five cases of eczema in children
under five years of age, being 14-4 per cent, of the total
number of cases treated. This percentage is small when
we compare it with Bulkley's figures drawn from a larger
number of cases.* In 2,500 cases of eczema he reported
614 cases occurring under the age of five years, or 24 per
cent.
Referring to Table I, it will be seen that 481 patients
were white and 39 colored, while 301 were males and 219
females.
Table II shows that no age is exempt from this disease,
and that the greatest number of cases occurring in a decade
was in persons between the ages of twenty and thirty.
There were seven between the ages of four and five, and
nine between seventy and eighty. So youth and age may
be alike affected.
Epithelioma. — A large majority of these cases were of
the rodent ulcer, or superficial variety of epithelioma, and
had not involved the neighboring glands. Eight cases were
of the deep variety, and characterized by all the clinical and
pathological symptoms noted in malignant disease. Some
still presented the flat, waxy node so characteristic of this
disease, while in others this had already broken down into
crust-covered ulcers. The face is the common seat of these
lesions, either on the cheeks, nose, temple, or forehead.
The youngest patient observed was a white man twenty-
eight years old. The lesion occurred on either side of his
nose as a waxy tubercle. After its removal by the curette,
he remained well for two years, when the disease reap-
peared on the right temple. This second lesion was of the
size of a silver quarter-dollar, and was removed with the
curette, followed by the application of arsenical paste. A
large ulcer was made, which healed slowly, but the dis-
ease has not yet returned. The oldest patient was eighty-
eight years old.
There were no cases among the negroes, who are more
subject to the deep-seated form of this disease. Fifteen
cases were in males and thirty-eight in females, a reversal
of the rule, as the disease is commonest iu men.
Table III.
Ages of Patients with Epithelioma.
Between twenty and thirty years 2
" thirty and forty years 6
" forty and fifty years 10
" fifty and sixty years 13
" sixty and seventy years 12
" seventy and eighty years 9
" eighty and ninety years 1
Total 53
Erythema. — A variety of affections are classed under
this heading, including simple localized, idiopathic erythe-
ma, erythema multiforme, erythema nodosum, and certain
* /»<•. ext.
BLANC: DERMA TOLOCTCAL PRACTICE IN NEW ORLEANS.
284
BLANC: DERMA TOLOGIGAL PRACTICE IN NEW ORLEANS. [N. Y. Med. Joub.,
other forms, such as erythema intertrigo and a number
of rashes due to the application of irritants to the skin.
Erythema multiforme constituted the majority of the
cases, while erythema nodosum was seen in but one pa-
tient.
Of the fifty cases of this affection recorded, there were
twenty-one in males and twenty-nine in females.
Erysipeloid. — Rosenbach* describes an eruption due to
wound infection with putrid animal matter, and this he has
called erysipeloid. It consists of a red spot upon the skin
which extends peripherally, while the center undergoes
involution. It produces a sensation of burning and passes
away in two or three weeks without febrile symptoms.
Six cases of this disease have come under my observa-
tion, two of them being typical, according to the description
given by Rosenbach. In the remaining four, the spot, though
circumscribed and clear-cut at the edges, did not fade in
the center, at least not before treatment was instituted.
This consisted in an ichthyol ointment, as recommended
by Elliot, f or in a salve of oil of cade with oxide-of-zinc
ointment. Five of these patients were cured after two weeks
of treatment, while the remaining one relapsed and was not
entirely well for a month. Erysipeloid evidently belongs
to the group of erythemas, and closely resembles erythema
armulatum. Considered from this point of view, it would
be classed as an erythema venenatum. It is my belief that
this disease occurs more frequently in surgical practice than
is generally supposed, and that a greater number of cases
have not been reported because of the mildness of the at-
tack, coupled, perhaps, with an inability to classify it der-
matologically. The surgeon, being satisfied as to its cause
and character, has been content to let a simple ointment
and Nature do the rest.
My cases were briefly as follows :
Case I. — Female, aged thirty-two. Cleaning crabs five
days ago, and next day noticed inflammation of index finger of
left hand. This has spread to the metacarpophalangeal joint,
and presents a circumscribed, convex border. Eruption is very
itchy, and at times burns and pains.
Case II. — Female, aged forty. Eruption located at root of
left index finger. Began one week ago after sbe had scratched
her hand while preparing food for cooking.
Case III. — Male, aged thirty-eight. Er-uption on back of
left thumb. Drive's a garbage-cart, and bruised his hand while
shoveling garbage.
Case IV. — Female, aged thirty. Scratched her hand twelve
days ago while cleaning crabs. Hand was painful same night,
but eruption came later. Eruption located around root of
thumb, and is painful.
Case V. — Female, aged twenty-six. Duration three weeks.
Cut left hand while slicing raw meat. This was followed in
two days by a circumscribed, itching erythema of palm and
back of hand.
Case VI. — Female, aged forty-five. Cut left hand in fold
between index and middle finger while peeling vegetables. On
the second day atter this the eruption appeared. This has
circular, well-defined edges, and is paler in the center than at
the periphery.
* Arch.f. klin. Chirurgie, 1887, No. 2.
■(- Jour, of <Jut. and Genilo-urinary Din., January, 1888, p. 12.
Herpes. — There were seven cases of herpes simplex, two
of them occurring on the prepuce — herpes praputialis. The
remainder appeared about the mouth.
The cases of herpes zoster were thirty-four in number,
and were distributed as follows :
Tablb IV.
Cases of Herpes Zoster.
Zoster facialis 5
" cervico-facialis 2
" cervico-brachialis 2
" collaris 2
" pectoralis 16
" abdominalis 4
" lumbo-femoralis 2
" sacro-femoralis 1
Total 34
One of the cases of zoster facialis involved the mucous mem-
brane of the mouth. The patient had taken Cayenne pepper
for colic,' followed by senna and salts, and experienced the next
day a burning sensation in the mouth. On the third day the
eruption appeared on the right side of the nose, spreading to the
cheek, the right eyelids swelling at the same time. When seen
by me, seven days afterwTard, the nose was red and discharging
mucus, the right cheek was swollen, and the lacrymal glands
occasionally discharging a tear. On the upper and lower lips
to the right of the median line, and on the right side of the hard
and soft palates, were a number of small, painful ulcers.
A second case is one of double zoster. The patient was a
white man, thirty-one years of age, who had been treated by
me for syphilis a year before. The grouped vesicles first ap-
peared on the left side of the abdomen, extending down over
Scarpa's triangle and on to the pubes. A few hours later
another grouped eruption, but of papules instead of vesicles, ap-
peared on the right side over the sacrum, extending down over
the great trochanter to the thigh. A mild ointment was used,
and the papular eruption of the right side began to yield to
treatment and never formed distinct vesicles. The grouping of
these lesions, and the erythemato-papular character of the
aborted eruption, together with the pain that accompanied it,
leave no doubt in my mind that here was a case of double
zoster.
Table V.
Ages of Patients 'with Zoster.
Under ten years 2
Between ten and twenty 1
" twenty and thirty 9
" thirty and forty . 7
" forty and fifty 4
" fifty and sixty 7
" sixty and seventy 2
" seventy and eighty 2
Total 34
Lepra. — Leprosy, like tuberculosis, is a disease which any
one is liable to contract, but which must be acquired under
certain conditions. Without pausing to give all of my data,
let me state that, in my experience, hereditary disease —
that is to say, leprosy in one's parents or grandparents — de-
bility from sickness or alcoholism, certain diets, such as
meat, and more particularly salt meat, predispose the pa-
tient to this baneful disease. Leprosy does not make a
March 12, *1892.]
woman more infertile than any other wasting disease,
though it does tend to produce miscarriages or very delicate
children. Even this rule has its exceptions, for 1 have seen
leprous women with non-leprous children, who were born
after the disease was well marked in the mother. Refer-
ring to predisposing causes, the following facts, taken
from my histories, will give an idea of the character of the
infirmity of which the patient and his relatives were subject,
each note being taken from a different case : 1. Stunted
growth and mind feeble ; is eighteen years old and has not
menstruated ; breasts and pubes undeveloped. 2. Leprosy
appeared just after childbirth — two cases. 3. Old age — is
seventy-nine years old ; stopped menstruating at age of
twenty-nine. 4. Imbeciles ; two patients, brothers. 5.
Followed measles. 6. Hard drinker. 7. Blind from early
childhood, and always feeble. 8. Mother insane. 9. Father
died of phthisis. 10. Delicate always. 11. Father insane
and uncle epileptic. 12. Followed typhoid fever. 13.
Brother insane. 14. Had tape-worm when disease began.
I have of late become convinced that one of the ways that
leprosy is produced is from animal matter introduced into
the system in an uncooked or raw condition.* My reasons
for coming to this conclusion are briefly these :
1. History of having eaten raw meat.
2. History of intestinal worms, which are frequently pro-
duced by the ingestion of imperfectly cooked meat or fish.
3. Fondness of patients for meat, preferring it greatly to
vegetables, and eating it in excess of the latter.
4. Occupation of such a character as to make patient liable
to inoculation from animal matter : one was a butcher, one was
a rag-picker, and a large majority of the women were either
cooks or in the habit of cooking their own meals.
The eighty-three cases here reported were all, with the ex-
ception of three, observed in New Orleans, and the patients
were residents of the State. t Seventy were white and thirteen
were colored ; forty-nine were male and thirty-four female.
The following tables will illustrate the age and nativity in the
* See communication from the writer in the Journal of the Leprosy
Investigation Committee, No. 2, February, 1891, p. 97.
f Forty-two cases of leprosy observed by the writer were reported
in the New Orleans Medical and Surgical Journal, September-October,
1888. Since then forty-one cases more have been observed, making the
eighty-three cases of this report.
285
f Missouri 1
I Tennessee 1
Other States. \ New York 1
I Virginia 2
| Alabama 1
f Germany 12
I France 1
j-, ■ England 1
r oreign < °
Austria 1
Ireland 4
I Spain 1
Total : 83
The two patients under ten years old were aged six and
nine, respectively. I have never seen the cutaneous lesions
of leprosy on a new-born baby. Leprosy produces a marked
dyscrasia, but the disease, so far as I am aware, is not in-
herited in the sense that syphilis is, for example.
It will be seen from Table VII that fifty-seven of my
patients were natives of Louisiana and that six were natives
of other States, making a total of sixty-three born in the
United States. Twenty were born in foreign countries, a
large majority coming from Germany.
My records do not give the birthplaces of the parents of
all the leprosy patients, but such notes as I have show that
twenty-seven of the patients recorded as having been born
in the LTnited States had either one or both parents of for-
eign birth.
Lichen Scrofulosorum. — The only case of this disease
observed is of such interest that it can not be passed over,
as it combined the ulcerative scrofuloderm with the papular
eruption of lichen scrofulosorum. It is natural that these
two affections, due to a common cause, should be found in
the same patient, though as a rule this is not the case.
The patient was a white woman, a prostitute, and entered
the Charity Hospital on March 8, 1891, with a history of hav-
ing had considerable flooding three years ago, after an abortion
had been produced upon her while she was in the third month
of gestation. This left her very weak and anaemic. Her father
and mother had both died of consumption, the latter having had
the disease only three months.
In August, 1890, the patient had chills and fever with bead-
ache, and, on recovering from the attack, her feet were swollen.
In the beginning of November she took a hot bath, after which
purplish spots appeared over the epigastrium and rapidly spread
all over the body, becoming more numerous and deeper in color
about the menstrual period.
In the latter part of November the glands on the left side
of the neck began to swell, followed in January by the glands on
the right side.
On admission to the hospital she was very thin and pale, and
presented on the neck, behind the angle of the jaws and an inch
and a half below the ears, a swelling from enlarged lymphatic
glands, which was covered by bluish rod patches of skin three
fourths of an inch wide and two indies and a half long. The
outline of the red patches was irregular, and hail none of the
characteristics of the syphilide. The patch on the left side was
open, discharging a purulent liquid. Besides these patches,
there was a papular eruption all over the body, except the head
and hands, which consisted of minute red papules in small
groups, each group being about half an inch in diameter, its
outer papules blending it somewhat with adjacent groups ; but
BLANC: DERMA TOL 0 GICA L PR A GTLGE IN NEW ORLEANS.
cases recorded :
Table VI.
Ages of Leprosy Patien ts.
Under ten years 2
Between ten and twenty 15
" twenty and thirty 20
" thirty and forty 10
" forty and fifty 12
" fifty and sixty . 8
" sixty and seventy 8
" ' seventy and eighty 1
" eighty and ninety 1
Total 83
Table VII.
Nativity of Leprosy Patients.
j • • \ New Orleans 39
Louisiana. . . . <
i Elsewhere in the State 18
286
BLANC: DERMA TOL 0 OICAL PRACTICE IN NEW ORLEANS. [N. Y. Mei>.'..Joub.,
this grouping was quite distinct. The eruption was deeper
and thicker on the legs below the knees. It did not itch. A
close examination of the lesions showed that some of the pap-
ules were raised and acuminate and covered with fine scales,
while others were flat, some seeming to be slightly below the
level of the skin and probably undergoing involution. Those
on the legs, if observed alone, might easily have been mistaken
for purpura simplex.
This case was under observation about twelve weeks, and
during this time the eruption faded or grew deeper several times,
owing to the absence or presence of the menstrual flow. The
ulcerated glands in the neck were removed under chloroform
by Dr. J. D. Bloom, and the glands sent to the pathologist of
the hospital, but I have never heard whether or not the bacillus
of tuberculosis was found. Erysipelas set in and retarded re-
covery from the operation, but when this had passed off the
patient improved rapidly, leaving the hospital much better,
though not yet cured.
Lupus. — Two varieties of this disease are generally rec-
ognized— lupus erythematosus and lupus vulgaris — though
I must confess that I have never seen very much resemblance
between them beyond the fact that both are circumscribed
lesions occurring usually on the face.
Four cases of erythematous lupus were treated by me,
three of the patients being white and one colored, while
two were males and two females. The location in all of
them was the face. All but one yielded readily to the
curette, followed by a pyrogallic-acid ointment. The one
that did not yield would improve for a time and relapse,
looking as badly as before.
Of the patients with lupus vulgaris, which is now gener-
ally recognized as a form of tuberculosis of the skin, one
was white and three were colored.
Three of these cases were of the warty variety — lupus
verrucosus. One consisted of a well-defined patch on the
back of the left hand in a mulatto aged twenty-eight
years.
The second case was that of a white man aged thirty-two.
The papillomatous growth appeared as large, ringed patches on
the legs below the knees. These rings spread entirely around the
legs, meeting in the rear, leaving the centers smooth, hard, and
mottled in color, causing the growth to present the appearance
called by French writers lupus sclereux.
The third case presented exactly the same appearance as
the second, except that it was in a colored boy and located on
the face and neck.* None of my cases were ulcerative — i. e.,
the so-called lupus exedens, a name which is very confusing, as
persons afflicted with the ulcerative syphilide of the nose, or
with epithelioma of that organ, have been sent to me more than
once as having lupus exedens.
Pediculosis. — This disease, due to one of the three va-
rieties of pediculi or lice — namely, the Pediculus capitis,
Pediculus corporis, and Pediculus pubis — is found usually in
filthy and unkempt persons, and frequently is accompanied
by an extensive dermatitis or artificial eczema. Sometimes,
however, very cleanly persons may be afflicted with these
little pests, as in a case of a young lady observed by me, who
had considerable irritation of the eyelids after having re-
* This patient reacted strongly to a subcutaneous injection of tuber-
culin. See New Orleans Medical and Surgical Journal, June, 1891.
mained two days on a sleeping-car. An examination with
a magnifying glass, and afterward with the naked eye, dis-
closed the presence of large numbers of the Pediculus pubis
adhering to the lashes near the eye.
Another case was that of a young lady who was con-
stantly troubled with very itchy erythematous patches on
the back of the neck and shoulders. I was able after a
long examination to discover a few nits, or ova, in the hair,
and cured the disease with antiparasitics. After some
months she returned to me with the same trouble, which
she had acquired on returning to her room after a summer
spent elsewhere. The majority of my cases of pediculosis
capitis were in females, probably on account of the greater
length of the hair in women and the greater amount of
shelter thereby afforded the insect, while the majority of
my cases of pediculosis corporis were in men.
The skin of the negro is not so tempting to the pedicu-
lus as that of the white man, and the two negroes recorded
as afflicted with this disease were half white. I have never
seen a case of pediculosis capitis in the genuine African,
and believe that these people have an immunity to some ex-
tent from the disease. The ninety-two cases of pediculosis
observed constitute 4-6 per cent, of the cases recorded.
Pompholyx. — Though only two cases of this disease
were observed, it is my desire to record one of them for
comparison with the cases of dysidrosis already considered.
Mr. J. H., aged forty-seven, consulted me February 7, 1887.
Patient had an iliac abscess opening at Poupart's ligament. He
had been afflicted with this about eighteen months and greatly
weakened by it. Eleven years ago an eruption appeared in the
spring-time at the tips of the first three fingers of each hand,
and continued to come at this season for four successive years,
lasting twenty or thirty days each time. During succeeding
years the eruption spread to the other digits, and finally to the
palms. When the eruption is present it makes him exceedingly
nervous in his already weak condition, and he has resorted to
large poultices to relieve the intensity of the itching. When ob-
served by me his hands were swollen and covered with vesicles
and blebs, the former being sunk deep into the skin and resem-
bling sago grains. They were located chiefly on the tips of the
fingers and the outer edges of the palms, while on the palms
and on the finger joints nearest the palms were large, loose
blebs tilled with a sero-purulent fluid which the patient was at
the moment busily removing. A few blebs and vesicles were
on the back of the hands. I ascertained that during the past
year the eruption had come at irregular intervals, appearing
every three or four months and lasting from two to six weeks.
It was evident, then, that the debility produced by the abscess
had aggravated the eruption. A salve composed of salicylic
acid, carbolic acid, and diachylon ointment was used, giving
great relief, and in two weeks the eruption had passed away,
leaving a smooth, red, scaling surface. During the two years
that ensued the eruption appeared some eight or ten times,
always relieved by the ointment. Finally it disappeared, and
has not troubled him since, though the abscess is not yet cured.
Pruritus. — This affection, consisting of cutaneous itch-
ing without eruption, was found in fifty-seven white and
four colored patients, while the sexes were nearly equally
divided. In many of these cases torpidity of the liver was
doubtless the exciting cause, as they were relieved by small
doses of calomel.
March 12, 1892.]
It is a well-known fact that jaundice produces itching,
but there are certain cases of intense itching not accom-
panied by this symptom and in which malaria seems to be
the exciting cause. This variety of pruritus may occur in
patients whose chills and fever have been broken for some
time, or in others in whom the malarial poison lies dormant ;
but the rule is for a cure to be effected by large doses of
quinine. I have treated nine cases of this character, and
others of doubtful origin, and have been in the habit of de-
scribing this disease to' classes of students as pruritus ma-
laria:.
Psoriasis. — None of the thirty-seven patients with pso-
riasis were negroes. Twenty-five were males and twelve were
females. All the varieties of psoriasis were represented in
these cases save the p. annulata, the lepra of Willan. Noth-
ing special was observed with reference to this disease save
its utter rebelliousness to arsenic, a remedy supposed by
some to be a specific in psoriasis.
Psoriasis constituted 1*8 percent, of the total number
of cases recorded.
Scabies. — Out of one hundred and ten cases of scabies
recorded, one hundred and four were in white persons.
Eighty-four were in males and twenty-five in females.
Scabies, though due to an animal parasite, was found in
a much more refined class of people than pediculosis.
This disease constituted 5-9 per cent, of the diseases ob-
served.
Syphiloderma. — In private practice the early and late
lesions of syphilis were about equally divided, but at the
hospital nearly all were late manifestations, the early ones
being relegated to the venereal wards.
Of the two hundred and fifty-nine cases recorded, two
hundred and thirty-six were in white persons. One hun-
dred and sixty-three were in males and ninety-six in females.
Syphilis constituted 12-8 per cent, of the total number of
cases recorded. Three cases of chancre of the lip were ob-
served, in two the lesion being located on the lower lip, and
in the third case upon the upper and lower lip — a double
chancre. A case of chancre of the cheek was treated.
The lesion was about two inches in front of the right ear,
and was regarded by me for nearly a week as a furuncle
which had not "pointed." On making an incision into it a
small amount of pus exuded from a honey-combed tissue
exactly like that found in carbuncle. In the mean time
the neighboring "'lands had become swollen and indurated,
j exciting my suspicion, when 1 ascertained that the patient,
i| who was a lady of refinement, had wiped upon a towel sev-
! eral weeks before which bad been used by a gentleman
visiting her bouse, who had had some sort of skin disease.
In due time the eruption appeared, confirming my tardy
diagnosis.
Tinea. — Only one case of tinea favosa, or favus, was
observed. It was in a Jewish girl, eleven years of age, born
of Sicilian parents.
Fifty-eight cases of tinea trichophytina, or ringworm,
> were observed — nine being ringworm of the beard ; seven,
ringworm of the scalp ; seventeen, ringworm of the body
ami face (tinea circinata) ; and twenty-five, ringworm of the
pubes and thighs (eczema marginatum). This latter, in sev-
287
eral cases, extended as far down as the foot, and in others
spread on to the abdomen and the axillary region.
Thirty-nine males and nineteen females were afflicted
with this disease.
Ringworm constituted 2-86 per cent, of the cases of dis-
ease here reported.
There were twenty-six males and ten females affected
by tinea versicolor. This eruption in the negro is of a
lighter hue than that of the skin.
LONGEVITY OF THE TUBERCLE BACILLUS.
A CONVENIENT AND RAPID METHOD OF COLORING THE ORGANISM.
THE EFFECTS OF SOME OF THE STRONGER ANTISEPTICS
ON ITS CHEMICAL DECOMPOSITION.*
By HENRY IIEIMAN, M. D.,
PHYSICIAN TO THE OUT-DOOR DEPARTMENT OF MOUNT 8INAI HOSPITAL.
It is not my purpose to present to you an exhaustive
paper on the tubercle bacillus. Voluminous literature has
been published from a bacteriological, hygienic, and, of
late, especially from a therapeutical standpoint. It is my
purpose to present to you a few observations regarding —
1. The length of time which this bacillus may be ex-
posed to ordinary temperatures outside the body without
losing its staining possibilities.
2. Concerning the most rapid and convenient method
of staining.
3. The effects of some of the stronger disinfectants on
the tubercle bacillus.
The duration of my labors dates back to January 15,
1891. In the month of March, 1891, f a similar paper was
published by Dr. A. K. Stone, of Boston. My paper may
seem to you a repetition, or at least a corroboration, of his
painstaking and competent labor. My work was, however,
done in my office and without the aid of a properly ap-
pointed laboratory. Being many times questioned as to
the possibility of staining specimens days, weeks, or months
exposed, I could give no positive answer. The different
coloring agents which I used for staining I shall hereafter
mention.
In order to give you a more rapid and comprehensive
way to look over the numerous examinations made as to
the length of time we are enabled to- color the tubercle
bacillus, as given to us for examination, and thus exposed
to ordinary room temperature, I have deemed it appropri-
ate to tabulate my work.
In viewing the result which I have obtained, you will
at first be impressed with the fact that in no single instance
bave 1 failed t<> find the tubercle bacillus after having once
determined its presence. Moreover, your attention will be
called to the varying number of bacilli found in some of
the same specimens. In order not to discuss the last ques-
tion at great length, I can only say that we can advance
numerous theories to account for this variation, the one
most plausible to my mind being the drying process of the
sputum, forcing out its watery constituents, and leaving be-
* Read before the Harlem Medical Association, October 7, 1891,
* A mcrit-aii Jour mil of /hi- .\/<-tli<-a! tiaenceg, March, 1S91.
HEIMAN: LONGEVITY OF THE TUBERCLE BACILLUS.
288
[N. Y. Med. Jouk.,
NUMBER OK BACILLI FOUND.
Specimen No. 1.
Specimen No. 2.
Specimen No. 3.
Specimen No. 4.
Specimen No. 5.
Specimen No. 0.
Specimen No. 7.
Specimen No. 8.
1891.
1891.
1891.
1891.
1891.
1891.
1891.
1891.
1
Jan.
17
b
Jan. 1 5
b
Jan. 20
c
Jan. 25
c
Jan. 26
c
Jan. 26
b
Jan. 29
1.
Jan. 31
b
2
a
20
b
" 17
c
it
22
c
u
26
c
" 29
c
" 29
b
Feb. 2
b
Feb. 1
b
3.
»
22
b
•' 20
c
tt
26
e
it
29
c
Feb. 2
c
Feb. 2
a
•' 3
c
a 4
b
4.
«
26
b
» 22
C, e
u
28
c
Feb.
2
5
c
5
a
6
b
tt 7
c
6.
28
c
" 26
c
31
b
5
c
" 8
b
8
a
" 9
b
" 10
b
6.
tt
31
c
" 28
c
Feb.
3
1)
u
8
c
" 11
c
" 11
a
" 12
b
•' 13
b
7.
Feb.
3
b
" 31
b
6
1)
it
1 1
c
" 14
b
" 14
c
" 16
b
« 16
b
8.
C(
6
b
Feb. 3
b
u
9
b
it
14
c
" 17
c
a 1?
a, f
" 18
a
" 19
c
9.
9
b
" 6
b
u
12
b
X
17
c
" 20
' <s .
" 20
a, f
" 21
b
« 22
b
10.
tt
12
b
" 9
b
u
16
b
tt
20
c
" 23
c
" 23
a
" 24
a
" 25
b
11.
16
b
" 12
b
a
18
1)
23
c
" 26
c
" 26
c
" 28
c
" 28
b
12.
»
18
b
" 16
b
21
b
26
c
Mar. 1
c
" 26
C
Mar. 2
b
Mar. 3
b
13.
21
b
" 18
b
24
b
Mar.
1
0
" 4
c
Mar. 1
a
" 5
b
6
b
14.
24
b
" 21
b
27
i.
4
c
" 7
c
4
a
" 8
b
<;
b
15.
27
b
" 24
e
Mar,
2
b
1
c
" 10
c
" 7
a
" 11
1»
" 12
b
16.
Mar.
2
1)
" 27
c
5
b
10
c
" 13
c
" 10
a
" 14
1)
" 15
c
17.
5
b
Mar. 2
c
8
c
13
c
" 16
c
" 13
c
" 18
b
" 18
b
18.
8
1.
5
e, e, f
1 1
e
a
16
c
" 19
c
" 16
c
20
1)
" 21
b
19.
11
b
" 8
c
14
c
l'.l
c
" 22
c
" 19
b
" 23
b
a 24
b
20.
14
1»
" 11
c
u
18
c
26
c
" 26
c
" 22
b
» 27
b
" 28
b
21.
18
b
" 14
c
u
20
c
26
c
" 29
c
" 26
b
" 31
b
April 1
b
22.
20
b
" 18
c
it
23
c
it
29
c
April 2
c
" 29
b
April 3
b, e
" 4
b
Zo.
23
b
" 20
b
27
c
April 2
c
" 5
c
April 2
c
it rj
e
" 8
c
24.
It
27
b
' 23
c
31
c
It
5
e
" 9
c
5
b
" 10
c
" 11
c
25.
30
b
" 27
c
April 3
1)
U
9
c
" 12
c
9
b
" 13
c
" 15
c
26.
April 3
a
" 30
c
«
7
b
((
12
c
" 16
c
" 12
b
a 1?
c
" 19
27!
u
7
b
April 3
c
It
10
1>
16
c
" 20
c
" 16
b
" 22
e
»
c
28.
10
b
" 7
c
it
13
b
2o
c
" 26
c
'• 20
b
29.
13
b
" 10
c
((
17
c
26
c
" 26
b
Oil
■50.
17
c
" 13
c
u
22
I)
Sept. 1
a
01.
22
b
" 17
c
• » - .
Sept, 1
c
" 22
1)
Specimen No. 9.
Specimen No. 10.
Specimen No. 11.
Specimen No. 12.
Specimen No. 13.
Specimen No. 14.
Specimen No. 15.
Non-tubercular.
1891.
1891.
1891.
1891.
1891.
1891.
1891.
1.
Feb.
1
c
Feb. 1
c
Feb.
1
c
Feb.
6
a
Feb. 19
c
Mar. 5
b
April 7
d
2.
4
c
" 4
c
4
c
8
b
" 23
c
" 8
c
" 19
d
3.
7
c
" 7
e
7
c
a
11
b
" 26
c
" 11
c
4.
lo
b, e
" 10
c
u
10
; c
14
b
Mar. 1
c, e
t. 14
c
5.
U
13
c
" 13
c
13
c
17
b
" 4
c, e
" 18
b
6.
16
b
" 16
c
16
b
20
b
" 7
c, e
" 20
b
7.
19
c
" 19
c, e
u
19
c
23
e
" 10
c
" 23
c
8.
22
c
" 22
c
a
22
c
tt
26
b
" 13
0 .
" 27
c
9.
25
c
" 25
c
it
25
c
Mar.
1
b
" 16
c
" 31
b
in.
28
c
" 28
c
28
c
4
b
" 19
c
April 3
c
1 1.
Mar.
3
e
Mar. 3
e
Mar.
3
c
7
c
" 22
e
" 7
c
1-.
6
e
6
c
6
c, e
10
c
" 26
c
" 10
c
13
9
c
9
c
if
9
c
a
13
c
'• 29
c
" 13
c
14.
12
c
" 12
c
it
12
c
16
c
April 2
e
a 17
c
15.
15
c
" 15
c
it
15
e
"
19
c
" 5
c
" 22
b
10.
18
" 18
c, f
i i
18
c
22
c
" 9
c
Sept. 1
b
17.
21
;
" 21
c
21
c
26
c
" 12
c
18.
24
c
" 24
c
24
c
29
c
" 16
c
19.
28
c
" 28
c
28
c
April 2
c
" 20
c
20.
April 1
c
April 1
c
April 1
c
5
c
" 26
e
21.
4
e
" 4
c
4
c
9
c
22.
8
c
"■ 8
c
8
c
12
c
23.
1 1
e
" . 11
c
11
c
16
c
24.
15
c
" 15
c
15
c
20
b
25.
19
c
" 19
c
19
c
26
e
26.
23
c
" 23
c i
23
c
a, great number; b, considerable number; c, few in number; d, none; e, broken appearance; f, in nests.
hind as sediment the solid materials, including the tubercle
bacilli. Their number on that account varies in an in-
verse ratio to the bulk of the sputum left and also to the
mechanical means employed in selecting the sputum to be
spread upon the slide. In the supernatant fluid I have not
been able to find any tubercle bacilli.
We must also consider that the constant decrease of
tubercle bacilli in some of the specimens is entirely due to
the continuous withdrawal of tubercular material and also
because tubercle bacilli only grow or multiply at blood
temperature, and in more favorable culture media than or-
dinary expectorations. The oldest specimen, which I first
stained successfully on March 5, 1891, has been in posses-
sion of Dr. E. Friedenberg for more than a year, and
still after twenty months have elapsed 1 have found tuber-
cle bacilli each time in sixteen examinations. Now, in
order to rule out the possibility of tubercle bacilli having
fallen itito my phials, I have kept non-tubercular spu-
tum amidst all the tubercular ones, one bottle even un-
covered, but after repeated examinations have not been
March 12, 18H2.J
HELM AN: LONGEVITY OF
THE TUBERCLE BACILLUS.
289
able to find any tubercle bacilli in the control bottles. As
far as finding the tubercle bacilli in the sputum of non-
tubercular patients, I have also in the specimens which I
have examined obtained a negative result. This work,
however, has been fully studied by Koch* in his master-
work, and by Fraentzel and Balmerf and Ziehl, J who have
also, after numerous examinations, been unable to detect
the tubercle bacillus in the sputum of non-tubercular
patients. The finding of living virulent germs even in dry
sputum after such Length of time, as Dr. Stone has shown,
I consider a most important practical point. Cornet,* by
his numerous experiments, has vividly and justly called our
attention to this matter, especially from a hygienic stand-
point— the importance of preventing the spread of tubercu-
losis by simply placing water in the cuspidors. We can
only conclude, from the results obtained, that the tubercle
bacilli under ordinary environments retain a longevity simi-
lar to the other bacteria, due to their true spore formation.
I have seen Koch demonstrate a pure culture of anthrax
bacilli still retaining their virulency after eighteen years.
As regards the changes undergone by the tubercle ba-
cilli || in course of time, they seem to me to be that they
did not take on the coloring agents as well [Ziehl's solu-
tion], and that they appear of a more brownish color. To
determine the presence of the tubercle bacillus in local tu-
berculosis, I have examined the discharges of forty cases,
including joint disease, cold abscesses, and scrofulous glands.
Eighty specimens were prepared. Only in one — that com-
ing from a cervical (cheesy) gland — I have found the germ.
I firmly believe in their presence in all the other aforesaid
affections. Koch A mentions three cases of freshly extir-
pated scrofulous glands, in two of which the tubercle bacillus
was found. Out of four cases of tubercular joint disease,
its presence was detected in two. It is a well known and
recognized fact that we rarely find them in pus, but gener-
ally in cheesy concretions. Dr. Kanzler Q reports thirty-one
cases of scrofulous glands, finding the tubercle bacillus four-
teen times in two hundred and thirteen prepared slides.
Thirteen cases of bone tuberculosis with eight positive results.
Concerning the most convenient and rapid method of
staining the tubercle bacillus, I shall not describe the vari-
ous methods known, or those which I have employed. Suf-
fice it to say, Koch's, J Ehrlich's,J Biedert's,J and Gram's**
were used for some of my specimens. For over four hun-
dred of them, however, I have employed Friedliinder's meth-
od, as described by Dr. M. Manges, ff and, on account of its
simplicity, I was prompted to undertake this labor. Its ap-
plication insures cleanliness, rapidity, efficiency, and little
* Berliner klinischc Wochenschrift, No. 15, 1882.
t Ibid., No. 45, 1882.
\ Deutsche medizinische Wochenschrift, No. 4, 1883.
* Berliner klinische Wochcnschi iff, 1880, No. 12.
|| Leitz ocular I, oil immersion, -fa ; Abbe's condenser.
A Berliner klinische Wochenschrift, 1882, No. 15.
0 Ibid., 1884, Nos. 2 and 3.
j Ibid., 18S2, No. 15.
1 Ibid.. 1883, No. 1.
{ Virehow's Archiv, 1884, B. 98, p. ill.
** Fortschrilte der Medizin, 1884, No. 2, p. 185.
ff Medical Record, November 22, 1891.
expense. Methylene blue is used as the differential color-
ing. I, however, substitute malachite green, because of its
property of coloring the specimen more intensely and quick-
ly, at the same time differentiating the red colored bacillus
as well as is done by the methylene blue. The disadvan-
tages of Friedlander's method, however, consist in the man-
ner of spreading the sputum on the slide and the continuous
and exposed friction causing it to dry with great rapidity,
thus separating numbers of little particles, and in this man-
ner jeopardizing our own respiratory apparatus. Weichsel-
baum * has clearly proved that after inhalations of tubercu-
lar sputum, tubercles were found in the lungs, also in other
organs. May this point be a special warning to those ex-
aminers predisposed to tuberculosis. I have stained and
examined slides with this method in six minutes' time, es-
pecially if the sputum be old. For your convenience I shall
briefly quote this excellent method. Special attention I
have paid in all my work never to use an old slide. Thus
I exclude one possible error. In collecting the sputum in
a small wide-mouthed bottle, I have never required the
transfer of it into a watch-glass. The solutions used for
this method are :
ZiehVs Fuchsine Solution :
Fuchsine 1 0 j
Alcohol, 95 per cent 10-0;
Sol. acidi carbolici, 5 per cent 100-0,
2. Decolorizing Solution :
Nitric acid 5-0 ;;
Alcohol, 95 per cent 85-0 ;
Distilled water 15-0.
S. Differential Staining Solution. — Concentrated aque-
ous malachite-green solution, prepared by taking an excess
of malachite green ; add to distilled water, allow it to stand
for two days, then filter.
Now clean the slide ; sterilize it by passing slowly through
flame. With a sterilized platinum hook select sputum and
spread it in the eeriter of the slide to the size of a one-cent
piece until dry. As slides require longer to become heated,
pass them through a flame quickly ten to twenty times
add with a pipette fifteen to twenty drops of Ziehl's solu-
tion, which amount protects the separated particles. Allow
this solution to act about five minutes, then hold the slide
with swaying movements over a small alcoholic or Bunsen
flame until the specimen steams; wash off with water, and
dry with filter paper. Now add the decolorizing solution,
to act on it about thirty seconds, or rather until all the red
color disappears. Wash off and dry again with filter paper.
Finally cover with a few drops of the concentrated aqueous
malachite-green solution for about five to ten seconds.
Wash off and dry with filter paper. The specimen is now
made ready for examination by placing one drop of cedar
oil on it. For permanency first add one drop of Canada
balsam and a cover glass. In the heginnino- this method
may appear discouraging, but after a few trials a pretty
even surface of the sputum on slide will be obtained. On
this our success depends.
As to the effects of some of the stronger disinfectants
* Wictur uiidizinischc Fresse, 1883, p. 1574.
290
(HADDOCK: RHEUMATIC EXDOCA RUITIS WITH ERYTHEMA XODOSUM. [N\ Y. Mku. Jock.,
on the tubercle bacillus, I must confess that my experi-
ments were few and partly unfinished, because of the dis-
advantages under which 1 hail to labor. To carry out this
work properly, one must make biological experiments, and
direct inoculation of animals, for which a complete labora-
tory is essential. I have confined myself only to the use of
some of the stronger disinfectants, and their action on the
tubercle bacillus, as far as the microscope reveals to us.
Koch * has already shown that the tubercular sputum, even
in a dry state, after two to four or eight weeks, still retains
its virulence, but finally the organisms die or become trans-
formed into spores, and then lose their coloring property.
The cadaver will certainly take on coloring agents up to the
time it becomes chemically decomposed, which I believe to
be able to demonstrate to you in cases of the disinfectants I
have u^ed. A tive-per-cent. carbolic solution does not de-
stroy them chemically, for we employ it in our Ziehl's solu-
tion. On that account I have employed a ten-per-cent.
carbol-glvcerin solution, with the result of staining the
tubercle bacillus. Schiller and Fiseher.t in their experi-
ments with disinfectants, have proved by inoculations that
tubercle bacilli were killed by a three-per-cent. carbolic so-
lution in twenty hours. A. Yersin, \ a French observer, re-
ports having killed them after heating for ten minutes up to
70° C. Pam pukes,* in Athens, heated them up to 120° C,
obtaining the same results, though still taking on the color-
ing agents. I applied sublimate solutions (1 to 1,000 and
1 to 500). and after either solutions, well mixed with tu-
bercular sputum, I have been enabled to color the tubercle
bacillus. Their resistance to such great heat and rather
strong disinfectants indicates to us the kind of disin-
fectants we ought to employ in order to destroy them chem-
ically.
As the last ami strongest disinfectant, I applied chlorine
solutions — twenty five per cent., fifty per cent., and in a
concentrated form. In none of the specimens, after the use
of these strong solutions, have I been able to determine the
presence of the tubercle bacillus, nor other organized ele-
ments of sputum. Nut withstanding the disagreeable and
pungent odor of chlorine, it certainly bears to-day the name
of one of our most efficient disinfectants for such dangerous
germs.
May the publication of this paper be especially of some
aid to the general practitioner, who may be far distant
from his colleague who is practicing clinical microscopy.
The physician can instruct his patient to expectorate di-
rectly into a small, sterilized, wide-mouthed bottle, with a
cotton-covered cork. It is best to collect the first sputum
raised in the morning, as in day-time the large amount of
mucus formed dilutes the specimen. In this manner send-
inc it for examination, the same result will be obtained as
if examining the sputum directly after expectoration. To
Dr. B. Stiefel I must extend my sincere gratitude for his
able assistance in this work.
220 East One Hindred and Sixteenth Street.
* fin-liner klinische Wochenxchrift, 1882, No. 15.
■f Ctrlbl fur Bakteriologie und 1'arnxitenkunde.
X Ibid., Hi, No. 18.
« Ibid., 1691, is, No. 139.
PRIMARY RHEUMATIC ENDOCARDITIS
WITH ERYTHEMA NODOSUM.
By C. G. CHADDOCK, M. I)..
TRAVERSE CITT, MICH ,
assistant medical superintendent OF THE NORTHERN MICHIGAN AST ml :
FELLOW OF TnE CHICAGO ACADEMT OF MEDICINE.
The following case presents several features of interest
and importance with reference to diagnosis, and it shows a
distinct relation between rheumatism and erythema nodo-
sum that is not sufficiently appreciated :
On October 4, 1891, W. P., a young man aged eighteen, con-
sulted me concerning a cough that had troubled him tor nearly
two weeks. I was thoroughly acquainted with his previous
health and habits, as well as with the f»ct that he was working
in a basement where light and ventilation were bad. Some
weeks before, a sister, six years older than himself, had died of
pulmonary phthisis. On September 27th, a week before I saw
him, his lungs were examined by a colleague, who found the
breath-sounds of the right apex equivocal, and was inclined to
fear incipient phthisis. In the week before he came to me he
had lost nine pounds in weight. When I examined his lungs I
found the condition that had been described to me by my col-
league. The heart-sounds were without murmurs; there may
have been accentuation of the pulmonary second sound at that
time, but I failed to discover it. The apex-beat was in a normal
position, and the superficial cardiac dullness was not increased.
The pulse was full and regular at 80. During the examination
he coughed frequently, but there was no expectoration and had
been none. ITis subjective symptoms were a general feeling of
malaise, indefinite pains through the chest, shortness of breath,
annoying thirst, and chills at times followed by what seemed to
him mild fever. For more than two weeks he had had night-
sweats. According to his statement, his illness had begun on the
night of September 21st. when he woke up to find himself per-
spiring very freely. He was never in better health than just
before this illness.
Temperature on the evening of October 4th. 101° F. A
diagnosis of incipient phthisis seemed all but justified, and pre-
scriptions with this view were made.
The patient had been working up to that time. Kest was
enjoined. The temperature reached 102° F. the following even-
ing, and on the evening of the 6th it was 103° F. ; and examina-
tion of heart at that time revealed a soft systolic murmur at the
apex, with accentuation of the second sound of the pulmonary
valve. The following morning the murmur was again heard.
The thought that this murmur was hamiic did not seem entirely
satisfactory, and rheumatic endocarditis suggested itself as its
cause. The suspicion of rheumatism led to careful examina-
tion of joints, and revealed no anomalies; but on the front of
each leg were found six spots of erythema nodosum, which va-
ried in size from a quarter to half an inch in diameter. These
spots were excessively painful on pressure. The patient had
noticed them the day before, but had failed to speak of them^
owing to the fact that they caused him no pain save when he
touched them. This discovery, with the systolic mitral murmur,
led to the diagnosis of rheumatism, and the treatment recom-
mended by Dr. Latham * was undertaken. The diet was re-
stricted, and seventy-six grains of salicylic acid were given dur-
ing the afternoon. The result of this was an evening fall of
temperature to 98° F., and a slowing of the pulse to (>4, while
all tenderness of the spots of erythema was removed. Slight
hebetude was also induced. There was annoying breath lessness
on attempting to rise in bed, and absolute rest was enjoined.
* Lancet, 1886, vol. i, p. 818.
March 12, IS92.] CHADDOCK: RHEl VATIC ENDOCARDITIS WITH ERYTHEMA NODOSUM.
291
October Temperature at 8.30 p.m.. 98° F. ; pulse, 56,
with hesitancy of the bent. Thirteen grains of salicylic acid
during the day. dough less troublesome.
Uih. — Right ankle very painful; some swelling and great ten
derness over front of joint. Temperature rose to 102'4° F. at
0 p. \i Seventeen grains of salicylic acid during the day. The
cardiac murmur was very distinct at apex and there was marked
reduplication and accentuation of the pulmonary second sound,
the reduplication of second sound being heard also at apex. It
was evident that the left ventricle was undergoing hypertrophy.
The apex-beat had reached the mammillary line in the fifth in-
terspace, and the heaving could be seen in both the fourth and
fifth interspaces. The cardiac dullness had increased, but there
was no dullness to the right of the sternum. Tne spots of ery-
thema were still distinctly red, but were only slightly tender.
10th. — Both shoulders and both elbows stiff and tender. < me
tender spot of erythema nodosum over middle of spine of right
scapula. Several similar spots on back of neck ; one back of
left ear. Several red herpetic spots on left side of neck ; all ten-
der on pressure. Reduplication of second sound at apex no
longer heard. Temperature reached 104° F. Pulse, 72, with
slight irregularity and some hesitancy of beat. Thirty grains of
salicylic acid during the day. The temperature chart shows the
subsequent events of fever and pulse.
From October 11th. forty grains of salicylic acid were taken
daily until the 15th, when the amount was increased to fifty
grains; and this daily dose was continued until the 23d, when
it was reduced to thirty grains. This dose was continued until
the 26th, when it was reduced to twenty grains, and finally dis-
continued on the 30th.
During treatment the bowels were moved almost daily with
calomel and salines. The tenderness of shoulder and elbow
joints disappeared on the 12th, but the ankle continued painful
until the 26th. On the 22d it is noted that the erythema is
gone, save for a few spots on back of neck. There was some
desquamation of the spots on the neck. There were two spots
on the dorsal surface of left hand half an inch in diameter that
were herpetic in character. Sweating occurred occasionally at
night during the illness.
may be seen in the fourth, fifth, and sixth interspaces. No
dullness to the right of sternum. Pulse regular, full, and strong
at 72. During the last two weeks of the illness there was no
cough.
It should be added that there is a strong hereditary predis-
position to rheumatism. On both the father's and mother's side
there is rheumatism, and the patient's brother passed through a
severe attack.
The actual duration of the disease was forty two days, but
the symptoms were not such as to induce the patient to consult
a physician, though several were immediately at his service, un-
til a week had elapsed, and then actual treatment was postponed
for a week more, owing to uncertainty of diagnosis. The
symptom that was earliest to appear and most troublesome was
dry cough, and this was due to pulmonary congestion, not to
incipient phthisis. When the diagnosis of endocarditis was
made there was no other evidence to support it than the mitral
insufficiency with fever. At no time were there any subject-
ive cardiac symptoms; at no time was the cardiac rhythm seri-
ously altered. The discovery of erythema nodosum, occupying
its favorite seat, made it seem, with the strong existing predis-
position, almost certain that the malady was of a rheumatic na-
ture, and salicylic acid was given. The medicine altered the
condition of the erythema at once, but it did not prevent the
development of the joint affection, though the joints involved
were never so much affected as to cause the patient suffering.
With the advent of these symptoms there could no longer beany
doubt about the correctness of the diagnosis.
In this case the erythema nodosum developed subse-
quently to the endocarditis, but before the joint affection,
and it formed a prominent feature of the disease. It was
not due to the acid, for it was present before that medicine
was exhibited ; but it was affected by it — made less painful.
Those spots that developed during the exhibition of the
acid were less painful than the first eruption had been, and
showed a herpetic tendency with ultimate desquamation.
Certainly, erythema nodosum should be assigned a place in
27th — The temperature reached normal without medicine
(antifebrine had occasionally been given), and on November 2d
there was an absence of fever.
Condition of the heart on November 1st: Soft mitral regur-
gitant murmur heard at apex; second pulmonary sound much
accentuated; apex-beat, in fifth intercostal space half an inch
outside mammillary line. The heart-beat is very diffuse and
the symptomatology of rheumatism ; even one case like
this goes far to confirm the conclusions reached by .Mac-
kenzie* in his study of the relations of rheumatism, car-
diac disease, and erythema nodosum.
* Dr. Stephen Mackenzie. Erythema Nodosum,
fore the Clinical Society of Loudon, April 9, 18S0.
A paper read lie-
292
It is noteworthy that large doses of salicylic acid, with
its decided antipyretic influence, had no other effect on the
heart than to reduce the number of the heats. It does not
seem that the acid exerted any effect on the duration of the
fever, but it certainly made the symptoms of the disease,
usually so insufferable, quite endurable.
The marked prolongation of the fever after it had ceased
to rise above 100° F. is remarkable, and, in the absence of
any other explanation, may be ascribed to the continuance
of an inflammatory condition of the endocardium. The
patient is now convalescent and shows but slight etiolation,
though he lost sixteen pounds in weight.
ON THE OPERATIVE TREATMENT OF
DIVERGENT STRABISMUS*
By EMIL GRUENING, M. D.
Absolute divergent strabismus is so often associated
with high degrees of myopia, with anisometropia, or with
monolateral amblyopia, that these conditions are regarded
as causative in the development of the muscular anomaly in
question. Not infrequently, however, this very form of
squint is observed in persons whose two eyes are emme-
tropic and equal in vision. In divergent strabismus the
range of motility is normal ; both in the squinting eye and
its fellow the inner edge of the cornea touches the caruncle
upon extreme adduction, and the outer edge of the cornea
the outer canthus upon extreme abduction. The power of
accommodative convergence is lost. In some cases the de-
gree of divergence changes with the position of the object,
the deviation being more pronounced in distant than in near
vision. There is no tendency to use both retinas for the bi-
nocular act of vision for any position of the object.
These characteristic features are pointed out here because,
for the purpose of this paper, it is necessary to exclude on
the one hand the various forms of periodic divergence, and
on the other hand all forms of divergence known as sec-
ondary, paretic, and paralytic.
The latter go to make up separate classes of deviation,
are recognizable by limitation of motility inward, and re-
quire for their correction the operation of advancement-
The ordinary divergent squint, on the contrary, shows no
limitation of motility and can be corrected by simple te-
notomy of both recti extend muscles. In many of our re-
cent text-books of ophthalmology the various forms of diver-
gent squint and the operative methods applicable to their
relief are somewhat commingled. As a consequence of this
intermixture of classes and measures, the following propo-
sition is induced : " Tenotomy of the recti extend muscles
generally proves insufficient for the correction of absolute
divergent strabismus." Yet the reverse is true. If by ab-
solute divergent strabismus the so-called concomitant diver-
gent strabismus is understood, the proposition should read :
Tenotomy of the recti externi muscles, with the addition of
* Read before the American Ophthalmological Society at its twenty-
seventh annual meeting.
an adducting suture, generally proves sufficient for the cor-
rection of divergent strabismus.
In the past ten years I have practiced this operation with
the greatest satisfaction in all my cases of absolute divergent
squint, and of many I possess a detailed record. Home of
them remained under observation a number of years — a suf-
ficiently long time to permit me to say that the favorable
results were not only immediate, but also permanent. It is
now almost forty years since Albrecht von Graefe wrote
that the precautionary measures so essential in tenotomy of
the rectus interims did not apply to the rectus externus, in-
asmuch as a free division of the conjunctiva over the ex-
ternus and of the muscle itself could cause neither an un-
sightly recession of the caruncle nor a vexatious limitation
of motility. These considerations guide me, and in my op-
erations the conjunctiva is freely incised and the whole ex-
tent of the tendon and its insertion exposed. Both recti
externi are operated upon at one sitting. In cases of diver-
gence of not more than two millimetres the tendons are di-
vided at their points of insertion. Whenever the deviation
measures more than two millimetres, the tendons are divided
at a distance from their insertions, the distance correspond-
ing to the degree of squint.
Thus, in a case of divergence where the measurement
by corneal reflex, according to Hirschberg, showed a devia-
tion of five millimetres, both tendons were divided at that
distance from their points of insertion. The tendinous
stumps are not removed. The conjunctival wounds are
closed by a few interrupted sutures placed horizontally. A
silk thread is passed through the conjunctiva over both in-
terni muscles in a line with the horizontal meridian of the
cornea and tied over a pledget of cotton on the bridge of
the nose. The eyes are thus coupled in a position of strong
convergence which is maintained twenty-four hours. A bi-
nocular bandage may be applied ; it relieves the discomfort
caused by the suture.
Conclusions. — (a) The operation here described yields
better results in cases of absolute divergent strabismus than
advancement.
(A) It is a simpler operation.
(r) In advancement the graduation of the effect is im-
possible.
(d) In tenotomy of the externi, the shortening of the
muscles in accordance with the degree of squint, though
practiced empirically at present, suggests the possibility of
attaining mathematical exactitude in the graduation of the
effect.
ON TAN NATE OF MERCURY.*
By S. LUSTGARTEN, M. D.
I have to express my thanks for the opportunity ex-
tended to me of giving my views in this learned society
concerning the subject upon which Dr. Allen has dwelt
in so elaborate a manner. This opportunity is so much
* Read before the Section in Genito-urinary Diseases of the New
York Academy of Medicine, December Hi, 1891, in the discussion of
Dr. Charles \V. Allen's paper on the same subject.
March 12, 1892.]
more welcome as, since I first brought the tannate of mer-
cury before the profession, in 1884,* I have not communi-
cated until now my further experiences with this prepara-
tion. In spite of the latter circumstance, the tannate has
now many friends, although a marked predilection in some
countries for the hypodermic treatment has not been fa-
vorable to more extensive and unprejudiced trials of internal
methods in the treatment of syphilis. To the list of au-
thors who speak favorably of the preparation in question
I could add several more — such as Campana, Dornig, Ep-
stein, Lane, Monti, Zeisler. Furthermore, the hydrargyrum
tannicum oxydulatum was made about three years ago an
ofKeial preparation of the Austrian Pharmacopoeia.
What gives this preparation a remarkable position is
its peculiar chemical reactions. As it is not acted upon by
dilute acids, it will pass the normal stomach without any
symptoms whatever. As soon as, in the duodenum, the
reaction changes to an alkaline one, it is reduced to ex-
ceedingly small globules of metallic mercury — so small that
a direct absorption in this state, by the villi of the small
intestines, is imaginable. That is the reason why, in my
original publication, in discussing this point, I ventured
the expression, " internal inunction.'1'' It is indeed highly
probable that the chemical process, which finally brings about
the solution of mercury and its entrance into the circula-
tion, is the same with the metallic globules of the gray
ointment in the skin and the reduced particles of mercury
of the tannate in the intestines. That would account for
the satisfactory therapeutic action and for the freedom
from irritation of the latter. Although, in a small minority
of cases, irritation of the bowels has been recorded, it is
still generally admitted that the salt in question is a com-
paratively mild and non-irritating one.
I have proved the presence of mercury in the urine
within twenty-four hours after the administration of the
tannate. In an elaborate series of quantitative examinations
of the urine in different mercurial treatments, Winternitz \
has found the largest amounts after injections with in-
soluble mercurial compounds, and the smallest after in-
ternal treatment, among others, with the tannate. Inas-
much as the internal medication shares the same fate with
the inunctions, which I, with many others, think to be, if
properly applied, the most energetic treatment, these in-
teresting experiments prove once more that theoretical
views are not always in accordance with the facts derived
from practical observations.
There are two methods for the manufacture of the tan-
nate of mercury — a wet and a dry process. The former one,
which I used myself in my first experiments, consists in
precipitating a concentrated solution of tannic acid by
fleshly prepared oxydulated nitrate of mercury, dissolved
in water, and drying the precipitate at a low temperature.
The second consists in rubbing together tannic acid and
oxydulated nitrate of mercury, washing and drying. The
more expensive wet process gives, as wet processes in gen-
eral do, a preferable preparation, consisting in an impal-
* Wiener med. Wocfiens., 1848.
+ Arch, fur Derm. un,l Syph., 1889, 6. Heft.
293
pable powder, free from nitric acid, which guarantees a
quicker and more complete absorption. Such a prepara-
tion, manufactured by 6. Hell & Co., Troppau, Austria, is
mostly used in Austria. The French tannate is prepared in
a similar manner, while Merck's drug is obtained by the dry-
process.
My experience extends to about three hundred cases.
It would take too much time to develop my views concern-
ing the treatment of syphilis, so I shall confine myself to
describing the role which the tannate plays. I am an ad-
herent of a modified intermittent treatment. In this treat-
ment, in order to bring about the most favorable results, it
is of the greatest importance that the first treatment after
the appearance of the secondary eruption be as energetic as
possible, and, if practicable, it always ought to be a course
of thirty to forty inunctions. The subsequent treatment
consists in the administration, for one month at a time, of
three to five grains daily of tannate of mercury, with in-
creasing intervals of from one to three months.
The tannate has also given me very satisfactory results
in the recurrent forms of the secondary stage and in the
tertiary stages, where iodide of potassium can be given, if
the precaution be taken to leave an interval of several
hours between the alternating doses — e. y., in the morning
a dose of potassium, three hours afterward the tannate, six
hours later another dose of potassium, and before retiring
a second dose of the tannate.
The daily dose for adults begins with three grains, and
if this is well borne and it be found necessary, it can be in-
creased to five grains or even more. One course of treat-
ment consists of 100 to 150 grains.
In a healthy state of the digestive tract — and only in this
case should mercury be given internally — I have never ob-
served symptoms on the part of the stomach, which is only
natural, as the tannate, as above stated, does not, in all
probability, undergo any change in its acid contents. With
regard to the bowels, it is in a minority of cases apt to pro-
duce two or three soft passages a day, which is often de-
sirable ; in the majority of cases it does not interfere at
all. Certain dietetic precautions ought, of course, to be
taken, especially with persons given to diarrhoea — such
as refraining from fresh fruit, beer, white wine, etc.
For years I have refrained from combining with this
treatment even the slight doses of opium formerly em-
ployed, as the continued use of this drug has seemed un-
desirable.
I have never had a bad case of stomatitis, as this prepa-
ration has no cumulative qualities and as 1 have watched the
mouth carefully and stopped the use of the tannate for a
while, upon the slightest appearance of irritation, until these
symptoms had disappeared. This is a great advantage of
the tannate, especially over the injections of insoluble com-
pounds of mercury with their trea'cherous stomatitis and
other dangerous possibilities. I use the latter only where
for some reason the other methods are not applicable or
where delay is dangerous, as in syphilis of the nervous
system, where it is desired to bring a large quantity of
mercury into the circulation at short notice.
The tannate has given me excellent results in the trcat-
L USTGA R TEN: ON TANNATE OF MERCURY.
294 CURRIER: AMPUTATION OF CERVIX UTERI IN SUSPECTED CARCINOMA. [N. Y. Med. Jouh.,
ment of children in hereditary as well as in acquired forms.
I have prescribed in these cases a third of a grain two to
four times a day, to be taken in a teaspoon with milk — if
feasible, mother's milk.
The formula which I have generally used with adults is
the following :
R Ilydrarg. tannic, oxydulat gr. jss. ;
Acid, tannic, )
Sacch. lactis, f ' a *r"
M. F. in pulv. sive in capsul. gelatin.
Sig. : One twice or three times a day.
In America I have used largely, in private practice, the
one-grain soluble pills manufactured by W. H. Schieffelin &
Co., and have reason to be satisfied with the results.
In dispensary practice, for the sake of economy, I have
used the one-grain compressed tablets made by John Wyeth"
& Brother. Tablet triturates can not be used, as water is
necessary for their preparation, which^causes chemical de-
composition in a short time.
In conclusion, I wish to state that, in my hands, the
tannate of mercury has proved a very efficacious and val-
uable preparation of mercury, comparatively free from un-
pleasant accompanying symptoms, and I should be loath to
dispense with it in the treatment of syphilis.
15 East Sixty-second Street.
AMPUTATION OF
THE VAGINAL PORTION OF THE CERVIX UTERI
IN CASES OF SUSPECTED CARCINOMA*
By ANDREW F. CURRIER, M.D.,
NEW YORK.
Perhaps it would be better to say provisional amputa-
tion, or " exploratory excision," as Muller styled it in a paper
written in 1884 (Ann. de la Soc. de med. d'Anvers, 1884,
xlv, 235), the idea being that the operation is to be per-
formed to enable one to complete a diagnosis which is in-
complete and unsatisfactory without it. The object of the
operation is also to avoid the alternative of removing the
entire uterus and finding that the carcinoma was only a sus-
picion existing in the mind of the operator, which certainly
does not magnify the wisdom or judgment of the latter
and leaves the patient unnecessarily mutilated, even if she
escapes with her life. As has already been intimated, the
idea is not a new one, but I am not aware that the opera-
tion has been practiced to any considerable extent for the
purpose of verifying a diagnosis of carcinoma of the vagi-
nal portion. It is suggested because of the inconclusive
results which so often attend the examination of scrapings
from the endometrium, and even of small portions of the
cervical tissue itself. If a segment of tissue large enough
and long enough to reveal the vital condition in the entire
length and breadth of the vaginal portion is removed from
any except very large organs, in which case amputation or
trachelorrhaphy will frequently be indicated whether there
* Head before the Medical Soeiety of the State of New York at its
eighty-si xtli annual meeting.
is malignant disease or not, the resulting wound will
quite destroy the symmetry and usefulness of the organ
and may necessitate amputation, which might better have
been determined upon at the outset. With the entire
vaginal portion removed, we are in a position to study the
extent of the disease, if disease exists, to decide with a
greater degree of certainty, by the preparation of many sec-
tions, if necessary, as to the virulence of the disease, and
either to interfere no further surgically or to perform
hysterectomy if the conditions warrant such an operation.
To a certain extent the proposition is analogous to that
which is meeting with no little approval among general
surgeons — namely, to precede resection of the intestine by
colotoin v.
The position which I take is entirely in harmony w ith
the view which I have held and expressed for years, that
upon early diagnosis must we mainly depend for the suc-
cessful surgical treatment of malignant disease of the
uterus. This point can not be too often repeated or too
strongly emphasized, and the gynaecologist can not insist
too vigorously that the general practitioner should seek ad-
vice whenever he finds a patient suffering with a stubborn
erosion or ulcer of the mucous membrane of the vaginal
portion or with hannorrhage from the endometrium for
which he can not satisfactorily account. But this position
is aside from the question of precision in diagnosis, which
in many cases will only be attained by the performance of
the exploratory or provisional operation to which I have
alluded. Excluded from consideration at the present time
are all those cases in which the- existence of malignant dis-
ease is so unmistakable, both clinically and microscopically,
that no time need be lost in provisional procedures. For
£uch I would advocate, as I have done for years, the imme-
diate total removal of the uterus and its diseased surround-
ings, or the palliative operation with scissors, curette,
caustic, and cautery, if radical removal is impossible. Two
motives have influenced me to the discussion of this sub-
ject in a brief paper. The first is that, in common with
many other gynaecologists, I frequently see cases which
make me suspicious of the presence of malignant disease of
the vaginal portion of the cervix uteri. As already stated,
the examination of scrapings and bits of tissue in such
cases is often very inconclusive, and upon such evidence
one should hesitate to recommend to a woman the dangers
of a grave operation, the resulting mutilation and deformity,
and the interference with important functions. The sec-
ond is that operations have been performed, uteri and
adnexa removed, only to find that there was no serious dis-
ease present in the organs. Naturally enough, the history
of such cases is never published in all its details, the speci-
mens are seldom shown at our society meetings, and he
would be a very courageous or a very ignorant man who
would run the gantlet of the criticism which the presenta-
tion of such specimens would call forth. But there is no
man so acute in his judgment or so skillful in his opera-
tive work that he can afford to ignore the lesson which
such experiences, real or potential, teach — namely, that
careful diagnosis is at the bottom of all good work in the
field which is under consideration.
March 12, 1892.] CURRIER: AMPUTATION OF CERVIX UTERI IN SUSPECTED CARCINOMA.
295
Among the conditions which render diagnosis difficult
with reference to the presence or absence of malignant
disease of the vaginal portion may be mentioned the fol-
lowing :
1. Endometritis, with or without haemorrhage from the
interior of the uterus.
2. Hyperplasia, with or without fissure of the os and
endometritis.
3. Erosions, ulcers, and glandular disease.
In other words, the conditions which must always call
for careful attention in connection with disease of the vagi-
nal portion are haemorrhage, infiltration, and ulceration, and
the conditions which are kindred to or suggestive of them.
I. Endometritis is a comprehensive term. In its ordi-
nary acceptation, in which there is merely a catarrhal con-
dition of the endometrium, it does not excite apprehension
of any serious pathological disturbance. It is the most
common of all the disorders of the endometrium ; there are
few women who have experienced the pregnant state who
do not suffer with it, and I am satisfied that we frequently
attach greater importance to it than is warranted by the
actual condition of affairs. But if the condition is one of
active inflammation, with a constant discharge of pus, or of
pus mingled with blood, it is neither simple nor harmless,
and calls for serious investigation as to its cause and the
proper means for its relief. It may be entirely unaccom-
panied by pain. There may or may not be a certain degree
of debility resulting from the discharge. But in any case
the endometrium should be thoroughly curetted, the tissue
being scraped away to the submucous tissue, and the scrap-
ings carefully examined. As has already been stated, such
an examination frequently shows us nothing but the evi-
dence of an inflammatory process, or it may leave us in
doubt whether there is not also the existence of a neoplasm-
If after the lapse of a few weeks there is no evidence of im-
provement, the discharges of pus, blood, and epithelium
continuing, we are justified as the next step in the treat-
ment in amputating the vaginal portion, which will yield us
material for determining with greater certainty as to the
extent of the disease, and we can then decide whether all
necessary operative procedures have been adopted, or
whether we should take steps of a more radical character
and remove the entire uterus. If the disease proves to be
purely inflammatory, or is very limited in its extent as a
malignant process, no harm will have been done, the uterus
will still be enabled to perform its customary functions, and
we will have been placed on our guard for subsequent de-
velopments. I have known of cases of this kind which
have retained their suspicious, semi-malignant character for
years which have been held in check by curetting per-
formed at sufficiently frequent intervals, and which have
never enabled one to say with certainty that there was suf-
ficient severity of the symptoms to warrant complete re-
moval of the uterus. I have had cases in which the vaginal
portion was amputated and in which the microscope showed
that the malignant disease was limited to an area well below
the plane of section. Of course one must not ignore the
fact that the corporeal endometrium may be the seat of dis-
ease simultaneously with that of the cervix, perhaps even
to a greater extent than the latter. Such cases unquestion-
ably require the radical operation, and our investigation
should not be limited to any one portion of the organ in
determining the extent to which it is the subject of a dis-
ease process. The endometritis with haemorrhage which
results from abortion, retroflexion of the uterus, and the
presence of submucous myomata has not infrequently given
rise to the suspicion of malignant disease of the vaginal
portion. I have seen illustrations of all these conditions in
which such a suspicion was aroused.
II. Hyperplasia of the vaginal portion may be suggest-
ive of the infiltration which accompanies malignant dis-
ease. T have seen such a suspicious condition in both
nulliparous and parous women. The mucous membrane
may be smooth and apparently healthy and the endome-
trium show nothing abnormal or only a slight catarrhal con-
dition, and yet the unusual size of the vaginal portion sug-
gests the possibility of a neoplastic process. I can recall
such a case in a nulliparous woman in which the vaginal
portion was amputated more than three years ago, nothing
more than an excess of connective tissue being found in the
specimen. The body of the uterus is still very large, the
patient continues to suffer with dysmenorrhea, and it is yet
undecided whether she is afflicted with a slowly progressing
interstitial inflammation or with an adenoma which may yet
require radical measures.
In the cases in which there is not only enormous in-
crease in the size and density of the vaginal portion but fis-
sure of the os as well, with eversion of the endometrium,
and possibly endometritis and haemorrhage, the suspicion of
malignant disease is often a reasonable one. It is this class of
cases, in which the nutrition is so perverted, that suggested
to the mind of Emmet years ago the possibility of the de-
velopment of carcinoma upon such a foundation. I believe
that with these conditions such a development frequently
does occur. At any rate, amputation should be performed
and the diagnosis can then be determined. Amputation, in
my experience, is preferable in such cases to Emmet's op-
eration, for though the latter would enable one to obtain a
sufficient quantity of tissue for careful microscopic investi-
gation, the depraved character of the tissue is not conducive
to good union in case the wounded surfaces are brought to-
gether by a plastic operation. Of course this remark ap-
plies only to the cases in which the vaginal portion is very
large, the Assuring very extensive, and the density of the
tissue excessive.
III. Erosions, ulcers, and glandular disease of the vagi-
nal portion are frequently mistaken for malignant disease,
but in many cases amputation will not be necessary to com-
plete the diagnosis.
Erosions are sufficiently common, may include only a
narrow circle of mucous membrane immediately contiguous
to the os uteri, or may present a much more extensive area.
The typical erosion, of benign character, is simply an ac-
cumulation of granulation tissue, which bleeds easily, like
all granulation tissue, is never of spontaneous origin, and
frequently disappears when the exciting cause is removed.
In the great majority of cases it is caused by the discharge
which accompanies endometritis, whether that be pus, blood-
29H
CURRIER: AMPUTATION OF CERVIX UTERI IX SUSPECTED CARCINOMA. [N. Y. Mbd. Jod«m
or mucus, and whether the endometritis he the consequence
of an abortion, an intra-uterine tumor, or some other lesion
of the endometrium. It is occasionally of traumatic origin,
as in cases in which coitus has been violent, or in which a
large and heavy vaginal portion has rested upon the floor
of the vagina and the epithelium has been rubbed off by the
movements of the patient. The free haemorrhage which so
often accompanies it, with the enlargement of the vaginal
portion, which is also frequently present, should excite sus-
picion. If there is an endometritis or an intra-uterine
tumor, the latter should be removed if possible, curetting
should be performed, and the latter operation should in-
clude the careful scraping away of the granulation tissue
forming the erosion. I have seen suspicious cases satis-
factorily cleared up by such treatment and the diagnosis of
benign disease determined ; but if the eroded tissue abso-
lutely refuses to heal, amputation of the vaginal portion
will be indicated as the next procedure. Ulceration of the
vaginal portion, apart from that which occurs in well-
marked cases of malignant disease, may be traumatic, syphi-
litic, or chancroidal, rodent and papillomatous. The trau-
matic ulcer may be the result and extension of erosion, it
may follow an oedematous condition of the vaginal portion,
to which condition I called the attention of the profession
in a paper presented to the American Gynaecological So-
ciety in 1889, or it may be the result of violence from
various causes. The syphilitic or chancroidal ulcer is not
of frequent occurrence and should depend for diagnosis
upon the data by which venereal sores are identified in
other locations. The papillomatous ulcer, or papilloma
verrucosum, was described by Heitzmann in 1887 {Allge-
meine Wiener medicinische Zeitung, 1887, xxxii, 596). He
had seen four cases — three in multipara' and one in a nul-
lipara— which subsequently became malignant and required
extirpation of the uterus. He describes it as beginning as
a small hypertrophic development upon the mucous mem-
brane, usually upon the anterior lip, which may be as large
as a lentil or a chestnut. It may become eroded or ulcer-
ated and bleed freely. Its structure is papillomatous, with
new glandular formation, and at the border of the erosion
there may be groups of epithelial cells in nests, as in
epithelioma. It may develop into epithelioma, but per-
haps not until years have elapsed. The rodent or cor-
roding ulcer of the vaginal portion was described by John
and Charles Clarke, and is also a rare form of ulcera-
tion. John Williams has described three cases [Transac-
tions of the Obstetrical Society of London, 1885, p. 60), and
a paper upon the same subject has more recently been con-
tributed by Browicz (Ctrlbl. fur Gynakologie, 1888, p. 94).
This disease is quite suggestive of lupus, may continue for
years, and may terminate in carcinoma. One of Williams's
patients was under observation ten years, the second died
from paralysis nine years after the discovery of the ulcer,
and in the third the cervix and vagina were nearly destroyed
by the ulcerative process, and the fatal issue was probably
influenced thereby. Browicz found no traces of carcinoma
in his investigations, nor did Williams in either of his
cases, but the number is too small to be considered as an
argument against the development of carcinoma with this
condition. The rodent ulcer is seen almost solely among
the aged, with whom degenerative changes take place
slowly. As this condition upon the exterior of the body
may degenerate or develop into carcinoma, I see no reason
for thinking that the same result may not occur upon the
vaginal portion of the cervix uteri. For this condition?
therefore, as well as for all other forms of ulceration which
refuse to heal after treatment for a sufficient length of time
with astringent and stimulating applications, amputation is
indicated, not only for its diagnostic but also for its proba-
ble curative value.
I ^have referred to glandular disease of the vaginal por-
tion as leading to uncertainty concerning the presence or
absence of malignant disease, because nearly or quite all
the subject of erosions and ulceration of the os uteri is re-
ferred by Kuge and Veit to the new formation of glandular
tissue. Included also are the retention cysts and follicles
of the vaginal portion as a part of the same process.
Kuge and Veit see in this condition not only one which is
very suspicious, but one which it is often impossible to
differentiate from carcinoma. The carefulness with which
their investigations were made and the closeness of their
reasoning compel respect, though clinical experience may
not always harmonize with their conclusions. I believe,
however, that their investigations would amply justify the
proposition which I have suggested — to perform amputation
in all cases in which the diagnosis is doubtful. I have said
that stimulating and astringent applications were sometimes
indicated before resorting to amputation. There is a de-
cree of uncertainty as to the result in such treatment. It
is impossible to foretell the degree of tissue irritation which
will be caused by contact with a powerful astringent or
caustic. I have seen cases in which the application of
powerful solutions of chloride of zinc seemed to stimulate
a malignant growth to increased activity. Spanton recently
reported (British Gynaecological Journal, 1890, vi, 70) a
case in which nitric acid was applied to a supposed syphi-
litic ulcer of the vaginal portion, the patient being at the
same time subjected to constitutional treatment. The ulcer
healed, but in six months another appeared upon the same
situation, and examination of the excised tissue revealed its
malignancy. In the discussion of Spanton's paper Inglis
Parsons stated that many cases were on record (unfortu-
nately, none were referred to) iu which cancer had formed
upon the site of syphilitic lesions. On the same occasion
Fenwick reported a case in which there was a supposed
syphilitic erosion of the vaginal portion. It disappeared
in two weeks without treatment, but three months later there
was a malignant growth of the cervix and vagina.
It may be asked why this operation is proposed rather
than the high amputation of the cervix, which was so ear-
nestly advocated by Schroder. The reply, which is a re-
iteration of what has already been said, is that this opera-
tion is proposed chiefly for diagnostic purposes ; incident-
ally it will be curative in a certain proportion of cases.
Schroder believed that carcinoma of the vaginal por-
tion usually remained limited to the cervix, and hence con-
sistently and logically performed high amputation in such
cases, while hysterectomy was reserved for those in which
March 12, 18*02. ]
LEADING ARTICLES.
297
the body or the supravaginal cervix were involved. (See
Winter. Zeitsc.hr if t fur Geburtshiilfe und Gynakologie,
xxxii, 1, p. 106.)
There is" probably a field for the supravaginal amputa-
tion, though I doubt if it is as extensive as is believed by
Hofmeier, Winter, and others of Schroder's followers ; but
this is not entirely germain to the question under discus-
sion. The same may be said of an indication for amputa-
tion of the vaginal portion, which occasionally occurs in
the coexistence of carcinoma with pregnancy. The supra-
vaginal operation is manifestly inadmissible, while the other
operation can usually be done without great danger to
mother or child. Interesting cases of this character have
been recorded by Ashton [Maryland Medical Journal, 1887,
xviii, p. 77) and Godson (Transactions of the Obstetrical So-
ciety of London, 1884, xxv, p. 18). Concerning the method
of performing the operation I have nothing new to offer.
It is a simple operation, and I have usually performed it
with curved scissors and a tenaculum or volsella. In cases in
which the tissue is very dense a knife is preferable to scis-
sors. The circumstances connected with each individual
case will determine whether it is better to cauterize the
wounded surface of the uterus, to allow it to granulate, or
to cover it with the contiguous mucous membrane of the
vagina.
159 East Thirty-seventh Street.
The Study of Cancer. — " Professor Adamkiewicz, of Cracow, who
has been making researches on the .etiology and treatment of cance",
which he thinks likely to lead to important practical results, recently
applied to the Austiian Minister of Education for permission to pursue
his investigations in a larger clinical field than he can command at
Cracow. The minister has placed the material in the First Surgical
Clinic of the Vienna General Hospital at his disposal for the purpose
during the next winter semester." — Boston Medical awl Surgical
Journal.
Glycerin for Burns. — "According to Dr. Grigorescu, of Bucharest,
glycerin is a perfect and lasting analgesic in the case of burns. Ap-
plied at once to the burned surface, it occasions at the instant of appli-
cation a slight feeling of burning, followed by complete relief from
pain. Where the wound is large it should be kept constantly moist
with glycerin. By means of this application inflammation is almost
entirely avoided, and sloughing takes place gradually, leaving a much
less marked scar than is the case with ordinary dressings." — Druggists'
Circular and Chemical Gazette.
The Society of Medical Jurisprudence. — At the next meeting, on
Monday evening, the 14th inst., Dr. William A. Hammond, of Wash-
ington, is to read a paper on A New Substitute for Capital Punishment
and Means for preventing the Propagation of Criminals.
Honorary Degrees.-— The Lancet announces that the senate of the
University of St. Andrew's has resolved to confer the honorary degree
of LL. D. on Professor Michael Foster, M D., of Cambridge, and Pro-
fessor George McLeod, M. D., of Glasgow.
The Medico-chirurgical College of Philadelphia. — The chair of ob-
stetrics has become vacant by the resignation of Dr. E. K. Montgomery,
who will hereafter devote himself entirely to the chair of gynaecology,
The Annals of Surgery. — It is announced that this journal is hence-
forth to be published in Philadelphia, by the University of Pennsyl-
vania Press. It will still be edited by Dr. Lewis S. Pilcher, of Brooklyn.
The St. Louis College of Physicians and Surgeons will hold its an-
nual commencement exercises on Monday, the Mth inst.
THE
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by Edited by
D. Appleton & Co. Frank P. Foster, M. D.
NEW YORK, SATURDAY, MARCH 12, 1892.
THE LIBRARY OF THE SURGEON-GENERAL'S OFFICE.
On the general question of the advisability of extending
governmental aid to medical education we do not feel called
upon to express an opinion. We do feel at liberty, however, to
say that, once the Government has entered upon an undertak-
ing that is designed to further that purpose, it should not
weaken its efforts. These remarks are called forth by a propo-
sition now before Congress to reduce the annual appropriation
for the Library of the Surgeon-General's Office from ten thou-
sand dollars to five thousand.
The library has for many years been widely known as one
of the leading medical libraries of the world, and its manage-
ment has been in such competent hands that it has proved of
material usefulness to the whole medical profession, as well as
to the medical corps of the army. Primarily, of course, the
object of the library, as well as that of the Army Medical
Museum, is to strengthen the resources of the medical officers
of the army. If incidentally it at the same time benefits the
whole medical profession, it does it at no additional cost; and,
since the medical corps of the army is recruited from physicians
in civil life, it goes without saying that the higher we can make
the standard of attainments among the profession at large, the
better will be the quality of the material on which the army
can draw for the care of its sick and wounded.
All this is well known to thoughtful and well-informed per-
sons, and it is to be hoped that our national legislators need
only have their attention drawn to these considerations to lead
them to lay aside all thought of crippling so beneficent an insti-
tution as the library by reducing an appropriation that is
already none too large. Surely, in view of the country's pros-
perity, no requirement of economy calls for such a course.
PROGRESSIVE UNILATERAL ATROPHY OF THE FACE.
This is a rare disease, beginning early in life and occurring
more frequently among women than among men. An instance
of this disorder was first recorded by Parry in L825, but the
singular abnormity only received attention after it hail been
described by Romberg thirty years later. The disease has fol-
lowed acute rheumatism, erysipelas, ami syphilis, anil appeared
in persons hereditarily predisposed In tuberculosis. In one
very remarkable case the affection began after an attack of scar-
let fever with diphtheria at the age of six, and an attack of
typhoid fever many years alter was followed by distinct atrophy
of the other side. Gowers gives as a fact in the history of one
case the existence of the same trouble in an aunt of the pa-
tient's. With the exception of deformity and impaired motility
298
LEADING ARTICLES
[N. Y. Med. Jouh.,
of tlie month, the condition causes little or no inconvenience,
and though the prognosis as regards curt- i> unfavorable, it does
not shorten life.
The most striking symptom is the obvious deformity. In
well-marked cases the diagnosis presents no difficulties. Bui
when the atrophy is but slight, the affection may possibly be
confounded with facial paralysis, progressive muscular atrophy
affecting the facial muscles, unilateral hypertrophy of the face,
congenital asymmetry of the face and head, and central lesions,
such as tumors at the base of the brain involving the fifth
nerve. The chief points in the diagnosis are the slow and in-
sidious onset, the chronic and progressive course, and the uni-
lateral character of the atrophy, that in the majority of cases
is sharply limited to the area of distribution of the filth nerve,
together with the fact that the skin and subcutaneous fat are
the tissues most affected. When the disease appears before tin-
skeleton is fully developed, the bones also are involved. Even
in cases of later manifestation the bones probably undergo some
change. The tongue on the affected side is often atrophied.
White patches of morphcea may appear in the skin, and are by
some considered the earliest visible change. More frequently,
however, when the disease comes under observation, the skin
presents a mottled appearance, owing to yellow or brown pig-
mentary deposits. Sometimes there is the glossy condition
characteristic of trophic nerve disturbance. Anidrosia of the
diseased region is not uncommon. The hair on the affected
side may change color, become thinner, or fall out in places.
The pupils are equal. Subjective sensations — such as pain, tin-
gling, and burning — occasionally exist, but cutaneous anaesthe-
sia or hyperesthesia is rarely present. The sight, hearing, and
smell are normal. Alterations in the sense of taste are excep-
tional. The electrical reactions in typical unilateral atrophy of
the face present no distinctive changes, although there is dimi-
nution in some cases.
The subject is considered at length in the latest fasciculus
of Bram well's Atlas of Clinical Ve-licine. Local injury to the
face or bead seems in certain instances to have been the excit-
ing cause. Mr. Jonathan Hutchinson's view is that facial uni-
lateral atrophy is "nothing more than the arrest of growth
following fifth-nerve morphoea." Clinical facts support the
theory that it is a nerve lesion involving the trophic nerve
fibers or cells of the fifth nerve. There is also some evidence
in favor of a central origin. Mendel's post-mortem examina-
tion in the case reported by Virchow. in which the skin and
muscles of the upper extremity were also affected, revealed the
fac^ that, notwithstanding the distinct wasting of the facial
muscles as the result of a simple atrophy, the facial nerve was
healthy. The fifth nerve was diseased in all its peripheral
branches, especially the second, and was affected with an in-
terstitial neuritis. There was no change in the motor and
sensory ganglia, though the descending root of the nerve within
the medulla oblongata was atrophied. During life the sensi-
bility of the skin on the affected side had not been impaired.
The radial nerve was the seat of a peripheral interstitial neu-
ritis. The nerve cells in the anterior horn of the spinal cord, at
the level of the origin of the fifth cervical nerve, corresponding
to the origin of the radial nerve, were decidedly less numerous
on the affected than on the sound side.
Opinion- max readily differ in regard to the relative im-
portance of the central ami peripheral lesions in this particular
case. If the atrophy of the tongue that sometimes exists is due
to a nerve lesion, Bramwell very justly observes that it must
involve the multipolar cells of the hypoglossal nerve nucleus, or
their peripheral prolongations, within the medulla or outside it.
In this event, the present view of restricted fifth-nerve lesion as
the sole pathological factor will be proved to be unsatisfactory.
The nutrition of the muscles of the tongue may possibly be
maintained and regulated by nerve cells other than the multi-
polar nerve cells of the hypoglossal nucleus. In researches on
the minute anatomy of the hypoglossal and other nerves of the
medulla, Alexander Bruce found groups of small round cells in
close connection with the nr.clei of the hypoglossal and some of
the other motor nerves. These small round cells may have
a trophic function. Involvement of any part of the hypo-
glossal nerve must be determined by future post-mortem ob-
servation.
Experimentally, unilateral atrophy of the face has been in-
duced in a dog by (iirard (Revue med. lie la Suixse romande,
1891), who divided within the skull the sensory root of the
fifth nerve, with the following results: Progressive unilateral
atrophy of the muscles of mastication and ot the bones and
tongue on the same side, together with thinning of the skin
and asymmetry of the face. From this (rirard concludes that
the trophic fibers of the trifacial nerve are contained in its sen-
sory root, and that the facial nerve plays no part whatever in
progressive unilateral facial atrophy. He also calls attention to
two distinct forms of this particular disease — namely, the
typical form due to defective power of function of the trophic
fibers of the trifacial nerve, and a facial psendo-trophoneurosis
consequent on atrophy induced by paralysis of muscles follow-
ing motor-nerve disease. In other words, there is a partial uni-
lateral atrophy following neuritis of the facial nerve. This is
an interesting and just'distinction.
Two very instructive examples of this disease are reported
in the Xeurologischex Centralhlatt for 1891, of which one is re-
corded by Muratow. The patient first sought treatment for
clonic spasms in the muscles of mastication on the right side.
Afterward the spasms became tonic and bilateral. Atrophy of
the right side of the face had preceded the convulsive move-
ments, together with facial asymmetry and thinning of the lips
and tongue on the affected side. There was no alteration in
the electrical reaction. Antedating the facial atrophy by sev-
eral years were spots of circumscribed sclerodermia (morphcea)
on the right side of the face and on the back, which were at
first white and the seat of a tingling sensation. Subsequently
the sclerosed patches thickened and became yellowish-brown.
The second case, Jankan's, occurred in a patient twenty-two
years old, hereditarily predisposed to tuberculosis and conse-
quently to chronic inflammations. The condition of unilateral
atrophy followed hypertrophic pharyngitis and ozama. Two
March 12, 1892.]
years before the patient's coming under observation there had
been white patches on the right side of the face, atrophy, and
localized deposits of yellowish pigment. The hair on the af-
fected side had fallen out in spots, and the bone conduction of
sound differed materially from that of the healthy side, which
would seem to indicate some change in the bones of the
skull. The thyreoid gland was increased in volume and con-
sistence. The urine was high-colored, and contained an ex-
cess nf chlorides, indican, and uric acid. The author of the
paper states that all three branches of the trigeminus were
involved.
In an Italian journal Borgherini gives an account of another
interesting and unusual case, manifestly of peripheral origin, oc-
curring in a peasant over sixty years old and coming on after
incision of the lacrymal gland to relieve phlegmonous dacryo-
cystitis. This incision was followed by pains and formication
about the orbit, together with a sensation of numbness in the
skin as far as the right ala of the nose. There were spasms of
the muscles of the face and forehead on the right side, also uni-
lateral atrophy and keratitis and subsequently opacity of the
cornea. By degrees the disease advanced as far as the lower
border of the temporal muscle, involving also the masseter, but
remaining limited to the territory supplied by the fifth nerve-
In time the pathological process involved certain parts of the
lelt side of the face. The atrophied muscles gave no response
to faradaism. Direct galvanic excitability was absent in all the
muscles supplied by branches of the trifacial nerve. There was
the reaction of degeneration on the left side in the muscles of
the lips and in the orbicularis palpebralis.
While treatment fails to effect a cure, it is not improbable,
Bramwell thinks, that in cases where the process becomes ar-
rested this happy circumstance is due in part to therapeutic
measures. The indications are to arrest the atrophic process
and to maintain and restore the nutrition of the affected region.
All conditions that produce nerve exhaustion should as far as
possible be avoided. Nervine tonics are the most valuable, such
as arsenic, strychnine, iron, and quinine. Massage of the face
should be tried, care being taken to avoid irritation of the skin.
The systematic and diligent practice of voluntary movements for
a regular stated time each day must be insisted upon. Both
forms of the electric current, constant and faradaic, have been
employed with apparent benefit. The experiment of resection
of the various branches of the trifacial nerve, as far as accessi-
ble, is advocated by Dr. F. X. Dercum {Journal of Mental and
. Nervous Disease, February. 1892). The maximum benefit to be
derived from interrupting the communication between the tro-
phic center and the peripheral distribution can only be obtained
by an early operation, one performed as soon as the ominous
white patch that is otten the initial change makes its appear-
ance on the cheek. Should the experiment fail, its advocate
maintains that little or no harm can result, anaesthesia being the
only unpleasant consequence, and to this patients readily adapt
themselves. The do-nothing plan of treatment is highly repre-
hensible.
299
Mr NOR PARAGRAPHS.
STEAM AS AN AGENT IN CAUSING THE SPREAD OF
DIPHTHERIA.
In a discussion on diphtheria, published in the British Medi-
cal Journal for September 19, 1891, Dr. Russell cited several in-
stances in which steam had seemed to be an active factor in the
propagation of the disease. Hot water and steam from a brew-
ery were introduced into some old cesspools and evidently wak-
ened into activity germs which, if undisturbed, would have re-
mained dormant. An epidemic of diphtheria soon developed in
the vicinity, and was not checked until the steam was turned
into other channels, when it quickly ceased. If, as we now be-
lieve, the bacillus of diphtheria develops with special rapidity in
the presence of warmth and moisture and absence of light, it is
not unreasonable to suppose that the introduction of hot water
or steam into cesspools or sewers may be a most dangerous pro-
cedure. The maintaining of a considerable degree of heat in
sewers can certainly not be wise from a hygienic point of view.
Yet this condition prevails quite largely in New York, where
sewers and water pipes are in many places kept at a continuous
high temperature by the close proximity of the pipes of the
steam-heating companies. No more favorable medium for the
culture of micro-organisms could be found than warm sewage.
Given an imperfect trap and a vulnerable mucous membrane, and
an attack of diphtheria is almost assured.
DISEASE OK THE BRAIN FOLLOWING A SIMPLE NASAL
OPERATION.
The Journal of Laryngology, Rhinology, and Otology gives
an abstract of an account of an unfortunate accident described
by Wagner in the Munehener medicinische Wochenschrift. The
author performed a galvano-cauterization of the left turbinated
body in a patient twenty years of age, on account of headache.
There was no special pain and there was no bleeding. The next
day the patient had a severe headache, and on the third day
there was hemorrhage from both nasal cavities. This was
treated first with ice water, then by tamponing the anterior and
posterior nares. In the evening the patient became feverish,
and Cheyne Stokes respiration appeared. The tampons were re-
moved, but the temperature did not fall and symptoms of a se-
vere affection of the brain- appeared. Seven days later death
eccurred. A post-mortem examination was not allowed. The
author concludes that the bleeding could not have been the di-
rect consequence of the operation, because it followed some
days afterward, and because parts bled which had not been
operated on. He believes that thrombosis of a sinus occurred
which disturbed the circulation in the nose. In some other
published case operative treatment of the middle turbinated
body was followed by meningeal disease.
LEPROPHOBIA IX PHILADELPHIA.
It is stated in the public press that the health officer of
Philadelphia, having discovered that a leper had been employed
as a cook in a hotel in that city, has recommended that the
hotel be closed, the furniture disinfected, the house fumigated,
and the proprietor arrested lor maintaining a nuisance preju-
dicial to public health. We are glad to be able to state that the
health officer is not a physician, and thus relieve the medical
profession of the responsibility for such unscientific and un-
called for measures. Philadelphia officialism seems to be af-
flicted with leprophobia, and at any time it might be expected
MINOR PARAGRAPHS.
300
MINOR PARAGRAPHS.— ITEMS.— LETTERS TO Till-: EDITOR.
[N. Y. Med. Jouk.,
to declare quarantine against Louisiana because there are a few
cases of leprosy in that State.
THE INFLUENCE OF THE NERVOUS SYSTEM UPON
INFECTION.
Observations by Fere upon this subject are noted in the
Mercredi medical for February 10, 1802. In an earlier com-
munication be had made known the fact that vaccine virus
proved more efficacious in paralytics upon the affected than
upon the sound side. This is also true in cases of infantile
paralysis. Vaccination during the stupor following epilepsy
was performed upon all epileptic patients without result, with
one exception only.
THE DECADENCE OF THE GRADUATION THESIS.
The Progres medical and the Gazette des hopitaux are favor-
ing the discontinuance of the custom of requiring a graduation
thesis from candidates for the Paris medical degree. There is
much to be said for and against the requirement. We are under
the impression that it was done away with several years ago by
the New York College of Physicians and Surgeons, and the
action of the school does not seem to have worked to anybody's
disadvantage.
ITEMS, ETC.
Infectious Diseases in New York. — We are indebted to the Sanitary
Bureau of the Health Department for the follow ing statement of cases
and deaths reported duiing the two weeks ending March 8, 1892 :
DISEASES.
Week ending Mar. 1.
Week ending Mar.
Cases.
Deaths.
Cases.
Deaths.
32
4
20
3
12
13
8
4
241
35
219
38
Cerebro-spinal meningitis
1
2
2
4
339
18
337
21
132
48
119
43
4
3
6
1
1
0
0
0
17
12
0
1
0
1
0
0
0
2
0
Army Intelligence. — Official List of Changes in the Stations and
Duties of Officers serving in 'he Medical Department, United State*
Army, from February 28 to March 5, 1892 :
Kean, Jefferson R., Captain and Assistant Surgeon, is relieved from
duty at Fort Robinson, Nebraska, and ordered to St. Francis Bar-
racks, Missouri, for duty, not later than March 25, 1892, relieving
David L. Hdntington, Major and Surgeon. Major Huntington,
upon being relieved by Captain Kean, will proceed to New York
city for duty in connection with the Army Medical Board.
Wyeth, Marlborough O, Captain and Assistant Surgeon, is relieved
from further duty at Fort Mcintosh, Texas, and ordered to Fort
Supply, Indian Territory, upon the expiration of his present sick
leave of absence.
Taylor, Marcus E., Captain and Assistant Surgeon. Granted leave of
absence for six months on surgeon's certificate of disability.
Naval Intelligence. — Official List of Changes in the Medical Corps
of the United States Navy for the week ending March 5, 1892 :
Brush, George R., Medical Inspector. Ordered to the Navy Yard,
Brooklyn, N. Y.
Kershner, Edward, Medical ' Inspector. Detached from the Navy
Yard, New York, and ordered to the U. S. Steamer San Francisco.
Clark, J. EL, Medical Inspector. Detached from the U. S. Steamer
San Francisco and ordered home.
GlHON, A. L., Medical Director. Detached from the Naval Hospital
and assigned to special duty at New York, attending officer* of the
Navy and Marine Corps.
Scofield, W. K., Medical Director. Detached from special duty at New
York, attending olficers of the Navy and Marine Corps, and to wait
orders.
Bogert, E. S., Medical Director. Detached from the Medical Examin-
ing Board and ordered to the Naval Hospital, Brooklyn, New York.
De Valin, C. M., Assistant Surgeon. Ordered to the Naval Hospital,
Norfolk, Va.
Society Meetings for the Coming Week :
Monday, March l^/h : New York Academy of Medicine (Section in
General Surgery); New York Ophthalmological Society (private);
New York Medico-historical Society (private); New York Academy
of Sciences (Section in Chemistry and Technology); Lenox Medical
and Surgical Society (New York — private); Society of Medical
Jurisprudence (New York); Boston Society for Medical Improve-
ment; Gynajcological Society of Boston; Burlington, Vt., Medical
and Surgical Club; Norwalk, Conn., Medical Society (piivate);
Baltimore Medical Association.
Tuesday, March 15th : New York Academy of Medicine (Section in
General Medicine); New York Obstetrical Society (private) ; Medi-
cal Society of the County of Kings, N. Y. ; Ogdensburgh (N. Y.)
Medical Association ; Baltimore Academy of Medicine.
Wednesday, March 16th : New York Academy of Medicine (Section
in Public Health and Hygiene); Northwestern Medical and Surgical
Society of New York (private) ; Harlem Medical Association of the
City of New Yoik; Medicolegal Society (New York); Medical So-
ciety of the County of Allegany (quarterly), N. Y. ; New Jersey
Academy of Medicine (Newark).
Thursday, March 17th: New York Academy of Medicine; Brooklyn
Surgical Society ; New Bedford, Mass , Society for Medical Improve-
ment (private).
Friday, March 18th : New York Academy of Medicine (Section in
Oithopasdic Surgery) ; Baltimore Clinical Society ; Chicago Gynae-
cological Society.
Saturday, March 19th : Clinical Society of the New Y'ork Post-
graduate Medical School and Hospital.
Answers to Correspondents
Mo. 374- — The following comparative analysis is given in Dr.
Rotch's article in Keating's Cycloptedia of Diseases of Children :
Human Cow's
milk. milk.
Water 87 to 88 86 to 87
Total solids 12 to 13 13 to 14
Fat 4 4
Albuminoids 1 4
Milk sugar 7 4-5
Ash : 0-2 0-7
fetters to tbc Suitor.
INTUBATION IX TUBERCULAR LARYNGITIS.
Columbus, Ohio, February 29, 1892.
To the Editor of the Sew York Medical Journal :
Sir : Apropos of Dr. F. E. Hopkins's report of a case of intu-
bation in tubercular laryngitis, in your last issue, I desire to
state that in the Medical Record of March 8, 1890, I reported a.
case of intubation for the relief of dyspncea in tubercular laryn-
gitis. Although, according to Dr. Hopkins's article, I presume
I was the first to adopt this method of securing relief, I am
merely a general practitioner, not a specialist, and hence did.
not imagine that I had done anything very wonderful.
J. F. Baldwin, M. D..
Maroh 12, 18HS.|
PROCEEDINGS
OF SOCIETIES.
301
|1roceefjings of Societies.
NEW YORK NEUROLOGICAL SOCIETY.
Meeting of February 2, 1892.
The President, Dr. Landon Carter Gray, in the Ghair.
Pachymeningitis and Myelitis.— Dr. Mary Putnam Ja-
ooki read an account of a case of this condition, which had at
first been supposed to be due to Pott's disease, but in which a
solid tumor had developed against the spine during tbe last
weeks of life, and been diagnosticated as sarcoma.
The Surgical Treatment of Epilepsy.— Dr. Joseph Price,
of Philadelphia, read a paper in which epilepsy was defined as
an apyretic nervous affection characterized by seizures of loss
of consciousness with tonic or clonic convulsions. Its history,
from a therapeutic standpoint, was one that had taxed the efforts
of supreme superstition and defied the resources of scientific
medication. Its treatment had been one of trial and disappoint-
ment, for it still remained one of the greatest opprobria of
medicine. Its attacks were visited upon both sexes, hystero-
epilepsy for the most part being confined to females. Women
were attacked when a marriageable age was reached. Debauch-
ery had frequently led to it. Young widows were prone to at-
tacks, and its origin outside of physical causes might be traced
to amorous songs and certain stimulants, such as chocolate and
coffee. For its cure various suggestions had been made, among
others that of resorting to venery. It had, however, been
abundantly proved that excessive lust had produced epilepsy,
and was, no doubt, yet to be recognized as a great factor in its
causation. That it was transmissible did not admit of dispute
any more than that it was caused by traumatism. Operative
interference in the traumatic cases, for the removal of the cause,
was logical and often successful. The operation of clitoridecti >my
had brought Baker Brown into disrepute, and yet we had to day
no lets a person than Lawson 'fait boldly expressing the opinion
that there was doubtless a place for the operation. The belief
that a moral element must be reached in addition to the physi-
cal interference was no doubt justified by the facts. One table
that the author had consulted gave as high as 73*7 per cent, of
patients cured of masturbation by clitoridectomy. This surely
made it not presumptive to favor its recognition. Epilepsy in
women appeared to be more fatal than in men. The acquired
epileptic habit was more fatal than the congenital. In the con-
genital form it was twice as fatal, and in the acquired form three
to four times as fatal, in women as in men. As to the heredi-
tary nature of the disease, it was sufficiently evident to require
that marriage should be discouraged among epileptics. The his-
tory of eunuchism as a preventive of epileptic propagation, and
also the edicts forbidding the marriage of epileptics, were of in-
terest to the student of law as well as to the theologian and the
physician. In the treatment of epilepsy proper there was no
doubt that surgery must form an important factor, whether in
traumatic, cases or tor tin' removal of ivfiex causes. In entering
upon tbe consideration of the removal of the uterine append-
ages in women for the cure of epilepsy it was unnecessary to
take ii]) in detail the history of castration as practiced upon the
male for the same purpose. Suffice it to say that the history of
this operation, both from a priestly standpoint and from a
carnal or musical standpoint, was often instructive and ol'iener
horrifying. The mortality was often simply terrible, while the
practice of mutilating children to preserve their voices for song
marked an era of refined religious cruelty scarcely conceivable.
So far as the surgery of the disease was concerned, in a general
way the operation bad the best of the argument. Out of sev-
enty-one cases treated medically, and out of a second series of
seventy one treated surgically, statistics showed that by the sur-
gical treatment all were at least benefited, while in the medical
series a great proportion showed no effect at all from treatment,
and in others the conditions were aggravated. In a general
surgical way, then, if the operation was beneficial when the
trouble could be directly traced to the ovaries or their diseases,
logical deduction would seem to indicate that beneficial results
might at least be hoped for, So far as unsexing an epileptic
was concerned, the author did not understand how or why
there was reason to feel compunction at such a suggestion. He
could hardly question the protective value to society, not "illy
of forbidding epileptics to marry, but of rendering them unable
to procreate. Wise legislation would of course be needed to
prevent abuse, but the essential right of society to protect itself
ought not to be questioned. Aside from the actually demon-
strable disease, what was to he done in the presence of epi-
lepsy? In the case of an unmarried woman in whom every
menstrual period, from the initiation of puberty to the time that
she came under the physician's care, was marked by an epileptic
seizure, who at ether times was entirely free from attacks and
showed no tendency to fall into them, who recovered as ?oon as
the period was over, and who had no other demonstrable dis-
ease or probable cause of seizures than her monthly irritation,
there was little doubt that an operation was justifiable. Unless
we could thus pin down the seizures to definite time and cause,
the author held that it was wrong to burden surgery with an
operation that could not fail to detract from its good name,
while it did no possible good to the individual. If ovarian dis-
ease was found to be the cause of the epileptic seizures, it was
of no use to do a partial removal and expect relief or cure. The
effect obtained might be due to either one of two causes: first
to the removal of an irritable or diseased organ whose piesence
stirred up the reflexes into a commotion, or to the excitation
by the operation of a different epileptigenous zone Charcot
had laid down as a principle that irritation of one epileptige-
nous zone might be relieved by irritation of or pressure upon an-
other. Assuming it as a fact that the disease was often a reflex
manifestation of a local trouble, it followed that in those cases
in which deposits were found as a result of a sy>temic affection
resort should be had to tbe recognized remedies, and the
chances for effecting a cure were equal to those of cases " here
operative interference was resorted to.
Dr. C. A. Herter thought it unfortunate that no autopsy
had been made in the case reported by Dr. Jacobi, as the diag-
nosis seemed open to a good deal of speculation. There was
apparently no justification for the assumption that two lesions
existed, and a single one would explain the symptoms. This
lesion might have been one of sarcoma or of tubercular disease,
and it would be difficult to determine which.
Dr. \V. II. Thomson disagreed with the last speaker. The
chief point of interest was in the fact that there might have
been two distinct lesions in the cord, presenting in their symp-
toms the contrast in the nature (if the lesions. It was well
known that in the case of tumors pressing upon the cord
there was present as a symptom local pain, especially in move-
ment of the parts. Transverse myelitis would present, this
kind of pain, and, unless i' was accompanied by distinct menin-
gitis, there would be no irritation ol ihe nerve roots. There-
fore, according to the description, there might have been two
conditions of the cord occurring in the same patient. I he
symptoms developing afterward in the legs wore the soqneho of
transverse myelitis Finally, the effect of the presence of a
tumor invading and spreading into the tissues was simply press-
ui e at that point.
Dr. B. Saohs doubted if in the majority of cases there was
302 PROCEEDINGS
myelitis associated with the presence of a turner, though in a
tuberculous case this sometimes occurred. Tubercular myelitis
was distinguished by being more destructive to the substance of
the cord than other forms.
Dr. Jacobi said that the reason for supposing that there was
a second lesion differing from the original one was the persist-
ence of the epigastric reflexes. It was presumed that there was
a tumor of the cord beginning in the first dorsal vertebra, caus-
ing pachymeningitis at that point followed by myelitis.
Dr. H. -I. Boldt, speaking on the subject of Dr. Price's pa-
per, thought that some nervous diseases might be due to men-
strual disorders, but they were not numerous. The removal of
the uterine aunexa was one of the gravest operations in sur-
gery, both in its medical and in its medico-legal aspects. It was
most important to select the cases. When absolute pathological
conditions were present and treatment had been carried on un-
successfully by all the methods known to the profession, and
when a gross lesion could be discovered to be present in the
annexa, the operation was perhaps justifiable and good results
might accrue. If the epileptic attacks were restricted to the
menstrual period, and it was concluded that the prime cause lav
in the annexa, the operation might be resorted to, but little else
but bad results were to be expected.
Dr. G. M. Hammond thought that two points should be
borne in mind — the establishment of the epileptic habit, and the
influence of pathological conditions of the uterus and ovaries in
producing epilepsy. The fact that operations performed on the
brain for the relief of epilepsy when there existed a well-defined
lesion were not in the majority of cases followed by cure of the
seizures was well known now. The habit persisted, and many
of the patients so operated upon had been reported cured too
soon. The condition was, in fact, only abated or rendered dor-
mant for a more or less limited period. As to the influence of
abnormities of the genital apparatus in the production of epi-
lepsy, it seemed to the speaker that those of the uterus were more
potent, than those of the ovaries. Lacerations, malpositions, and
inflammations of the uterus were more likely to cause epileptic
seizures than irritation of the ovaries. At a time when gynae-
cologists were removing ovaries by the bushel, the speaker bad
sought to inform himself of some of the results by writing to a
number of asylums The questions put had been as to the cases of
melancholia in which operation had been done. He had received
a stock of reports. The consensus of opinion was to the effect
that epilepsy and insanity had not been relieved by removal of
the ovaries. As to the effect of oophorectomy in producing
insanity, he had seen tour or five cases of epilepsy and bystero-
epilepsy come on in a few days after it bad been performed.
Others had met with the same experience. While he had seen
some subjects of insanity and melancholia recover after relief
from uterine irritation, he had never seen such result follow
oophorectomy.
Dr. A. H. Buokmastek said it was hardly fair to call epilepsy
a disease. It was a collection of symptoms which had no ana-
tomical basis. It was influenced by irritation of all kinds, and
naturally those produced in the reproductive organs would bo
ol the. most marked character, though observers were not agreed
upon the exact role that these organs played in this respect. The
previous speaker was probably correct in assuming that more
irritation could arise from injuries of the uterus than from le-
sions in the Falloppian tubes or ovaries. The evidence was so
strong that no good was accomplished by oophorectomy in the
conditions under consideration that it was to be condemned.
Dr. W. M. Polk said his experience of the results of opera-
tions for the cure of hystero-epilepsy was limited to three cases,
and was not such as to embolden him to continue to operate.
Two of the patients bad become insane, and the third one was
OF SOCIETIES. [N. Y. Med. Jouu.,
in a distressing condition of nervous irritability. Epilepsy was
still really a fruitful field for investigation. It must be remem-
bered that eighty per cent, of women were stated to be hys-
terical. A large amount of epilepsy was known to be due to
peripheral irritation, and there was no reason why the ovaries
should not set up some of this. If they did this, they should be
taken out.
Dr. Sachs bad seen a number of cases in which the opera-
tion had been done, and with no effect upon the epilepsy. It
was a mistake to remove ovaries because the patient had epi-
lepsy at the menstrual period. If it could be proved that the
person had no congenital epilepsy, that the first attack had come
on with menstruation, and that seizures had occurred constantly
since, but only at the menstrual period, there might be some fair
reason to remove some of the sexual organs. Because a woman
was an epileptic and had sensitive organs which could be re-
moved was a ridiculous argument in favor of their removal.
Dr. L. Weber did not hold the view that the irritation fol-
lowing laceration of the uterus was a cause of epilep-y. In a
large experience of twenty -eight years he had never seen more
than two cases in which the epileptic condition had been thus
induced, unless there was a history of hysterical or epileptoid
taint before the age of puberty. He believed that true epilepsy
acquired from lesions of the genital org.ins was a rare condition.
He would only give his consent to operative interference on very
narrow grounds and where there was a fair hope that by the
removal of the ovary the condition could be cured.
Dr. Buckmaster explained that he had not meant that in-
juries to the uterus following parturition were active in produc-
ing epilepsy, but that of all lesions to the reproductive organs
these were most likely to act as irritants, and were therefore
quite likely to result in the nervous condition under discussion.
The President said that all neurologists were agreed that
what was called the epileptic state was nothing more than a
symptom indicating intracranial disturbance, spinal or peripheral
nerve irritation, or inflammation of the visceral nerves. The
most frequent source of the symptoms lay in intracranial disor-
ders. Spinal epilepsy was rare, as was also that arising from
peripheral irritation. How important a part the abdominal
nervous system played was not quite known. But the most un-
certain of all was the influence of the female generative organs
in producing the epileptic symptoms. At any rate, there was
not a single reputable record of the cure of epilepsy ; not one
that would stand the test of examination. To report relief for
a few months or even a few years was to report nothing, and
this was all that had been done. Almost every therapeutic or
surgical measure had done good, but there was nothing more in
the way of cure reported bv modern effort than could be found
chronicled by Esquirol in 1828.
Dr. Price reiterated his opinion that permanent benefit was
possible in properly selected cases.
NEW YORK ACADEMY OF MEDICINE.
SECTION IN GENERAL SURGE KY.
Meeting of February 8, 1S92.
Dr. Joseph D. Bryant in the Chair.
A Cutting Operation for the Relief of an Old Disloca-
tion of the Inferior Maxilla.— Dr. R. II. M. Dawbarn pre-
sented a patient who had suffered along lime with dislocation
of the inferior maxilla, the mouth being permanently open.
The patient bad had several attacks which suggested tetanus,
and many attempts on the part of skillful surgeons to reduce the
dislocation had failed. As a last resort, the speaker had made
incisions almost dividing both masseter muscles, enabling him
\
March 12, 1892.]
to reach the displaced hone and pry it back into place. The re-
sult had been permanent and satisfactory. In another case the
speaker had been able to effect reduction after nearly dividing
only one of the masseter muscles.
The Chairman thought that dislocations of the inferior
maxilla must be preceded by relaxation of the muscular or liga-
mentous structures. In experiments upon animals it had been
shown that dislocation could not be caused by spasmodic action
of the muscles alone.
The further discussion of the question elicited several cases
of the same character, due to a variety of causes, such as vomit-
ing, talking, laughing, gaping, also the direct application of
severe force, as that of a blow from the clinched fist.
Primary Amputation, Consecutive Amputation, and Re-
section in Traumatisms of the Extremities.— Dr. T. H.
Mani.ey read a paper with this title. He believed that primary
amputation should never be resorted to in civil life unless the
vitality of all the tissues had been destroyed. In such cases
amputation should not be delayed. In children, even though
the injury was severe, amputation should be delayed as long as
possible, and a resection should be preferred to amputation if
practicable. In consecutive amputation after injury one could
proceed along precise lines. The flaps should be as long as pos-
sible, should contain as much muscular tissue as practicable, and
should be so approximated that the resulting scar would not be
impinged upon by the end of the bone. During the operation
he objected to the use of antiseptics about the bone. However
unirritating they might be to the soft parts, he believed they
often produced injury to the bone. If drainage-tubes were re-
quired they should be used for the shortest possible time. An
abundance of soft gauze dressings was indicated in all cases. In
cases of compound comminuted fracture of the thigh amputa-
tion would frequently be necessary for the reason that the femur
seemed to tolerate such injuries less readily than the other long
bones. Another reason for avoiding amputations in children,
when possible, was that they bore the shock and loss of blood
of such operations badly. In injuries of the hands and feet the
successes of osteoplasty encouraged delay. Oilier had demon-
strated the great reparative force of the periosteum ; hence,
though the bone was destroyed, if the periosteum was preserved
the bone might be renewed. If the bone was shattered and
separated from the periosteum, it (the bone) should be removed.
The speaker was not in favor of the insertion or introduction of
wedges of decalcified bone. In general it would be well to save
as much tissue as possible in doing amputations, and to avoid
opening joints when this could be done. If sublimate or other
antiseptic solutions were used in the course of an operation,
their use should be followed by abundant irrigation with plain
hot water.
Dr. Dawbarn thought that the name of Macewen was quite
as worthy of mention as that -of Oilier in connection with the
subject of saving bony structures. With reference to hetero-
plasty, he was in favor of the introduction of Neuber's decalci-
fied bone wedges into the gaps between bone fragments.
Dr. R. II. Sayre approved of the policy of waiting before
amputation as a general principle, since reparative processes
were often very vigorous.
Dr. F. Kammerer thought the same rules should apply for
adults as for children in the matter of primary amputation. It
had not been his experience that the use of antiseptics upon
osseous tissue was deleterious.
Dr. W. R. Townsend thought that the conservative princi-
ple in the matter of saving tissue at the time of an amputation
might be carried too far. If an amputation was imperative,
one of the most important considerations was to obtain such a
stump as would furnish a good base for an artificial limb.
303
The Chairman agreed to the statement that as much tissue
as possible should be saved in performing an amputation, but it
was equally desirable that only so much should be saved as
would be of practical utility.
Dr. Manley was aware that Macewen attached compara-
tively little value to the periosteum as a means of repair. But,
if he was right, all the teachings of physiology must be wrong.
With regard to the value of decalcified bone for ossific centers,
the speaker thought it had none. He had never seen a case of
successful bone grafting.
Senn's Hydrogen-gas Test.— Dr. Dawbarn believed there
were many objections to Senn's hydrogen-gas test for the de-
termination of wounds of the intestine. Although he had never
had an opportunity to try it upon the living subject, he had tried
it twenty-two times upon the cadaver. The gas was stored in
a large rubber bag and was pumped from the bag into the bowel
by means of a Davidson's syringe. The result had been very
great distention of the bowel, which in the living subject would
be harmful. In all but two of the cases the hydrogen had found
its way from the bullet wound which had been made in the in-
testine to the tube that was placed in an opening in the abdomi-
nal wall, and its presence had been ascertained by combustion
when a flame was applied to the tube.
If a bullet wound, or other intestinal wound in which the
test was applied, was clogged with fasces, or if the lumen of the
bowel was obstructed by faecal masses, the test would be una-
vailing. It was a well-known fact that not all bullet wounds
of the intestine required treatment by abdominal section, for
leakage from a wound might not take place if the wound was
closely pressed upon by a coil or coils of uninjured intestine.
On the other hand, the pressure of the hydrogen might force
ftecal matter out of a wound and into the peritoneal cavity and
be followed almost inevitably by a fatal result unless an ab-
dominal section was made. In those wounds of the intestine
which occurred below the navel, abdominal section should be
promptly performed and the hydrogen test would be unneces-
sary. On two occasions the application of the flame to the tube
from which the hydrogen emerged had been followed by an ex-
plosion of the gas within the abdomen. If the conditions were
ever such that a similar explosion should take place in the ab-
domen of a living person the result would probably be disas-
trous.
ooh |loticcs.
The Microscope and Histology ; for the Use of Laboratory Stu-
dents in the Anatomical Department of Cornell University.
By Simon Henry Gage, Associate Professor of Physiology.
Third Edition, entirely rewritten. Part I. The Microscope
and Microscopical Methods. Illustrated. Ithaca, N. Y.,
1891. Pp. 96.
This volume deals particularly with homogeneous immer-
sion objectives, the substage illuminator, the camera lucida, the
microspectroscope, and the micropolariscope.
The author deserves credit for expounding his subject in a
very readable form. No one will fail to detect easily that the
work is the result of long experience in practical laboratory
work, or that many obscure points in microscopic technique are
skillfully explained.
Though the readers of the book are supposed to be familiar
with the principles of optics, the author takes particular pains
in impressing upon the student's mind the fact of the importance
BOOK NOTICES.
304
BOOK NOTICES.— MISCELLANY.
[N. Y. Med. Joi.b.,
of knowing the working of the optic systems and of their being
explained.
The section on slides and cover-glasses and on mounting,
labeling, and staining microscopical preparations will he found
of assistance. The value of the book lies greatly in the fact that
it gives the most recent methods of microscopy as found in the
leading current literature.
BOOKS, ETC., RECEIVED.
A Case of Congenital Malformation of the Heart. Atresia of the
Pulmonary Artery, with Persistence of the Foetal Circulation. By
William T. Howard, Jr., M. D., Baltimore. [Reprinted from the Ar-
chives of Pcediatrics.]
Human Monstrosities. By Barton Cooke Hirst, M. D., Professor of
Obstetrics in the University of Pennsylvania, and George A. Piersol,
M. D., Professor of Histology and Embryology in the University of
Pennsylvania. Part II. Illustrated with Thirteen Photographic Re-
productions and Twenty-five Woodcuts. Philadelphia : Lea Brothers &
Co., 1892. Pp. 112.
The ^Etiology, Pathology, and Treatment of Diseases of the Hip
Joint. By Robert W. Lovett, M. D., Out-patient Surgeon to the Boston
City Hospital, etc. Boston : Damrell and Upham, 1892. Pp. 9 to 220.
[Fiske Prize Fund Dissertation, Xo. xlii.]
The Human Figure: its Beauties and Defects. By Ernst Briieke,
Emeritus Professor of Physiology in the University of Vienna, etc.
With a Preface by William Anderson, Professor of Anatomy to the
Royal Academy of Arts, London, etc. Authorized Translation, revised
by the Author. With Twenty-nine Illustrations by Hermann Paar.
London : H. Grevel & Co., 1891. B. Westermann & Co., New York.
Coca and Cocaine: their History, Medical and Economic Uses, and
Medicinal Preparations. By William Martindale, F. C. S., etc. Second
Edition. London: H. K. Lewis, 1892. Pp. viii to 76.
Impure Air, and Ventilation of Private Dwellings. (The Orton
Prize Esssay.) By Howard Van Rensselaer, M. D., Albany, X. Y. [Re-
printed from the 1 ransactions of the New York State Medical Asso-
ciation. ]
Abscess of the Antrum, with Cases and Treatment. By I. P. Wil-
son, D. D. S., Burlington, Iowa.
Empiricism ; Rational Practice ; Practice under Guidance of Law.
A Lecture to Medical Students. By Charles S. Mack, M. D., Ann Arbor,
Mich. [Reprinted from the North American Journal of Homoeopathy. J
Tuberculin. The Value and Limitation of its Use in Consumption.
By Charles Dennison, A. M., M. D., Denver, Col. [Reprinted from the
Transactions of the Colorado Stale Medical Society.]
Rheumatism and its Treatment by Turkish Baths. By Charles H.
Sheppard, M. D., Brooklyn.
To what Extent is the Diagnosis of Pregnancy possible in the Early
Months ? By Charles Jewett, A. M., M. D., Brooklyn. [Reprinted
from the Brooklyn Medical Journal.]
An Account of the Influenza as it appeared in Philadelphia in the
Winters of 1889-'90 and of 1891-'92. By J. Howe Adams, M. D.
Philadelphia. [Reprinted from the University Medical Magazine.]
Trendelenburg's Posture in Gynaecology. By Florian Krug, M. D.,
Xew York. [Reprinted from the Transactions of the Association of
American Obstetricians and Gynecologists.]
Total Extirpation versus leaving a Stump in Operation for Uterine
Fibro-Myomata. By Florian Krug, M. D., Xew York. [Reprinted from
the New York Journal of Gynceco/ogy and Obstetrics.]
Methodes pour preparer de l'eau aseptique. Par le docteur J. F.
Heymans. [Extrait des Annates de la Soriete de medecine de Gand.]
Considerations pathogeniques sur l'hemospermie d'oiigine non in-
flammatoire (observations d'ejaeulations sanglantes). Par le Dr. R.
Jamin. [Kxtrait des Annates des maladies des organes genito-urinaires.]
Presence du phosphate d'alumine dans l'urine. Par M. le docteur
R. Jamin et M. Alexandre Girard. [Extrait des Annates des maladies
des organes genito-urinaires.]
Some Educational Problems. The Introductory Address to the
Eleventh Lecture Course of the Albany College of Pharmacy, delivered
October 5, 1891. By Willis G. Tucker, M. D , Ph. D.
Transactions of the American Ophthalmological Society. Twenty-
seventh Annual Meeting, Washington, D. C, 1891.
Fifth and Sixth Annual Reports of the State Board of Health and
Vital Statistics of the Commonwealth of Pennsylvania. 1891 and
1892.
Annual Report of the Hospital of the Xew York Medical College
and Hospital for Women.
The Demilt Dispensary, in the City of Xew York. Forty-first An-
nual Report, for the Year 1891.
First Annual Report of the State Board of Medical Examiners of
Xew Jersey. 1891.
Transactions of the Detroit Medical and Library Association. 1891.
Ittistellanp; .
Removal of the Uterine Appendages. — The Medical Record for
March 5th contains the following editorial article :
The University Medical Magazine of December, 1891, contains arti-
cles on the subject of the remote effects of the removal of the uterine
appendages by Dr. Wharton Sinkler and Dr. Charles Carroll Lee.
These articles are written in a judicial spirit, and present very fairly
the opinions which medical men may and should hold at the present
time regarding the matter in question.
Dr. Sinkler first shows what the ordinary phenomena are that follow
removal of the ovaries. These phenomena, as has long been known,
resemble in many respects the changes of the climacteric. They con-
sist of flushings and sweatings, which are very common, appear early,
and last with lessening intensity for two or three years. Disturbance
of the heart's action, including rapid heart beat, is frequent; numbness
and various parasthesia? also appear. Patients may gain some flesh,
but they rarely get fat, contrary to a common belief. They do not
necessarily have wasting of the mammae, nor is there ever a change in
voice or growth of coarse hair. The sexual appetite is not much
changed for two or three years, but eventually tends to become lessened
and abolished. Xervousness, irritability, and mental depression appear
to be common, especially in women originally of a neurotic tempera-
ment. Insanity occurs undoubtedly in a certain percentage of cases,
variously estimated at five or ten.
As to the effect of the removal of the appendages upon neuroses
and psychoses, the consensus of opinion seems to be very decidedly to
the effect that good is rarely accomplished and harm often done.
Very little, if any, trustworthy evidence is given to show that
oophorectomy is useful in insanity, although in the periodic menstrual
form some successes are reported. As periodic insanities are of the
psycho-degenerative class, one must always expect a recurrence of the
disease eventually. There is much evidence to show that, at least in
neurotic persons, oophorectomy tends to produce a condition of mental
depression amounting often to melancholia.
In true epilepsy, even of a menstrual type, the operation is useless.
In hystero-epilepsy, .. hich many gynaecologists seem to think is a form
of epilepsy and not a form of hysteria, the removal of the ovaries is not
a legitimate procedure. In certain forms of neurasthenia and hysteria
minor, associated with decided pelvic trouble, the operation sometimes
does good, but the results are slow, and the operation should not be at-
tempted until every other measure has been carefully tried.
Dr. Lee's paper is a most candid and scientific presentation of the
results of his own work. In the main his conclusions agree with that
of others ; but he does not find that removal of the ovaries produces
the melancholic condition which has been observed by some.
The conclusions of Dr. Sinkler, which embody the main points
given above, may be inserted here :
"The remote effects of removal of the ovaries and tubes upon the
general health are, as a rule, to improve nutrition and to better the
strength, especially if the operation has been done for diseased ovaries
or pus tubes.
" That excessive gain of flesh is rare, and that change of voice,
\
March 12, 1892.]
MISCELLANY.
305
growth of hair upon the face, and loss of feminine characteristics do not
occur.
" That the sexual appetite in women is seldom changed by castra-
tion within two or three years after the operation, but after several
years it becomes lessened.
" That it is often the case that after this operation patients are
more nervous than formerly, and mental disturbances of various forms,
insanity, and epilepsy, not infrequently follow it.
" That the influence of the operation is sometimes good upon in-
sanity and epilepsy winch are associated with severe dysmenorrhcea or
occur periodically at the menstrual epochs ; but when the insanity is
constant, although it may be aggravated at the monthly periods, re-
moval of the appendages is of no benefit. Hystero-epilepsy is seldom
permanently cured by the operation. Prolonged after-treatment is gen-
erally necessary to relieve such cases.
" Local pain is often not relieved by the operation.
" Certain cases of neurasthenia which are associated with dysmenor-
rhcea, or with structural changes of the ovaries, are cured by the opera-
tion ; nevertheless, no such case should be subjected to the operation
without beforehand having the benefit of prolonged and patient treat-
ment. It is unjustifiable to remove the ovaries and tubes in cases of
neurasthenia, hysteria, etc., when these organs are healthy."
We trust that the general practitioner and ambitious gynaecologists
will both consider carefully the foregoing conclusions. They undoubt-
edly embody the experience of the profession, gained — at what a cost —
during the past ten years.
The Baby Students' Relief Bill. — Several of the more influential
newspapers have come to the aid of the medical profession in its oppo-
sition to Assembly bill No. 513, and not all of them are published in
the metropolitan district. We are glad to see such an article as the
following, from the Syracuse Daily Journal:
For many years the better part of the medical profession have
striven to elevate the standard of medical education. At county, State,
and national associations addresses have been delivered and resolutions
passed urging medical colleges not only to adopt a better system of in-
struction and longer courses of lectures, but, by frequent and thorough
examinations, to ascertain the fitness of their students for advancement
and graduation. The majority of the schools have given little heed to
these addresses and resolutions. They did not adopt a graded course
extending through at least three years. They have not required each
student to pass numerous oral and written examinations. They have
not turned from the even tenor of their ancient way — faulty, unnatural,
and jumbled though it concededly has been. In most of the schools
the examinations have been so infrequent and superficial as to be of
little if any practical value; so that, of the horde of graduates annually
turned out upon a confiding community, the fitness of the majority has
been complacently surmised rather than rigidly ascertained. Indeed,
we understand that in some colleges the candidate for medical honors
has been subjected to but a single and brief compulsory examination
by each of the seven or more eminent professors throughout his entire
two identical courses of six months each. It is evident that while
many bright students, in spite of the faulty system, did derive great
benefit from the admirable lectures and clinical advantages and volun-
tary attendance at quiz classes, the one only required examination —
and that at the close of the students' course — could have furnished
little guarantee to the public that the graduate possessed adequate
qualifications.
Failing to accomplish needed reforms and secure protection to com-
munity through the action of the colossal rival medical schools, the pro-
fession at last applied to the Legislature. After long-continued efforts,
partial success was achieved. Laws were enacted requiring each per-
son proposing to enter a medical college to satisfy a St ite Board of Ex-
aminers that he possessed at least a fair acquaintance with the element-
ary branches of an English education. They also required him to attend
three courses of lectures, and then, after obtaining his diploma from the
college, to have his fitness to receive a license to practice ascertained
by a carefully selected, independent Stale board. These laws were to
take effect on the first of September, 189:), but were not to be applica-
ble to those students who matriculated in 1889 or prior to that time.
The lazy and unworthy person who entered a medical college in 1890
had a full knowledge of the requirements. He received due notice that
he could no longer neglect attendance on lectures and clinics and quizzes
and feel assured that his easily obtained diploma would give him license
to practice. He knew that, unless the wholesome law could be repealed
or its action postponed till the next year's crop of candidates should be
ripened, his ambition to gain an undeserved access to the bedside of
human suffering would be checked by the ordeal through which all
bright and worthy students willingly and successfully pass. So he sum-
moned to his aid a great number of the dubious and timorous and inca-
pable (who knew well enough that they would certainly pass the college
examination and receive diplomas), and petitioned the Legislature to ex-
empt him and them from this terrible examination of the State board,
but righteously to subject all who should come after them, and all doctors
coming from other States, to its searching and beneficent exactions.
Thoughtlessly the Senate complied with the cowardly and unmanly pe-
tition, and passed the bill known as Assembly bill No. 513. There is
no good reason why the qualifications of every medical graduate of 1893
to practice should not be determined by the Board of State Examiners.
In the interest of humanity the passage of this bill, No. 513, whose
title should be : An ad to promote the admission of incompetent persons
to the medical 'profession, should not be possible. The Syracuse medical
association unanimously protests against its passage. The Faculty of
the College of Medicine of Syracuse University unanimously oppose its
passage. And, to the high honor of their class, not one of the students
of the college who would be affected by it has petitioned to have it
passed.
It is but justice to the Syracuse college to state that it did not wait
for compulsory legislation. We are informed that from its organiza-
tion, twenty years ago, it has required an entrance examination — in-
creasing beyond the State requirements in its salutary exactions. It
has had a graded course extending through three years of eight months
each instead of the customary two years' course of six months. Every
graduate has been subjected to more than three hundred oral or written
examinations before receiving his diploma ; and he is willing and ready
to go before the State board for its examination.
The public should join the medical profession in demanding that the
safeguards against dangerous medical incompetency shall not be dis-
turbed.
Chronic Endometritis. — At a recent meeting of the Philadelphia
County Medical Society, Dr. J. M Baldy read a paper in which he said
that of late years it had become the habit of gynecologists to consider
almost all endometrial diseases as symptomatic, and not as independ-
ent lesions. It was certainly true that many pelvic diseases were ac-
companied by an unhealthy condition of the endometrium ; especially
in pelvic inflammatory disorders the lining membrane of the uterus was
so frequently affected as to have given rise to the supposition that
either it was caused by the pelvic disease or rarely occurred independ-
ently of it. In fact, such assertions were frequently made in print and
before socieths. The temptation was strong to accept this theory,
which appeared at first blush to be so plausible, but which was never-
theless most fallacious. His daily experience was teaching him that
endometritis as an independent disease was quite a common disorder,
and was at the bottom of many of the discomforts suffered by women.
The causes giving rise to this disease were much the same as those that
originated colpitis, and particularly salpingitis — specific infection and
post-puerperal sepsis being the most prolific, and giving rise to the bulk
of the cases. Oftentimes the beginning of the trouble could easily lie
traced to a childbirth or to an abortion. The woman had had a slow
getting up, and would give the history of some fever, or she had re.
gained her usual health very slowly, possibly not at all ; she would have
complained of a vaginal discharge since her confinement, when pre-
viously she had been free from this annoyance. The history might be
that of an attack of specific infection. Sometimes the history in such
a case was clear — a sudden appearance of a yellowish vaginal discharge,
with swelling of the labia and burning in micturition. At other times
the evidence of specific infection was not entirely satisfactory, but it
was notorious that women often became contaminated without giving
the matter any particular attention, or the discomfort had been so
306
MISCELLANY,
[N. Y. Med. Jouh.,
slight as to be soon forgotten. In any event, if the disease was
neglected and spread to the cavity of the uterus, it soon spent its force
and settled down to a chronic condition. It might or might not extend
into the Falloppian tubes and cause salpingitis and peritonitis. Should
it do so, as was often the case, the removal of the appendages would
not necessarily bring about a cure of the patient. In fact, this was the
secret of the failure of laparotomy in many cases. Even il the disease
was complicated by pelvic disorders of an inflammatory nature, espe-
cially if the two arose from the same cause.it was well to first turn our
attention to the endometritis, in which case a laparotomy might at
times be avoided. In other words, in certain cases embracing the two
diseases the symptoms of the endometritis might overshadow those
of the salpingitis; this was especially true of many instances in which
the intraperitoneal damage had not been very serious. Ju cases
where the intraperitoneal inflammation had subsided, and only its
products remained, the treatment of the endometrial inflammation,
which, under these circumstances, was usually chronic-, could be car-
ried out with impunity if ordinary care w;is taken. Of course, in
the event of there being an acute or even a subacute pelvic in-
flammation present, great care must be taken not to interfere with
the uterus in any way, else an already bad condition of affairs might
be made much worse, and even serious. In many patients in
whom there existed post-puerperal septic endometritis or specific en-
dometritis, the disease had stopped short of the tubes, and had not
involved either them or the peritonaeum. These cases were quite com-
mon, and were daily overlooked. The women wandered from one doc-
tor's office to another, and finally, when their money was all gone, into
the public clinics, seeking relief in vain. It was often a matter of sur-
prise that many of them had never even had an examination made, but
had been treated for months and years with drugs, or had been advised
to use injections Jof hot water. The hot-water injections as usually
given were worse than useless. Just sufficient water at a moderate
temperature was used to cause a congestion of the uterus and pelvis,
which congestion was not relieved by the secondary effect of the hot
water — viz., the contraction of the blood-vessels and consequent driving
away of the blood from the parts. These women suffered from a con-
tinual uteiine discharge more or less profuse ; there was, perchance, a
feeling of weight and heaviness in the pelvis, accompanied by back-
ache ; sometimes they felt weak and worn out. The menstrual func-
tion was disordered, being generally irregular and profuse; pain might
or might not attend this function. These symptoms existed either
alone or in various combinations, the only constant and reliable one be-
ing the uterine discharge. A local examination disclosed an enlarged
and heavy uterus, from the cervical canal of which an unhealthy thiev-
ish discharge was oozing. Oftentimes the cervix was eroded, and the
mucous membrane of the everted lips, if the lips were everted, bled on
being touched with a piece of cotton or an instrument. This hscmor-
rhagie condition was more apt to be present when the disease was still
acute or subacute; but, nevertheless, it was at times seen in the chronic
cases. In some instances the uterine body was comparatively normal
to the touch si far as its consistence was concerned ; again, it might be
either too soft or, what was more common, extremely hard, and even
almost fibrous in character. These changes indicated that the disease
was not altogether confined to the endometrium, but had invaded the
structures comprising the uterine wall. It was no uncommon thing to
see an endometritis and a metritis coexisting ; in fact, in chronic cases
it was rather the rule than the exception. The disease was almost
always primarily an endometritis, and treatment which would cure this
affection would be followed by a cure of the metritis almost as a mat-
ter of course. So much was this the rule that the author had got to
look on these two diseases as very much one and the same.
Where this condition of affairs existed — a large and abnormally
heavy uterus — there was very apt to be a retro-displacement of the
womb sooner or later. Whether or not all displacements which gave
rise to trouble were originally caused by uterine inflammations, it was
a curious fact that it was a very raie thing to find a troublesome retro-
displacement without either [uterine or pelvic inflammatory diseases
complicating it.
For the treatment of uncomplicated endometritis and metritis there
was a variety of remedies, some of them quite effective, while many of
them were useless and were applied in a haphazard way. His own
preference was to adopt the shortest and surest course of procedure.
The woman was etherized, the cervix dilated, and the uterus thoroughly
curetted; the uterine cavity was then washed out, and an application
of Churchill's tincture of iodine made to its surface. If there was
pretty free bleeding in consequence of these manipulations, the uterus
was packed full of iodoform gauze, which was removed in the course
of a day or two, as circumstances demanded. Ergot might or might
not be given by the mouth, the indications for its use being haemor-
rhage or an enlarged, heavy uterus. Usually, the author gave half a
drachm of the fluid extract three times a day for a short period, gradu-
ally reducing the quantity until it was dispensed with altogether within
about a week.
As to the steps of the operation: The patient was placed in the
dorsal posture, and the dilatation was made with the Goodell rapid
dilators after careful antiseptic precautions — only sufficient to intro-
duce and manipulate the instruments easily — from three quarters of an
inch to an inch. Great care was taken to make the curettement a thor-
ough one. All dibris could be washed away, and the cavity cleansed
by the use of the rectal nozzle of a Davidson syringe. The application
of iodine followed immediately by means of a long-nozzled uterine
syringe. The patient was now returned to bed, and nothing more was
done for a week or two, except to give absolute rest and hot-water in-
jections, and keep the bowels soluble, together with the use of ergot
as indicated. The author had not found occasion to place a hard-rub-
ber drain in the uterus, as Wylie did, nor to pack it with iodoform
gauze for a prolonged period, as Polk proposed. He found, if the dila-
tation had been properly made, that the cervical canal remained suffi-
ciently patulous for the necessary drainage. The uterus would resent
in one way or another the presence of a foreign body, and these pro-
cedures could only result in just so much more irritation and conse-
quent discharge.
Some patients were cured altogether by this treatment; but, for the
most part, in order to secure a thoroughly satisfactory result, treatment
must be kept up for some little time after the woman was allowed to
get out of bed. It was the author's habit, in these cases, to make an
intra-uterine application of iodine about twice a week for a few weeks,
then once a week, and finally to withdraw the treatment altogether;
the hot-water injection should be kept up twice a day throughout the
whole course of treatment. It was not uncommon, where the endo-
metrium had undergone a fungous change, for the disease to return,
and the whole treatment had thus to be gone through with a second
time.
Many patients would not submit to this treatment, in which event
it became necessary to resort to other methods of management. A pro-
longed course of intra-uterine treatment would, in many cases, eventu-
ally bring about the same result. The author did not maintain that
iodine was the only remedy to be used for this purpose, but he had come
to use it habitually for the reason that he had found no other drug
which would give better results. It was not advisable always to use it
in full strength, in which case it might with advantage be diluted with
glycerin in the required proportions. Ichthyol and all similar substi-
tutes had only proved disappointing.
So much for the uncomplicated cases of endometritis. Where the
disease was accompanied by a pelvic inflammatory condition the first
question to settle was whether or not an abdominal section was to be
performed for the removal of the appendages. If they were not suffi-
ciently affected to call for the operation, and if the uterine symptoms
predominated and were very annoying, he had no hesitation in treating
the uterine cavity. A long-nozzled utetine syringe might with safety
be passed into the uterus, even in the presence of considerable pel-
vic disease, and a local application thus made. In these cases the
strength of the material injected should be regulated by the amount of
inflammation, as a strongly irritating fluid would be much more likely
to cause trouble than the mere passage of the instrument itself. When
the pelvic disease was an old one and quiescent he had no hesitation
in gently dilating the cervix and curetting the cavity of the uterus, and
he had never seen any trouble follow such a procedure. In this class
of patients there was an opportunity for the nicest kind of judgment,
and if one was skillful and careful in selecting the proper cases the
March 12, 1892T.J
MISCELLANY.
307
treatment might be followed by the greatest benefit. The author was
perfectly well aware that this was contrary to the teachings of many
gynaecologists of the present day, but his own experience in these mat-
ters had opened his eyes to the fallacy of such ideas. If the gentlemen
opposing the practice of intra uterine treatment would try it on some of
their patients who continued to have enlarged uteri and a vaginal dis-
charge after the removal of the appendages they would soon become
convinced of its practical value, even in these cases.
The Pathology of Genius. — In an editorial article the British Medi-
cal Journal says :
Huxley defines genius as innate capacity of any kind above the
average mental level. Accepting the definition that genius is an in-
born tendency to do certain things better than most men, it may be
called something abnormal, but to treat it as something pathological is
neither new nor true. Nevertheless, there will always be people will-
ing to believe that men favored by Nature with great mental powers
have some compensating deficiencies. Genius is perhaps not so un-
common as some assume, but there is a great reluctance to recognize
it. There have been men of genius who never gained distinction ow-
ing to adverse circumstances. There is always a goodly number of
men who step beyond the line in physical and mental endowments, and
this superiority is evidently inborn. So far is this from being a proof
of any morbid condition, that perfection of function is the highest re-
sult of happy heredity and healthy nutrition.
Mr. Nisbet, who, a short time ago, wrote a book on the insanity of
genius,* does not venture to espouse the statement of Moreau that
genius is a neurosis, but he holds that great mental gifts are not ob-
tained, as a rule, without some disturbance of the brain and nervous
system. In favor of this view he quotes, curiously enough, an opinion
expressed by Professor Huxley to the effect that a. genius among men
stands in the same position as a " sport " among animals or plants.
He thinks it probable that "a large proportion of ' genius sports' are
likely to come to grief physically and socially, and that the intensity of
feeling which is one of the conditions of genius is especially liable to
run into the fixed ideas which are at the bottom of so much insanity."
Mr. Nisbet is able to enumerate a rather long list of celebrated persons
who suffered from diseases more or less remotely connected with the
nervous system, but whether in a given number of men of genius more
nervous disease would be found in them and in their families than in
the same number of ordinary men living under similar circumstances is
an inquiry which it would be very difficult to make. Mr. Nisbet makes
the most of the fact that toward the close of his life Julius Caesar had
occasional epileptic fits ; nevertheless, Julius Caesar was a man of as-
tonishing strength, both bodily and mental, but the strain to which he
subjected his constitution from his ceaseless toils and his sensual ex-
cesses seemed sufficient to wear out any human organism.
On looking over Mr. Nisbet's list of neurotic great men we miss a
large number against whom nothing can be said. He claims Alexander
the Great as a neuropathic genius, on the ground that he had an affec-
tion of the muscles of the neck, which compelled him to hold his head
on one side ; and that a brother of his was an idiot. This must be
Aridajus, son of Philip by a concubine, who is described as of feeble
intelligence, but certainly not an idiot. Plutarch merely says that
Alexander had a slight droop of the head, and that the weakness of
Aridaeus was not congenital, but Olympias destroyed his intellect with
her drugs. Besides these two, no other of the great generals of an-
tiquity are claimed as neuropaths. Mr. Nisbet seems satisfied if he
can assign any defect or disease against a man of genius, or even
against his ancestors. For example, he thinks it worth while to tell us
that Southey's father was "passionately fond of field sports," and then
observes: " Extraordinary physical energy is often found in connection
with nerve disorder, the result of an excessive stimulation of the motor
centers of the brain." We are told that Cromwell died of ague at fifty-
nine, a " malady the exciting causes of which are still unknown, but
which is obviou-'ly of a nervous character." Then Marlborough was
* The Insanity of Genius and the General Inequality of Human
Faculty physiologically considered. By J. F. Nisbet. New Edition.
Ward and Downey, 1891.
subject to headaches and giddiness; and Turenne had a weak constitu-
tion in boyhood, stuttered, and was subject to a convulsive movement
of the shoulders. We hear nothing of Conde or other great French
generals save Napoleon, as to whom we have the story of his being an
epileptic. We are told that Wellington was also an epileptic. Cer-
tainly Marlborough, Napoleon, and Wellington were all men of very
strong constitutions. All writers who have taken up this view about
the unhealthy character of genius soon take us away to poets and
painters, who are mostly men of extreme sensibility, and often leading
strange and unconventional lives.
There have been, no doubt, too many sickly poets who have gained
notoriety by gratifying a morhid taste for unwholesome reading, but
Tasso seems the only great poet who ever was insane. Mr. Nisbet tells
us he was confined for a time on account of homicidal mania. There
is, indeed, a story of Tasso's drawing a knife on a man, but we do not
know the provocation ; and this is the only record of his trying to in-
jure any one. The character of his insanity was certainly not homi-
cidal mania.
To those who are willing to believe that the poet has a touch of in-
sanity about him, Shakespeare is a great difficulty which Mr. Nisbet
evidently prides himself in having done something to remove. He tells
us that Masson has discovered that he (Shakespeare) " was, in his soli-
tary hours, an abject and melancholy man." Three of the poet's sisters
died in childhood, one brother in early manhood, and two others in what
ought to be the prime of life. Mr. Nisbet informs us that the retire-
ment of the great dramatist to Stratford-on-Avou when he was forty-
eight was not owing to his having made a fortune, but owing to his
health having broken down, and he assumes, without any adequate
proof, that his last illness looks like successive shocks of nervous dis-
order. Mr. Nisbet gives us the choice between a paralytic or an epi-
leptic seizure or paralysis agitans. As for his children, they either died
in infancy or they were stupid. Judith must have been either capricious
in her rejection of offers of marriage, or very unattractive, for she was
thirty -two years of age before she secured her husband, Thomas Quiney,
a vintner, not of good family nor particularly well-to-do. As for Susan-
nah, who married Dr. Hall in her twenty-fifth year, she was a stupid
woman who sold her husband's medical manuscripts without reading
them. The statement that she was " witty above her sex " Mr. Nisbet
regards as conventional " tombstone flattery." Suppressing the con-
tinuation of the epitaph, " More than all, wise to salvation was good
Mrs. Hall," he observes : " Unfortunately, this is all that can be told to
her credit." On the other side of the account, our author lets us know
that Mrs. Hall was troubled in childhood with scurvy, and had a daugh-
ter who had tortura oris, inflammation of the eyes, and ague. So that
we are bidden to insist no more about the healthy character of the
genius of Shakespeare.
The observation that the families of men of geuius have a tendency
to die out could be better considered under the broader statement that
aristocracies and families living in luxurious social conditions do not
habitually keep up their numbers.
Mr. Nisbet's book is written for the general reader, but his subject
will always have a great interest for medical men, who, however, will
be cautious in letting their assent wander far beyond the evidence ad-
duced. Perhaps if the author had been more careful in sifting his
statements, and had presented his conclusions in less startling terms,
his work would have had less attraction for the public.
The Association of American Physicians. — The next annual meet-
ing will be held on Tuesday, Wednesday, and the .: ciuing of Thurs-
day, May 24th, 26th, and 26th, in the Medical Museum and Library,
Washington, D. C, under the presidency of Dr. Henry M. Lyman, of
Chicago. The subject selected for discussion is Dysentery. Dr. William
T. Councilman, as referee, will consider the aetiology and pathology, and
Dr. A. Brayton Ball, as co-referee, the symptomatology, complications,
and treatment. Besides the president's address, papers are to be read
as follows : Dr. Charles Carey, The Production of Tubular Breathing
in Consolidation and other Conditions of the Lungs; Dr. Samuel C.
Chew (title to be announced); Dr. William 0. Dabney. A Contribution
to the Study of Hepatic Abscess; Dr. I. N. Danforth, Tube Casts and
their Diagnostic Value; Dr. George M. Garland, The Treatment of
308
MISCELLANY.
[N. Y. Med. Jotjk.
Follicular Tonsillitis ; Dr. Heneage Gibbes, The Morbid Anatomy of
Leprosy ; Dr. Hobart A. Hare, A Collective Investigation in regard to
the Value of Quinine in Malarial Hematuria or Malarial Ha?moglobinu-
ria ; Dr. A. Jacobi (title to be announced) ; Dr. W. W. Johnston, The
Treatment of Acute Dysentery by Antiseptic Colon and Rectal Irriga-
tion ; Dr. Thomas S. Latimer, Alcoholism ; Dr. Morris J. Lewis, A Study
of the Seasonal Relations of Chorea and Rheumatism for a Period of
Fifteen Years; Dr. Morris Longstreth (title to be announced); Dr.
Francis T. Miles, A Case presenting the Symptoms of Landry's Paraly-
sis, with Recovery ; Dr. William Pepper. Report of a Case of Glanders,
with Results ol Bacteriological Study ; Dr. T. Mitchell Prudden (title to
be announced) ; Dr. George M. Sternberg, Practical Results of Bacterio-
logical Researches; Dr. Charles G. Stockton, Misconceptions and Mis-
nomers revealed by Modern Gastric Research ; Dr. William H. Thom-
son, The Significance of Intermission in Functional Nervous Diseases;
Dr. Victor C. Vaughan, Certain Toxicogenic Germs found in Drinking-
water ; Dr. B. F. Westbrook, Studies in Hypnotism ; Dr. James C. Wil-
son, Pulsating Pleural Effusions ; and Dr. George Wilkins, The Cold-
water Treatment of Typhoid Fever. Members wishing to present pa-
pers are requested to send their names, with the title of the papers, to
the secretary, Dr. Henry Hun, 33 Elk Street, Albany, N. Y. Papers
can be read by title at the meeting and appear in the volume of Trans-
actions. The Constitution of the association (article VI, sections 4 and
5) provides that authors of papers, and referees and co-referees, who
open a discussion, shall not occupy more than thirty minutes each ; and
in the discussion following, the remarks of each speaker shall be lim-
ited to ten minutes. The referees, co-referees, and authors of papers
shall send abstracts of their papers to the council for distribution to
the members previous to the meeting. This provision, however, does
not preclude a fuller or more detailed presentation of the subject in
the articles prepared lor the Transactions, but the limits of time pre-
scribed for the reading of the papers will be enforced.
Mortality in Cities in the United States. — The following table
represents the mortality in the cities named, as reported to Dr. Walter
Wyman, Surgeon-General of the Marine-Hospital Service, and pub-
lished in the Abstract of Sanitary Reports for March 4th :
New York, N. Y Feb.
Philadelphia, Pa Feb.
Brooklyn, N. Y Feb.
Brooklyn, N Y Feb.
St. Louis, Mo Feb.
Baltimore, Md I Feb.
San Francisco, Cal . . . Feb.
Cincinnati, Ohio ] Feb.
Cleveland, Ohio Feb.
Cleveland. Ohio Feb.
Pittsburgh, Pa Feb.
Washington, D. C Feb.
Washington, D. C | Feb.
Milwaukee, Wis j Feb.
Milwaukee, Wis Feb.
Minneapolis, Minn. . . Feb.
Providence, R. I Feb.
Indianapolis, Ind Feb.
Toledo, Ohio J Feb.
Nashville, Tenn Feb.
Portland, Me Feb.
Blnghamton, N. Y. .. I Feb.
Mobile. Ala Feb.
Galveston, Texas Feb.
DEATHS FROM-
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5
110
63
41
45
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1
3
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>
P.
>,
4
>
a
12
15
4
1
GO
29
12
28
27
1
11
i
6
31
42
22
19
9
8
6
11
5
1
8
2
5
13
10
3
10
1
1
3
2
i
T
?
....
i
18
20
18
6
15
9
18
17
8
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8
2
1
1
1
1
1
2
3
2
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2
1
2
2
1
5
2
9
1
1
8
3
1
4
The Treatment of Chorea with Exalgine. — According to the Se-
maine medicale, Dr. H. Lowenthal, of Berlin, in a recent paper gave
the details of thirty-five cases of chorea treated with exalgine. The
results were very encouraging. The dose employed was three grains,
repeated three to live times a day; the duration of treatment varied,
according to the gravity of the case, from eight days to lour months.
The results were ootained the most rapidly where the treatment was
begun at the onset of the disorder. In some of the cases considerable
amelioration was established after twelve doses (36 grains) of exalgine
had been given, but in the majority double this number of doses was
necessary before improvement was manifested. One child, of eight
years, was completely cured after twelve doses of 3 grains each. The
greatest quantity of the drug employed was in a severe case, in which
about 1,700 grains were given in the course of more than three months.
In cases where the choreic movements were very violent the condition
of the patient was aggravated, in spite of the exalgine, for the first two
weeks of treatment, to be ameliorated afterward, slowly, but progress-
ively, until they were arrested. In addition to its action on the mus-
cular movements, the medicament influenced also very favorably cer-
tain other nervous phenomena, such as the mental excitement, feeble-
ness of memory, salivation, articular pains, and formication in the
fingers and arms. These symptoms improved very rapidly during the
first week of treatment. The drug was often well supported, but fre-
quently, after its prolonged use, ringing in the ears, nausea, cephalalgia,
and vertigo were complained of. In four cases there appeared a gen-
eralized icterus. None of these phenomena were ever of a serious na-
ture, and they required no treatment other than the temporary suspen-
sion of the use of the drug. After their disappearance the exalgine
was again given without the reappearance of the unpleasant symptoms.
In conclusion, M. Lowenthal expresses the opinion that exalgine should
be placed among the antichoreic remedies.
To Contributors and Correspondents. — The Mention of all who purpose
favoring us with communications is respectfully called to the follow-
ing:
Authors of articles intended for publication under the head of "original
contributions " are respectfully informed that, in accepting such arti-
cles, we always do so with the understanding that the following condi-
tions are to be observed: (1) when a manuscript is sent to this jour-
nal, a similar manuscript or any abstract thereof must not be or
have been sent to any other periodical, unless we are specially notified
of the fact at the time the article is sent to us ; (2) accepted articles
are subject to the customary rules of editorial revision, and will be
published as promptly as our other engagements will admit of — we
can not engage to publish an article in any specified issue ; (3) any
conditions which an author wishes complied with must be distinctly
stated in a communication accompanying the manuscripjt, and no
new conditions can be considered after the manuscript has been put
into the type-setters'1 hands. We are often constrained to decline
articles which, although they may be treditable to their authors, are
not suitable for publication in this journal, either because they are
too long, or are loaded with tabular matter or prolix histories of
cases, or deal with subjects of tilth interest to the medical profession
at large. We can not enter into any correspondence concerning our
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THE NEW YORK MEDICAL
(Original Communications.
CYST OF THE MIDDLE TURBINATED BONE.*
By CHARLES H. KNIGHT, M. D.,
NEW YORK.
The middle turbinated body may become of patho-
logical importance in various ways. Aside from malignant
disease and syphilis, which are prone to attack this struct-
ure in common with other intranasal tissues, the lesions of
this body with which we usually meet may be divided into
two classes — those involving its mucous membrane, and
those affecting its bony framework. The former are more
frequent and are more remediable, since osseous changes
are always associated with an advanced degree of disease
of the mucous membrane.
The object of the present paper is to add to the litera-
ture of a very interesting pathological change in the bony
framework of the middle turbinated body, which, notwith-
standing its frequency, has had but little notice. Many
years ago one of my associates at the Manhattan Eye and
Ear Hospital called my attention to a singular condition of
a middle turbinated body which he had just removed with
a cold-wire snare. We found that the loop had cut through
a mass of polypoid tissue attached to a bony shell, present-
ing a depression in which the tip of the little finger could
readily be placed. The bone was for the most part ex-
tremely thin, so that in the process of cutting through the
mass the existence of osseous tissue was not recognized.
The mucous membrane externally, which had not under-
gone polypoid degeneration, was in a state of decided
atrophv. The interior of the cyst was lined by a pale, thin
membrane. No attempt was then made to examine the tis-
sues microscopically. Since that time numerous similar
instances have come under my observation, and my friend
Dr. W. H. Park has been kind enough to make sections
and give me the results shown by the microscope. For the
photographic reproductions I am indebted to my assistant,
Dr. W. P. Brandegee. The illustrations show a side-view
Fig. 1. — Cyst of right middle tnrbi- Fig. 2.— Cyst of right middle turbi-
nated bone. External surface. Dated bone. Interior.
and a view of the interior of one of the largest of these
cysts with which I have met.f The patient from whom it
was obtained was a middle-aged woman, whose right nos-
tril was completely occluded by a mass which could easily
be seen without a speculum when the tip of the nose was
* Read before the American Laryngological Association at its thir-
teenth annual congress.
■f- (Zuckerkandl, whom nothing in nasal pathology seems to have
escaped, shows a typical example of this deformity in his classical
work, Normaleund palholog. Analomie dcr Nascuhbhle, Tafel 2, Kig. 6.)
JOURNAL, March 19, 1892.
raised, and which at first glance appeared to be a large
myxoma. But on palpation it was found to be hard and
resistant, and there was no sign of a polypoid condition of
the mucous membrane. On the contrary, the soft parts
were atrophied. The ssepfum was somewhat deviated to
the left, and there was some hyperplasia of the mucous
membrane in the left naris without apparent bony change.
The subjective symptoms complained of were impeded
nasal breathing, impaired sense of smell, and persistent
headache. The voice had a slightly nasal quality and there
was considerable annoyance from post-nasal discharge. The
obstructed nostril was freed by means of the cold-wire
snare and cutting forceps. The portion removed with the
snare and shown in the photographs measures an inch and
a quarter in its antero-posterior diameter, half an inch ver-
tically, and half an inch laterally. The greatest depth of
the cyst through which the wire passed was five eighths of
an inch. The part removed with the snare represents only
about two thirds of the entire cyst. The remnant was re-
moved with cutting forceps so as to relieve all pressure and
obstruction and permit free drainage. The patient experi-
enced great relief from the operation, which was done under
cocaine, and was followed by no unfavorable developments.
The clinical history in cases of this kind must of course
vary with the degree of enlargement. In nearly every case
the symptoms most prominent are those referable to press-
ure from the distending cyst, such as hemicrania and neu-
ralgias of the fifth pair. These reflex neuroses were espe-
cially marked in cases described by Glassmacher,* McBride,f
and others. The most serious complication likely to arise,
and one more apt to occur if myxomata coexist, is empy-
ema of one or more of the adjacent sinuses, obstruction of
the ostium mazillare being a frequent cause of antral dis-
ease. It is a remarkable fact that this cystic transforma-
tion but seldom involves the inferior turbinated. 1 have
myself never seen it except in the middle. A single case
has been reported by Schaeffer J in which the inferior tur-
binated was affected, and Bayer has reported a case in which
the superior turbinated was involved. It is also noticeable
that in a certain proportion of cases the condition is associ-
ated with well-defined myxomata or polypoid degeneration.
In my experience more than half the cases presented this
feature, and in every case there was more or less atrophv
of the mucous membrane. Children seem to be exempt.
None of my own patients was under twenty years of age,
most of them were past middle life, and the majority were
females. This condition requires to be distinguished from
osteoma, myxoma, and mucocele of the ethmoidal cells. I'.ut
little difficulty should be found in reaching a correct con-
clusion if we carefully observe the origin and situation of
the tumor, its immobility, its hardness and at the same time
its fragility, and possibly its translucencv (Zw illinger). Os-
teomata are harder and do not permit of penetration by
means of the exploring needle, and, moreover, are said to
* Berl. klin. Wbch., No. 36, 1884, p. 571.
f Brit. Med. Jour., 1888, p. 1116.
J Chir. Erfalirimgcn in dcr Ithinol. und LaryrujoL, Wiesbaden,
1885.
■Ml)
KNIGHT: CYST <>F THE MIDDLE TURBINATED BONE.
[N. Y. Med. Jock.,
l>i' movable at their inception. Myxomata are freely mova-
ble, are soft and yielding, and are generally multiple. Mu-
cocele of the ethmoidal cells is a rare condition, presenting
many of the features of ordinary myxoma, and could hardly
be mistaken fm- a bonv tumor.
cells, and quite vascular. This structure is rather more
dense in the immediate neighborhood of the bone. The
thickness of the bone varies greatly in different regions,
and distributed along its inner surface may be seen a row
of osteoblasts. Lining the bone is a layer of loose oedema-
The method of preparing the specimen for microscopic tous connective tissue resembling myxomatous tissue. Fi-
examination was as follows: The cyst was kept for eight-
een days in a saturated solution of picric acid, and was then
washed out in alcohol. It was then placed in absolute
alcohol for twenty-four hours, then transferred to equal
parts of absolute alcohol and ether, in which it was retained
another day, and finally was immersed for twenty-four
hours in a solution of.celloidin in absolute alcohol and supposes the lesion to have its origin in an osteophytic
nally, a complete row of columnar ciliated epithelium lines
the inner wall of the cyst.
Two theories have been advanced in explanation of this
condition. The first is that it is a result of a rarefying
osteitis, similar to that occurring in the long bones. The
second theory, recently sustained by Greville Macdonald,
IP mm
mmm
Fig. 3.— Section or Cyst of Middle Tuebinated Bone, cr, layer of stratified epithelium ; b, layer of richly
cellular vascular connective tissue, which is rather more dense about the laminae of bone c,e,d; e, layer of
very loosely arranged eedematous connective tissue resembling myxomatous tissue in structure ; /, layer of
ciliated epithelium : g, layer of osteoblasts.
ether. It was then im-
bedded in celloidin, cut,
and stained with hema-
toxylin and eosin, and
mounted in Canada
balsam.
The section, of
which an excellent
drawing has been made
by Dr. Van Gieson,
periostitis, doubtless secondary to a hypertrophic rhinitis
involving the soft parts. The margin of the bone begins
to curl outward and upward until it meets the body of the
bone at some point where at length adhesion takes place.
Thus, eventually, a closed cavity is formed, lined within
and without by mucous membrane. The external mem-
brane atrophies or becomes polypoid, or its hypertrophies
condition may persist. The internal membrane continues
to secrete until the cavity becomes distended, when, as a
result of pressure, the glandular elements undergo absorp-
consists of one half of a small and probably recent tion and the membrane becomes very much attenuated. In
cyst, which has been cut vertically at a right angle to some cases the lining membrane will be found to have be-
its long axis. Examined from without inward, we find come polypoid and granulating, giving rise to the forma-
externallv a layer of stratified epithelium, then a layer j tion of pns, perhaps in sufficient quantity to simulate ab-
of connective tissue of considerable thickness, rich in : scess. Macdonald, in an article on Cyst and Abscess of the
March 19, 1895.] MORRIS: REMOVAL OF CARIOUS BONE WltH ACID AND PEPSIX.
311
Middle Turbinated Bone (Lancet, London, June 20, 1891),
remarks that abscess " may possibly originate in a cyst
produced by retained secretion." The contents of these
cysts vary in character. The name given them by French
and German writers implies that they contain air, which is
doubtless generally the case. But it is equally true that
they sometimes contain fluid, mucous or purulent, as the
case may be. Unless one could remove a cyst unbroken,
which I never have succeeded in doing, it would be some-
what difficult to determine the quality and quantity of its
contents. The manipulations attending its removal must
of necessity provoke secretion and obscure its source. In
some cases the cyst is multilocular, or its cavity is traversed
by numerous bands of bony or membranous tissue. Bayer
(Rev. mens, de laryngologie, etc., June 1, 1885) minutely
describes a multilocular cyst of the right middle turbinated
bone which he punctured with the galvano-cautery. The
tumor occluded the naris and displaced the saeptum. It
Anally disappeared, and the parts regained their normal
contour in the course of two months, after repeated appli-
cations of the galvano-cautery and the use of injections of
chloride of zinc and phenic acid. A remarkable feature of
this case was a recurrence of cystic degeneration involving
not only the middle but the superior turbinated as well.
In the largest of the specimens exhibited and shown in the
photographs, the wall of the cyfst is quite thick on one side
and honeycombed. Elsewhere it is thin as tissue paper.
It is difficult to conceive that the appearance depicted in
this particular specimen could have been developed in the
manner suggested by the second theory. On the other
hand, I have met with several cases in which the cyst was
as yet incomplete and apparently in course of formation by
this process of curvation. The existence of columnar epi-
thelium provided with cilia still further supports, and in-
deed may be said to prove, the second theory. At the same
time other conditions can be satisfactorily explained only
by assuming an inflammatory process in the bone itself.
The indications for treatment are clear enough, and
may be enumerated as follows :
1. Interference with nasal respiration.
2. Prevention of nasal drainage.
3. Reflex neuroses.
4. Anosmia.
5. Impaired quality of voice.
Unless the cyst is so large as to cause pressure or im-
pede nasal breathing, it is seldom necessary to interfere.
The bone is usually so thin that it may easily be crushed
with forceps if desirable, and redundant tissue may be re-
moved with cutting forceps. In large cysts, especially if
associated with polypoid growths, the cold-wire snare will
be found to be most serviceable. Schmiegelow,* who has
carefully described this condition under the name " trans-
formation kystopneumatique," prefers to puncture the cyst
with the galvano-cautery and remove its walls to the neces-
sary extent with cutting forceps and scissors. A similar
method is advocated by Zwillinger,f who reports two cases,
and who claims to detect the presence of the cyst by trans-
amination and puncture. In my experience a diagnosis is
usually possible without resorting to either of these meth-
ods, and the advantage of the galvano-cautery over other
procedures as a mode of treatment is not apparent. The
pain of the operation, in spite of the free use of cocaine, is
sometimes considerable, and subsequent reflex neuralgias
are not infrequent. Haemorrhage is seldom excessive, and
in several of my cases it was surprisingly scanty.
20 West Thirtt-first Street.
THE REMOVAL OF
NECROTIC AND CARIOUS BONE
WITH HYDROCHLORIC ACID AND PEPSIN*
By ROBERT T. MORRIS, M. D.
Sometimes it is desirable to remove dead bone without
subjecting a weak patient to a dangerous or deforming
operation. Attempts have been made with some success at
clearing out this bone by a process of decalcification, but
there are two chief reasons why failures have resulted as a
rule. In the first place, it was discovered that superficial
layers of dead bone were decalcified easily enough, but the
acids did not reach deeply through the mass, especially if
portions were infiltrated with caseous or fatty debris. In
the second place, cellulitis was pretty apt to develop during
the course of treatment. After much experimentation I
have finally adopted a method of work which seems to be
complete. An opening is made through soft parts by the
most direct route to the seat of dead bone, and if sinuses
are present they are all led into the one large sinus if pos-
sible. The large direct sinus is kept open with antiseptic
gauze and the wound allowed to remain quiet until granu-
lations have formed.
Granulation tissue contains no lymphatics, and absorp-
tion of septic materials through it is so slow that we have
a very good protection against cellulitis. The next step
consists in injecting into the sinus a two- or three-per-cent.
solution of hydrochloric acid in distilled water. If the pa-
tient is confined to bed, the injections can be made at inter-
vals of two hours during the day ; but if it is best to keep
the patient up and about, the acid solution is thrown into
the sinus only at bed-time. In either case the patient is to
assume a position favorable for the retention of the fluid.
Decalcification takes place rapidly in exposed layers of dead
bone, and then comes the necessity for another and very
important step in the process. At intervals of about two
days an acidulated pepsin solution is throw n into the sinus
(] use distilled water, f \ iv ; hydrochloric acid, 1'lxvj;
Fairchild's pepsin, 3 ss.), and this will digest out decalci-
fied bone and caseous or fatty debris in about two hours,
leaving clean dead bone exposed t or a repetition of the pro-
cedure. The treatment is continued until the sinus closes
from the bottom, showing that the dead bone is all out.
Even in distinctly tuberculous cases the sinuses will
* Rev. de laryngologie, etc., May 15, 1890.
I Wiener Min. Wochenschrift, No. 19, 1891.
* Head before the Southern Surgical and Gynaecological Association,
November 12, 1891.
312
PATON: SUPERFICIAL PAPILLOMA OF THE OVARY.
[N. Y. Meu. Joub.,
close if apparatus for immobilizing diseased parts and
tonic constitutional treatment are employed, as they should
be in conjunction with our efforts at removing the dead hone.
If suppuration is free in any cavity in which we are at
work, it is well to make a routine practice of washing out
the cavity with peroxide of hydrogen before each injection.
It is a popular impression in the profession that living
bone is not attacked by dilute mineral acids, but, as it makes
a good deal of difference whether the impression is correct
or not, I experimented as follows : A portion of the kera-
tinoid layer was removed from the carapace of a turtle
(lYanemi/s guttatus), and the animal was then placed tail
downward in a glass of five-per-cent. hydrochloric-acid solu-
tion. In the same glass I placed also a segment snipped
from the plastron of the turtle, and a transverse section of
an old dried humerus of a man. The piece of humerus was
completely decalcified in six hours, the segment from the
plastron was soft in about twenty hours, and the carapace
of living bone was decalcified at the exposed part in thirty
hours. I was then curious to know what effect the acid
had had upon the blood-vessels of the decalcified bone, and
Dr. Smith, of the laboratory of the Post-graduate Medical
School, made for me several sections of the carapace which
included both decalcitied and healthy bone. Investigation
showed that all of the blood-vessels were destroyed wher-
ever the bone was softened, and the action of the acid had
extended farther up along the larger biood- vessels than else-
where. In the accompanying- photomicrographs the dark
Flo. 1.
portions represent decalcified bone stained with carmin,
and in the lighter portions the structure of the normal bone
cells is readily distinguished. In Fig. 2 can be seen the
line of extension of decalcification alony- three blood-vessels.
o
The difference in time between decalcification of the
dead bone (six hours) and of living bone (thirty hours) is
significant, a five-per-cent. solution of hydrochloric acid
having been used.
If we use a two- or three-per-cent. solution of hydro-
chloric acid, a wall of lymph and of granulation tissue is
Fig. -2.
thrown out upon the surface of living bone for protection,
and only dead bone is attacked. This at least has been my
observation in several cases in which the results of treat-
ment could be easily watched.
The details of treatment in some of the cases would be
very interesting, but if the paper were lengthened to accom-
modate them my main points would be apt to hide.
SIPERFICIAL PAPILLOMA OF THE OVARY.
WITH REPORT OF A CASE.
By STEWART PATON, M. D.
Since Proschaska reported his first case the literature
relating to superficial papillomata of the ovaries has steadily
increased. A few years ago it was very small, but the rea-
son for this somewhat rapid increase is not difficult of ex-
planation. The pathologist is particularly interested in the
development of these tumors, for structurally they may be
considered as on the border-line between benign and malig-
nant growths, and therefore the question of their innocence
or their varying degrees of malignancy and the possibility
of recurrence after removal is of especial import to the sur-
geon. The term malignant as applied to this class of tu-
mors is certainly an unfortunate misnomer, as it is mislead-
ing. Unquestionably these tumors recur. Starting from
the ovary, growths may occur on the uterus, tubes, broad
ligaments, bladder, and the various reflections of perito-
nauim, but recurrence takes place by direct implantation
and not by metastasis. I have carefully searched all rec-
ords for evidence of metastasis occurring with papillomata,
but have failed to find any reliable evidence to this effect.
Certain forms of truly malignant growths, such as the
cauliflower-like forms of carcinomatous tumors, may and
have been mistaken on superficial examination for papil-
March 19, 1892.]
PA TON: SUPERFICIAL PAPILLOMA OF THE OVARY.
313
lomatous excrescences — " les excroissances dendritiques " —
and only the microscope can distinguish them. There is
no more clinical evidence for calling papillomata malignant
than there is for placing myxo-adenoma of the ovary in the
•class of malignant neoplasms.
Unquestionably papillomata have a decided tendency
to become malignant if their growth is uninterfered with
for years, but cases winch have been under observation
for a considerable period, such as Doran's case, seven
years, or those of Marchand and Coblcnz, have never
shown any tendency to recur after removal. In one case
recorded by Marchand there was, in addition to the papil-
loma of the ovary, a coexistent carcinomatous mass on
the omentum. Both tumors were removed, but the car-
cinoma subsequently recurred. The record of the micro-
scopical examination of the ovarian tumor is incomplete
and I should be inclined to regard it as a carcinomatous
growth and probably an illustration of that class of cases
already alluded to where the gross similarities are so marked
that a purely malignant tumor has been mistaken for a be-
nign growth. This view is evidently corroborated by the
fact that there was " a well-defined carcinomatous growth
on the omentum." Apart from this negative evidence that
ovarian papillomata are not truly malignant growths, we
have somewhat more positive evidence in the histogenesis of
these tumors. Under the microscope the dissimilarity be-
tween the mode of devel-
1 U&/L^>yi>i%
0a&
'///.
\7i
6 V
I'v 8
Fig. 1. — Cancer of the ovary.
opment of papillomata and
that of the embryonic car-
cinomata and sarcomata is
very striking. In any care-
fully prepared series of sec-
tions of the former we can
see in the disposition of
the blood-vessels in rela-
tion to the surrounding
cells a dependence of the
new tissue upon definite
vascular channels for
blood-supply. To use a simile for clearness, the new tissue
is not cut off from a basis of food supply. Contrast with
this the process of tissue formation in any malignant
growth of the
ovary or of any
other organ. The
cell infiltration
is characteristic.
Each cell may be
looked upon as a
distinct entity,
and the process of
their development
is discretive as
considered in its
relation to the
whole tumor. Nothing is more distinctive of malignancy,
nothing is more trenchantly defined than the absence
of this cell autonomy in the growth of papillomata. The
new tissue is formed in intimate dependence upon the
FYg. i.— Papilloma of the ovary.
vascular supply ; there is no cellular invasion, no metastatic
diffusion, at least no case reported where the observations
are free from question regarding their accuracy. Regard-
ing papillomata as highly organized benign neoplasms, I
have been unable to find a single case in which there has
been a succession or recurrence of the growth in a more
lowly organized but malignant type.
The importance of this is great, not as a proof that
these growths would not have a malignant tendency if left
untouched, but rather as an encouragement to the surgeon
in attempting their removal. Recent observations point to
something more even than the non-succession of malignancy.
In the list of recorded cases where the peritoneal cavity has
been thoroughly washed and drained there has been no re-
currence of the papilloma, showing that the development of
the implantations which occur in the majority of cases, and
which it is often impossible to remove, has been successfully
interrupted. It is particularly interesting to note that in the
cases where recurrence after removal has been noted no
mention is made of the fact that the abdominal cavity
was drained after removal of the tumor. Naturally any
implantations which existed at the time of removal and
were overlooked develop, and consequently the records of
such cases are practically worthless. I have been unable
to find the record of any recurrence in situ. The re-
moval with subsequent drainage of the peritoneal cavity
undoubtedly prevents recurrence, at least as far as present
records can determine the question for us. Drainage is
all-important. It is often impossible to tell whether im-
plantations have taken place, and if they have, of course,
mere removal of the primary growth is not sufficient. If
implantations have been left undisturbed, the thorough
washing out of the peritoneal cavity apparently prevents the
development of offshoots from the original tumor. Con-
sidering the great difficulty of completely removing papil-
lomata, owing to their almost brittle character, the impor-
tance of always thoroughly washing out the abdominal cavity
with distilled water and the employment of drainage-tubes
can not be too strongly emphasized. In view of the rapid
development of papillomata and the long continuance of
symptoms, in some cases extending over a period of several
years, we can not fail to note, even in the cases of longest
standing, the absence of anything like an attendant cachexia.
This is a point of minor importance, but still is worthy of
attention. Apart from the local abdominal disturbances, such
as ascites, pressure symptoms, menstrual disturbances, some
pain, and the inconvenience afforded by the pressure of the
tumor, patients suffer comparatively little. The symptoms
are local. Too much stress must not be laid on this, how-
ever, for the absence of cachexia is often noteworthy in
malignant cases. It is in the study of the histogenesis of
these tumors and the correlative consideration of their
clinical history and symptoms that we find considerable
evidence of their primarily benign character. Striking con-
firmation of this is apparent in the following case, for the
record of which I am indebted to Dr. T. (Jailbird Thomas:
The patient was twenty-nine years of age; had been married
six years. Had had one child, three years before; no miscar-
riage. She complained of dysmenorrhcea for several years prior
314
POME HO Y: GLA UGOMA .
[N. Y. Med. Joiib.,
to becoming pregnant ; since birth of child menstruation has been
regular. On November 10, 1890, without any known cause, had
an attack of subacute peritonitis, which lasted for two weeks.
After the cessation of pain ascites rapidly developed. Since then
the patient has been tapped thirteen times, and each time ten
to thirty pints of clear serum were removed. Since the first
appearance of the ascites the patient's general health has not
suffered. Her appetite was unimpaired and her general strength
was good. On October 9th the abdomen was opened and
twenty pints of clear serum were removed; then with consider-
able difficulty a papillomatous mass, including both ovaries and
the left tube, wa9 torn loose from its attachments in Douglas's
pouch. On superficial examination the mass was plainly papil-
lomatous. Both ovaries were slightly enlarged. Their surfaces
were covered with pedunculated outgrowths with pointed or
rounded ends. The microscopical examination showed very
clearly what has already been indicated in speaking of the histo-
genesis of these tumors, the absence of cellular invasion, and the
evident dependence of the new-formed tissue upon dr finite vas-
cular supply. Incidentally we may note the papillomatous
mass connected with the right tube, as in the case reported by
Doleris. The clinical symptoms of the case are interesting and
show some points of importance in aiding in diagnosis.
As in this case, the majority of cases begin with symp-
toms resembling those of subacute peritonitis. These sub-
side, then generally there is a rapid development of ascites
with few other symptoms, the patient's general health being
only very slightly impaired. As regards age, an examina-
tion of the records shows that no age is exempt ; further
than this, it is not safe to draw inferences, for the records
of cases are yet too small in number.
Literature.
Pozzi. Treatise on Gynecology.
Winckel. Lehrb. der Frauenh rankheiten.
Olshau^en. KranJch. der Ovarien.
Howell, in Mann's Am. System of Gynecology \
Centrallil. f. Gynalcologie, xi, p. 409.
596 Lexington Avenue.
A REPORT OF CASES OF
GLAUCOMA OF DIFFERENT VARIETIES,
ILLUSTRATING SOME OP THE USUAL MEANS PRACTICED
FOR THEIR RELIEF.*
By OREN D. POMEROY, M. D.,
NEW YORK.
Case I. — Miss McG., aged twenty five, had acute inflamma-
tory glaucoma of the right eye of ten days' duration. The eye-
ball was very hard, much congested, and so painful that she had
not been able to sleep for more than a week. Iridectomy was
promptly done under ether. Complete relief was at once ob-
tained from all the symptoms. The vision was not much low-
ered, but it quickly returned to the normal.
Case II. — Mrs. R. M., aged forty-eight, received a penetrat-
ing wound in the right cornea from a carpet tack. The lens
was penetrated and soon became so swolli-n as to fill the ante-
rior ch umber. Increased tension of the eyeball and great pain
resulted.
* Read before the Medical Society of the State of New York at its
eighty-sixth annual meeting.
This lens matter was extracted through a corneal incision
and the patient was at once relieved.
Roth eyes were bandaged after the operation.
Four days subsequent to this the left eye was observed to
have defective sight, she being able only to count fingers at four
feet.
The corneal epithelium was somewhat hazy and the eyeball
too hard.
It being evening, an iridectomy was done by lamp-light with-
out difficulty.
The patient at once completely recovered, the vision and in-
creased tension being restored to the normal.
Case III. — Robert R., aged forty-one, was struck on the left
eye by a piece of iron rust from a hammer ; this lodged in the
cornea and was removed by a fellow-workman. The eye was
very painful, but the removal did not relieve the pain ; the pa-
tient still continued to work.
The accident occurred three weeks previous to this observa-
tion. Four days subsequent to his first visit to the hospital he
was again struck on the same eye by a piece of emery ; this was
at once removed, but intense pain still continued. Atropine was
found to aggravate the pain ; warm water was used to bathe the
eye. In a day or two the eyeball had increased tension, the
cornea was hazy and anaesthetic, the anterior chamber was shal-
low, and the pupil was widely dilated. There was considerable
circumcorneal injection. The vision was =
Eserine solution was instilled and on the same day the pain
disappeared, the pupil promptly contracted, the cornea began to
clear, and the vision at once became doubled.
Improvement continued for a few days, but on March 2oth
it was thought, proper to perforin a sclerotomy, which was ac-
cordingly done. Eserine was continued.
On April 7th the tension was normal and the vision — lxx»
whereas on March 9th it was only = jfc.
Case IV. — Marg. M., aged sixty. Ten years since an iridec-
tomy was done on the left eye.
Two weeks ago a severe pain appeared in the right eye. which
has continued to the present time (July 10, 1891). There is in-
tense ciliary congestion, steamy cornea, and shallow anterior
chamber. The intra-ocular tension is increased. The nerve can
not be seen. She counts fingers at six inches. Eserine was or-
dered to be instilled three times daily. In three days the pupil
had contracted and the tension was diminished. Continued
eserine and a leech to inner canthus, the latter repeated on the
next day, which afforded some relief. July 18th, the tension be-
ing increased, injections of pilocarpine were used, leech repeated,
and eserine continued. July 24th the tension is normal, pupil
smaller. Eserine was continued. On July 28th the patient was
discharged. It seems to the writer that the pilocarpine exerted
an important influence upon the patient. Subsequent vision was
not recorded.
Case V. — Mrs. M., aged sixty-eight, had had attacks of in-
flammatory glaucoma in both eyes, with all the symptoms of the
disease for several years. After three years the left eye became
sightless and very hard. During the attacks of pain, relief, more
or less complete, resulted from paracenteses of the cornea?, espe-
cially of the right. At the last bad attack of the right eye, the
cornea becoming so opaque that little sight remained, iridectomy
was reluctantly consented to and was done under ether on both
eyes. The right recovered promptly and vision reached x'xx and
so continued for ten years, until her death. The left eye con-
tinued painful after the iridectomy for two wreeks, when it was
removed and found to contain an enormous blood clot. It is
worthy of remark that the repeated paracenteses, at least a
dozen, contributed greatly to the relief of pain during the ex-
acerbations.
March 19, 18V<2.J
POMEROY: OLA UCOMA.
315
Case VI. — Henry M., aged sixty-four, has had chronic in-
flammatory glaucoma in each eye since a year. The tension is
Increased in both eyes. He counts fingers at three feet with
either eye. The visual fields are much narrowed. Optic nerves
are cupped with beaked vessels. Eyes moderately painful. An
iridectomy was done on both eyes without affecting the tension.
In tour weeks sclerotomy was done, which restored the tension
at once to the normal. The vision and the visual fields were
unaffected.
Case VII. — Miss S., aged forty-six years, hns signs of chronic
inflammatory glaucoma in the left eye dating back three months.
The cornea is slightly hazy; the pupil somewhat dilated; the
nerve shows glaucomatous excavation. The field is somewhat
limited, and the tension is increased.
There is some circumcorneal injection, with moderate pain,
which, however, is not constant. The vision = The other
eye is normal and emmetropic.
Iridectomy was done under ether. The pain was relieved
and the tension restored to the normal, but no other effect was
produced.
This was one of two cases of glaucoma where the cornea was
penetrated, in doing the iridectomy, with great difficulty.
Case VIII. — Hannah W., aged sixty-five years, was wakened
in the morning, about three months since, with a severe pain in
the left eye; there was also some pain in the right eye. There
was failure of sight in both eyes, but more so in the left.
On entering the hospital the vision of the left eye was =
The right eye was = jSgj. Both eyes were hypermetropic. The
left has been painful since first being attacked.
The anterior chamber was shallow, and the pupil was some-
what dilated and sluggish. There was incipient cataract. The
optic nerve showed signs of atrophy. There were flame-shaped
hemorrhages in the retina.
There was concentric limitation of both visual fields. Nei-
ther nerve showed glaucomatous excavation. The tension in the
left eye was much increased ; the right less so.
On June 16th sclerotomy was done on the left eye. It was
feared that an iridectomy might induce an intra-ocular haemor-
rhage.
After withdrawing the narrow cataract knife everything was
as usual for a few seconds, when suddenly the anterior chamber
was obliterated, and the iris prolapsed at either angle of the in-
cision. These prolapses were removed by the scissors. Intra-
ocular haemorrhage was the natural explanation of this phe-
nomenon. There was now only weak perception of light.
The operation resulted in quieting the pain and reducing the
tension to the normal. Ten days subsequently there was pain
in both eyes, and a one-grain solution of eserine was used in each
four times a day. This pain continued for a week.
After its subsidence the patient was sent home, but was di-
rected to report at the daily cliniques.
Twelve days afterward (July 19, 1891) there was slight in-
crease of tension and a little pain. On December 3d returned.
She has had occasional pain in both eyes, but it has been re-
lieved by a one-per-cect. solution of cocaine. The vision of the
right eye = xx'x ; that of the left is equal to counting fingers at
six inches.
April 25, 1891. — The right eye is painful and has increased
tension. A one-grain solution of eserine quickly relieved the
pain and increased tension.
During the last six months the increased tension and the pain
have been kept down by the eserine. The left eye lias now no
perception of light.
Case IX. — Frank L. P., aged thirty-two years, applied for
treatment on November 1, 1891, stating that for a year he had
had dimness of vision in the right eye. There was some pain
and a feeling of soreness in the eye when excessively used.
The vision = }c$ with — 1-50 D. The vision of the left =
with the same correction. A posterior polar cataract in the
right eye caused a scotoma of from 10° to 20° in diameter.
The field was concentrically limited to from 45° to 80°. The
iris was sluggish. The tension was increased. A one-grain
solution of eserine was used three times a day. Oleate of
mercury was used with a view to constitutional effects. On
November 14th the tension was normal and the patient was
discharged.
On December 5th the tension was increased and there was
some pain, but the vision = tf . Paracentesis of the cornea was
done with temporary improvement. By the 15th the symptoms
had disappeared.
In a few days, however, there was increased tension and
pain, and an iridectomy was done. In ten days all the symp-
toms had again disappeared.
< >n the 29th there was some intolerance of light, with con-
junctival injection, increased tension, and some pain.
Eserine was instilled three times daily, with hypodermic in-
jections of pilocarpine. The latter proving inoperative, the sali-
cylate of sodium was administered in sufficient doses to cause
free diaphoresis.
On January 27th all symptoms relieved.
On May 29th there was pain and augmented tension in the
left eye, which had existed tor three weeks.
Iridectomy was done at once, and completely relieved the
symptoms.
Since this date he has returned, with increased tension in
the right eye and some pain, which has been relieved by es-
erine.
Case X. — Miss EL, aged thirty-two, applied to me on Sep-
tember 19, 1890, with the right cornea so opaque as to only al-
low of perception of light. The projection showed perception
of light 15° on the nasal side and 60° on the opposite side.
There was some circumcorneal injection. In the upper portion
of the iris, between the pupil and the periphery, was a .small
circular opening (coloboma). The teusiou was slightly increased
and there was some pain. During two weeks a two-grain solu-
tion of eserine was instilled from two to six times daily. . Dur-
ing two weeks the tension was normal or slightly increased.
Paracentesis of the cornea was then done with temporary bene-
fit. After one month a sclerotomy was done, which lowered
the tension to the normal for three weeks. The cornea had
cleared sufficiently for the patient to count fingers at sixteen
inches. The nerve was now visible and found to show glau-
comatous excavation. After three weeks the tension w as in-
creased, and eserine sufficed to reduce it to the normal,
although it required to be used five or six times daily.
Six weeks from the performance of the sclerotomy, iridectomy
was done. Since this time there lias been only occasionally an
increased tension, when eserine has reduced it to the normal.
She then returned to her vocation of school-teaching, w hich
she has continued to the present. 1 saw her in February, 1891,
and the vision - Xx?x — • it seems to the writer very infrequent
for the vision to increase from perception of light to — in a
case of chronic inflammatory glaucoma.
Case XI. — N. W. A., aged fifty- five, applied to me on May
18, 1891. He had been rheumatic for several months. During
six weeks he had had fjlanoomatoas symptoms in the let! eye.
The eyeball showed considerable circumcorneal injection, with
moderate pain and greatly augmented tension. Iridectomy was
done at once.
Eserine was used. On the 23d the tension was normal, the
injection of the eyeball much diminished, and the pain had dis-
uppeared. On entering the hospital there was only perception
310
POMEROY:
G LA UCOMA.
[N. Y. Med. Jock.,
of light on the nasal side, and on September 2d lie could count
fingers at six feet on the nasal side.
The vision of the right eye = On September 15th the
tension was increased in the right eye. Eserine was ordered
for both eyes.
October 24th. — Tension normal in both eyes, and vision per-
fect in the right eye; eserine still used in both eyes. The optic
discs resemble those of glaucoma in the atrophic appearances,
with the atrophic ring of glaucoma, but there is no abrupt
peripheral excavation, except in the left there are a few bent
vessels.
The patient is still under observation, and occasionally re-
quires eserine to relieve pain and increased tension.
Case XII. — Mrs. M. R., aged sixty, has had periodic pains in
both eyes since three months, the right eye becoming first af-
fected, and accompanied by periodic obscuration of vision. The
nerves look atrophic, but not especially glaucomatous. The
tension is increased in both eyes. The fields are somewhat
limited.
The vision of the right = {■?■, and the left = )A\.
February 3d. — A sclerotomy was done on the right eye
Eserine was used.
llfth. — Tension normal, no pain.
18th. — Sclerotomy was done on the left eye.
March J^th.— The vision of the right eye = c°, of the left eye
20-
LXX-
11th. — Pain and increased tension in the left eye, which
soon gave way to eserine.
April 8th. — There was pain and increased tension in the left
eye, and an iridectomy was at once done, which completely re-
lieved the symptoms. The vision in the right eye = c1. and in
the left = go ; whereas on entering, the right eye was = and
the left was -Lxk-
Case XIII. — Mrs. S. A G., aged sixty-four, was admitted to
the hospital on May 15, 1884, with severe pain in the right
eye, which hail been constant since three weeks. The left eye
bad more recently become painful. The sight was rapidly low-
ering. The pupil of the right eye was widely dilated and oval.
Discs of both eyes atrophic, but having few glaucomatous char-
acteristics. Both eyeballs injected. The vision of the right eye
was perception of large objects; of the left, counted fingers at
three inches on the nasal side. Iridectomy was done on both
eyes on the day of admission.
Eight days afterward the tension was normal in the right
eye, but increased in the left eye. There was no perception of
light in the left, but the right eye counted fingers at two feet.
There were haemorrhages into the anterior chamber of each eye.
On the 29th the left eye counted fingers at fifteen feet, and the
right at six inches. Discharged June 23d.
Dr. Reed Burns, of Efonesdale, Pa., who referred her to
me, writes that the vision of the left eye = -§q ; and again on
July 16th, that the left eye is doing well but that the right is
painful and becoming cataractous. The patient returned April
3, 1885, with the right pupil occluded, and calcareous changes
in the cornea, with a red and painful globe. The left lens was
becoming cataractous. The right eyeball was at once enucleated.
The cataract in the left was not thought to be due to the
iridectomy.
Case XIV. — Washington L., aged forty-six. Ten years
since he received a wound in the left eye from a bit of iron,
which necessitated enucleation of the globe. Eight months ago
the right eye exhibited symptoms of glaucoma. On entering
the hospital the tension of the eyeball was increased, and the
nerve showed glaucomatous cupping, The vision = Eser-
ine was used with temporary benefit, but one week after ad-
mission it was found necessary to do an iridectomy. Eserine
was still continued. In one week the tension was normal,
there was no more pain, the redness had nearly disappeared
from the eyeball, and the vision =
Case XV. — Maggie VV., aged twenty- two. This patient has
had trachoma in both eyes for three years, and during the last
month there has been great pain in the right eye and tem-
ple. The cornea is hazy and anaesthetic, the anterior chamber
is shallow, and the eyeball too hard. Iridectomy was at once
done, eserine being used. The tension was soon reduced to the
normal and the pain was relieved. The patient counted fingers
at one foot, whereas before the operation she counted fingers at
four feet.
Case XVI. — Joseph D., aged forty-three, has had gradual
loss of vision since six months, without pain. The right eye
was first affected, and is now the worse of the two. Both
discs are deeply cupped. The pupils are moderately dilated,
and the anterior chambers are shallow. The right eye has
faint perception of light, and the left counts fingers at two feet.
The field is limited and extends from 30° to 45° around the
posterior pole. The tension is increased in each eye. A one-
grain solution of eserine was used three times daily. In a week
after the patient's entering the hospital Dr. Hepburn did a scle-
rotomy on the left eye, eserine being used in both eyes. Four-
teen days afterward the tension was normal in each eye. On
the next day sclerotomy was done on the right eye. Eserine
was used in both eyes. Perception of light in the right eye was
much improved. In the left eye the field is nearly normal
and the vision = Sc-
September lGth. — The right eye counted fingers at eighteen
inches.
30th. — There was increased tension in the left eye and eser-
ine was used.
October 22d. — She was discharged with vision improved,
but the field in the left had diminished to 70° by 20°, being
about three times the original size.
Case XVII. — Matthew R. R., aged fifty-four, has had symp-
toms of glaucoma simplex, dating back four years. There has
been no pain. There has been occasionally a halo about the
gas light. The fields are limited to about 20° in each eye.
The tension was slightly increased and the pupils moderately
dilated. The discs show glaucomatous excavation and appear
atrophic. The vision = Iridectomy was done on both
eyes at one sitting. The tension was reduced to the normal
but there was no change in the vision. Five years afterward
there was no change.
Case XVIII. — Mrs. T., aged fifty -seven, applied for treat-
ment July 23, 1889. Six months since, she had a severe pain in
the right, eye and temple, lasting a day or two. Since this
time she has had pain in the eye most of the time, except occa-
sional intervals of four or five days. One month since, she
noticed that the sight was lost and there was no perception of
light. There was increased tension and glaucomatous- excava-
tion of the nerve. In the left eye the vision = the tension
was slightly increased, and the nerve seemed to be physiologi-
cally excavated. Eserine was used in the right eye six times
daily, and in two days the pupil was much contracted and the
tension reduced to the normal. Did not return.
Case XIX. — Mrs. B., aged forty-two, was first seen January
29, 1890. At the age of fourteen a door fell upon her head,
wounding the left eye, and causing haemorrhage from the nose
and ears. She has seen badly out of this eye ever since, but
worse within two years. Since six months she has only per-
ception of light. There are numerous punctate opacities of
the cornea; the pupil is dilated, but responds slightly to light;
there are lenticular opacities and floating bodies in the vitreous.
The projection is imperfect; the nerve is so atrophic as to be
March 19, 1 802 J
HARTLEY: INTRACRANIAL NEURECTOMY.
317
indistinctly located, but tbero is no excavation. The tension is
slightly increased. The eye feels uncomfortable, but not posi-
tively painful. Eserine was used three times a day. The
pupil promptly contracted and the tension soon became nor-
mal. The eserine caused some pain, and was discontinued for
a short time.
December 20, 180 1. — The patient again presented herself,
saying that she had used the eserine daily ever since the last
record.
The eye shows normal tension, is not painful, and is doing
well. On November 2, 1891, the tension was increased, but
the eve was in fairly good condition. Eserine has been used
occasionally up to the present time and the eye is comfortable.
Case XX. — Mrs. W. C, aged sixty, eight years since had
rheumatism, which was accompanied by intense pain in the
righl eye. In a few days the sight of this eye was abolished.
Since that time there hive been occasional attacks of pain.
Five years ago the sight of the left eye was foggy, but there
was no pain. Three weeks ago it began to pain her, and the
sight grew worse. The pupil is dilated and the anterior cham-
ber is shallow ; there is no sight. The right eye has a scleral
staphyloma, with a similar condition otherwise as in the left.
Sclerotomy was at once done on the right eye and iridectomy
on the left. In three weeks the patient was discharged, having
no pain and with normal tension.
In all, there were twenty cases and thirty-two eyes.
Of these, there were four cases of acute inflammatory
glaucoma, one eye only being affected.
Of chronic inflammatory glaucoma there were twelve
cases and seventeen eyes. Of glaucoma simplex there were
two cases and four eyes. There was one case and one eye
with hemorrhagic glaucoma. There were four cases of
glaucoma absolutum, with five eyes affected.
Of the cases of acute inflammatory glaucoma, Case I
was completely relieved by iridectomy ; the same of Case
IT. Case III was treated by eserine before and after scle-
rotomy, with vision improved from t5e to lxx. Case IV was
relieved by eserine, leeches, and pilocarpine injections;
vision not tested.
Of the cases of chronic inflammatory glaucoma, the right
eye of Case V was completely relieved by iridectomy (vision
xx'x from counting- fingers). The glaucoma was kept in
abeyance for two years by occasional paracentesis of the
cornea.
In Case VI iridectomy failed to relieve tension in each
eye, and sclerotomy succeeded. In Case VII iridectomy
relieved pain and tension, but did not affect the sight. The
cornea was punctured by the keratome with great difficulty,
although the instrument was in perfect order.
In Case VIII, right eye, pain and increased tension was
relieved by eserine for more than a year; vision — x&
from first to the present time.
In Case IX both eyes were affected, on which paracen-
tesis, sclerotomy, and iridectomy were done ; eserine was
used most of the time, even after the iridectomy, the last
treatment being pilocarpine and salicylate of sodium.
In Case X the patient was treated with benefit by eser-
ine, paracentesis, sclerotomy, and iridectomy.
Eserine was found to be of service even after the per-
formance of iridectomy.
In Case XI, left eye, the sight was improved by iridec-
tomy and eserine, from perception of light to counting
fingers at six feet.
In Case XII neither nerve was excavated, but both were
atrophic ; sclerotomy permanently benefited the right eye,
but iridectomy was needed in the left.
In Case XIII iridectomy was of temporary benefit to
both eyes, but ultimately the left was enucleated and the
right became cataractous.
In Case XIV the left eye was relieved by iridectomy
and eserine. In Case XV iridectomy relieved tension, but
lowered vision.
In Case XVI, of glaucoma simplex, sclerotomy and eser-
ine relieved tension in each eye, improved the right eye
from perception of light to counting fingers at eighteen
inches, and in the left from fingers at two feet to c%.
In Case XVII iridectomy relieved tension, but had no
effect on the vision.
In glaucoma absolutum in the right eye of Case XVIII,
the augmented tension was relieved by eserine.
In Case XIX, in the left eye, eserine has relieved aug-
mented tension for two years, and so far has rendered an
operation unnecessary.
In Case XX, increased tension in the right eye with
some pain has been relieved by sclerotomy, and the left
eye has been relieved by iridectomy. In the left eye of
Case V iridectomy induced intra-ocular haemorrhage which
necessitated enucleation.
Eserine was usually used in solutions of oue grain to the
ounce, but sometimes in two-grain solutions, and as often,
in some cases, as six times daily, without in a single in-
stance causing iritis, and only occasionally inducing pain.
It has been found useful in acute inflammatory glau-
coma, and in most of the cases of chronic inflammatory
glaucoma, even before, during, or after operations.
hi glaucoma absolutum it has succeeded often in reliev-
ing pain and augmented tension, and indefinitely warding
off operations.
Paracentesis of the cornea has met with some success in
temporarily relieving pain or increased tension in all forms
of glaucoma, and seems to be free from danger.
I N TEA CRANIAL NEURECTOMY
OF THE SECOND AND THIRD DIVISIONS OF
THE FIFTH NERVE.
A NEW METHOD*
By FRANK HARTLEY. M. I).
In my experience, Mr. President, one of the most dilli-
cult instances in which the surgeon is called upon to decide
upon the feasibility of further operative interference exists
in recurrences of pain following neurectomies or neuroto-
mies for persistent neuralgia. It is not always possible to
determine whether the seat of pain is situated beyond the
seat of the previous operation, whether a new painful branch
still uncut sends by irradiation the feeiing of pain in the
* Head before the New York Surgical Society, January 13, 1892.
318
HARTLEY: I XT I! A < A'.
1 XI A L NEU RECTO M I '.
[ N. Y. MtD. JolTB.,
nerves operated on, or whether pressure or enlargement of
the proximal end of the nerve is the cause of the recurrence.
With such uncertainty we can not be reasonably certain
of a good prognosis until all branches of the trunk in which
pain is present are cut.
In many of the operations for the relief of prosopalgia
involving the second and third divisions of the fifth nerve,
the difficult technique, the small field of operation, the ar-
teries requiring ligature to preserve a clear field for the
neurectomy, are important considerations. Especially is this
the case where previous neurectomies have been done in
the field of the operation. The history of the case which
I wish to present this evening is as follows:
J. IX, aged forty-six years, married. England, salesman, ad-
mitted to Roosevelt Hospital on August 8, 1891. The patient's
father died of pleurisy; in oilier respects his family history is
negative.
Pergonal History. — Patient denies rheumatism and syphilis.
He has had malarial disease, but in other respects has been
perfectly healthy.
In December, 1882, he was seized with a sharp neuralgic
pain, at first referred to a spot about two inches to the left of
the symphysis menti. This pain radiated over the whole left
side of the face and head, involving the temporal region as far
as the temporal ridge, and the left side of the tongue and mouth
over the upper and lower jaws. The left orbit was involved in
this attack.
This attack lasted eighteen hours, and, after an interval of
four days, during which time momentary attacks of pain were
present in the same region, it reappeared. The second attack
was more severe, and iasted two or three days. For the next
two years lie had constant pain over this region and was treat-
ed medicinally with aconitine and morphine.
In September. 1884, the infra-orbital nerve, with Meckel's
ganglion, was removed.
From the scars left, one would judge that either Wagner's
or Chavasse's operation was performed at this time.
For four or five weeks he had partial relief. The constant
pain disappeared, but the spasmodic twitchings continued. It
soon reappeared, however, and th.e patient was again treated
with aconitine and morphine.
He had at this time thirty-one teeth drawn, thinking that
the origin of the pain was located in them.
After eighteen nmnths (1886), section of the inferior dental
nerve was made by the same surgeon. The scars would lead
one to think that Velpeau"s operation was performed at this
time.
On recovering from the ether he had an attack lasting sev-
enteen days. From that time to the present he has had no
change in his condition. The pain has been constant, except
for an occasional period of one or two days. The contractions in
the muscles of the face amount to forty in about thirty minutes.
Owing t<> the previous operations and Ibe involvement of
the lingual and auriculo-temporal nerves, I decided to attack
the nerve at a point where I could divide the second and third
divisions of the fifth nerve completely bjT one operation. The
operation intended was to attack the nerve on the inner surface
of the skull outside the dura mater, to isolate the second and
third branches completely, to divide and resect as long a portion
as possible. The advantages thought to exist in this method
over I'ancoast's. or its modifications by Kronlein. ('rede, and Salz-
er, or I.uckc's operation, were the easy access to the nerve, the
comparatively large field for work, the rapidity with which the
operation could be done, and the small amount of hemorrhage.
The disadvantage was the inability to resect as long a piece as
could be done in some of the other methods. This disadvantage
I am certain can be overcome in the future when the knowl-
edge of the degree of adhesion of the fifth nerve and dura
mater is better appreciated. It is not difficult to go beyond the
Gasserian ganglion.
This I did not appreciate fully before doing the operation
on August 15, 1891. The operation performed was one in which
an omega shaped incision was made, having it* base at the
zygoma and measuring a distance marked by a line drawn from
the external angular process of the frontal hone to the tragus of
the ear.
The curved and rounded portion of this incision reached as
high as the supratemporal ridge, the diameter of said circle
being three inches. The skin and deeper tissues were cut in
the shape of the Greek capital letter omega, a method of incision
I first saw recommended by Uhle two or three years ago. This
incision was carried down to the periosteum of the skull in all
portions of the incision, except in the straight part at the base;
the tissues were then retracted and the periosteum divided
upon the bone in the same direction and as far as the straight
part at the base.
With a chisel a groove was cut in the bone corresponding to
the divided periosteum. This groove went to the vitreous plate,
except at the upper angle over the rounded portion where it in-
cluded the vitreous plate.
A periosteum elevator was here inserted and used as a lever
to snap the bone on a line between the ends of the circular por-
tion of the incision. In this way the breakage occurs along
the lower portion of the wound, and a flap, consisting of skin,
muscle, periosteum, and bone is thrown down, exposing the
dura mater over a circular area of three inches in diameter.
The middle meningeal artery was then tied, the dura mater was-
then separated from tlie bone, and the floor of the middle fossa
of the skull was exposed. Broad retractors were used to raise
the dura mater with the brain and to expose the foramen ro-
tundum and the foramen ovale. The haemorrhage was stopped
by sponge pressure. The exposure of the first, second, and third
divisions of the tilth nerve, together with the carotid artery and
cavernous sinus, was exceedingly good.
The second and third divisions were isolated at the foramen
rotnndum and the foramen ovale, and, by slight pressure upon
the dura mater, it could be stripped from the nerves to beyond
the Gasserian ganglion. These were divided with a tenotome
at the foramen rotnndum and the foramen ovale, and that part
between these and a point beyond the Gasserian ganglion was
excised. As this amount of nerve is not very great, the ends
of the nerves were pushed through the two foramina so as, if
po-sible, to interfere with any reunion. In the retraction of
the dura mater, owing to imperfect instruments, the third,
fourth, and sixth nerves were somewhat injured. As no bleed-
ing was present, the brain was allowed to fill the fos-a. The
flap — consisting of bone, periosteum, muscle, and skin — was
replaced. The irregular edge of the vitreous plate which re-
mained attached to the bone not involved in the flap acted as a
shelf on which the flap rested and prevented its falling in upon
the dura mater. The periosteum was stitched, the muscle sut-
ured in place, and the skin sewn with silk. One drainage-tube
was inserted at the lower angle; an antiseptic dressing was ap-
plied. Time of operation, one -hour and forty minutes; the pa-
tient was carried to the ward in good condition. Following the
operation, August 16th, ptosis of the left upper lid appeared,
together with double vision and inability to move the eye. The
patient was entirely free from pain and continued to do well for
one week.
August 23d. — To-day a slight dermatitis appeared over the
March 19, 18K2.-J ABBE: A TOOTH-PLATE IN TEE (ESOPHAGUS MORE THAN A YEAR.
319
area of operation, which is treated with ichthyol (ten per cent.)
and bichloride irrigation.
On August 24th Dr. W. Vought examined the patient for
me, and reported as follows: "The area of anaesthesia may be
seen upon the shaded portion of the drawing. The other areas
were the left side of the mucous membrane of the mouth over
the upper and lower jaws, of the soft palate, of the anterior
two thirds of the left side of the tongue, of the left conjunctiva
and cornea, and of the left nostril. Muscular paralysis, com-
plete, of the left buccinator, the pterygoids, and the left occipito-
frontal'^ (frontal portion); almost complete, of all the external
muscles of the eye. Ptosis; pupil normal. Nerves divided:
the second and third
divisions of the fifth
nerve, the branch
of the seventh to
the occipito-fronta-
lis ; injured, the
third, fourth, and
sixth nerves. The
ophthalmoplegia ex-
terna I should give
a fair prognosis for
spontaneous recov-
ery, as you will see
by examining the
patient that slight
movement of all the
eye muscles is pres-
ent, which leads me
to think the nerves
have not been di-
vided, but merely
■severely injured. The ptosis could be corrected at any time."
August 30th. — Patient is to-day discharged cured and 're-
turned to the Vanderbilt Clinic, Nervous Department.
September 30th. — Patient has recovered from his paresis in
the third nerve; the double vision, ptosis, and inability to use tbe
third nerve have entirely disappeared. The paralysis of the
pterygoids, temporal, and masseter muscles produced by the
division of the motor portion of the fifth seems to have incom-
moded him to a very slight extent. The false teeth worn in the
lower jaw before the operation fit quite accurately their oppo-
nents in the upper. Protraction and retraction of the lower
jaw seem to be diminished, but elevation and depression of the
lower jaw seem good. As the patient has chewed since 1882 all
his food on the side opposite to the present paralysis, he has not
been distressed by the division of the motor portion of the fifth.
The patient informs me that he is at present entirely free
from pain and has gained in weight sixteen pounds.
I wish to say in conclusion that this method of reaching
the base of the skull I have employed in the posterior fossa
in a case of suppurative meningitis following otitis media.
Though the case had a fatal issue, the exposure of the pos-
terior fossa was- good.
January 13, 1892.
The Navy Register for 1892.— The recently published Register of
the Navy shows the following changes in the medical corps : The re-
tirement of Medical Directors J. Y. Taylor and T. J. Turner resulted in
the promotion of Medical Inspectors G. S. Beaidsley and Henry M.
Wells. These promotions and the retirement of Medical Inspector
Theoron Woolverton have given a "step" to Surgeons Edward Kersh-
ner, J. H. Trvon, and W. H. Jones.
A TOOT II-PL ATE
LODGED IN THE LOWER (ESOPHAGUS
MORE THAN A YEAR.
REMOVED BY EXTERNAL (ESOPHAGOTOMY*
By ROBERT ABBE, M. D.,
SURGEON TO ST. LUKE'S HOSPITAL.
In June last a man of thirty-five came under my care with a
history of oesophageal stricture, lie was emaciated and looked
like a patient in the third stage of phthisis. He had been run-
ning down in health during the previous year, and of late had
lost a pound daily. Attempts at swallowing produced severe
coughing and gagging. A few spoonfuls of fluid could be got
down at a time, but even that usually caused him to choke.
More often a considerable part of what he swallowed regurgi-
tated in a few minutes. He had been for three weeks under
medical care in the hospital when he was transferred to my
service. Not even the smallest oesophageal bougie could be got
past the stricture, which was four inches below the cricoid. As
this was an unusual site for a malignant growth, which it was
thought to be, I asked the man if he had ever swallowed any-
thing which might have stuck in his throat. He said "No."
But on the following day he said that since I had asked him he
remembered that on Decoration day the previous year he was
intoxicated, and on coming to himself the next day found that
he had lost his teeth and had a new set made at once. Some
little trouble in swallowing made him visit a physician a day or
two afterward, and during the next two months he visited two
or three physicians, and finally entered a Philadelphia hospital.
On all these occasions he expressed the fear that he might have
swallowed the teeth, but, after repeated examinations with soft
bougies, and being always told that nothing could be felt, he dis-
missed the matter from his mind, and was treated during the
remainder of the year as a dyspeptic or consumptive.
Pain was never a prominent symptom, but the hard gagging,
choking, and regurgitation of food, together with cough and pro-
gressive emaciation, made up the sum of his symptoms.
On hearing that he had possibly swallowed a hard substance,
I at once passed into the throat a metal bougie a boule, and was
gratified to feel the sharp]click of the tooth-plate, which the soft
gum-elastic bougies had never disclosed.
I regard that point as one of much importance in examina-
tions of the oesophagus for foreign bodies. I was wholly unable
to pass even the smallest bougie of any description beyond the
obstruction. The bougie a boule was arrested between nine and
ten inches from the incisor teeth.
On the following day I operated with the assistance of Dr.
Murray.
Under anaesthesia the throat was palpated, to locate if possi-
ble the site of the obstruction, but nothing was to be felt. The
usual three-inch incision was made as low as possible on the left
side at the edge of the sterno-mastoid muscle. The omo-hyoid
was divided and the superior thyreoid artery. The lobe of the
thyreoid gland was found wrapped round the oesophagus quite
well toward its posterior surface, and caused some delay in get-
ting at the latter. Its arborescent surface vessels made a good
guide to its recognition, as distinguished from the oesophagus,
which was hidden from view by the thyreoid lateral lobe. A
large, easily bent block-tin bougie was used through the mouth
to make the oesophagus prominent. The latter I incised verti-
cally for an inch and a quarter, and through (his gap my finger
felt the plate an inch and a half below the suprasternal noteh.
Loops of silk through the cut edges of the o'sophagus held them
* Head before the New York Surgical Society.
320
RABINO VITCH: THE REDUCTION OF FEVER.
[N. Y. Med. Jook.,
apart without damage during the extraction. A long curved
dressing forceps soon removed it, with the aid of one finger of
the other hand, which had
to loosen each imbedded
hooked end of the tooth-
plate several times during
its withdrawal.
The plate lay crossways
with its concavity upward,
the false teeth pointing for-
ward. The (esophagus was
dilated into a fusiform pouch in which the plate could move.
A large stomach tube was readily passed into the stomach after
its removal.
Believing, as I said five years since before this society, that
immediate suturing of the oesophagus was practicable and would
give less trouble afterward, I used fine catgut to make continu-
ous suture of the submucous and muscular coats of this tube;
the external wound was tamponed lightly with iodoform gauze.
For the first day afterward nutrient enemata were given.
During the second day sterilized milk was given through a small
soft-rubber tube slipped well down the oesophagus.
The patient, was greatly annoyed by copious secretions of
laryngeal and salivary fluid.
During the third day a quart of sterilized milk was allowed
the patient to swallow; nutrient enemata were also continued.
The iodoform gauze tampon was replaced by a small drain tube.
For ten days boiled fluids were allowed to be drank. The
(esophagus incision healed primarily, and not a drop of fluid ap-
peared in the neck.
The external part of the wound healed by granulation.
Soft solids were allowed on the eleventh day.
On the fifteenth day he was discharged, with the wound
healed. He had gained steadily in weight, and was taking a full-
sized oesophageal bougie.
Two months later the average-sized bougie was occasionally
passed and he was improving.
OX THE REDUCTION OF FEVER,
PARTICULARLY IN TYPHOID.
THE COMPARATIVE VALUE OF ANTIPYRETICS AND
THE COLD-WATER TREATMENT.
By LOUISE G. RABINO VITCH, B. S. (Paris), M. D.,
LATE RESIDENT PHYSICIAN, PHILADELPHIA HOSPITAL ;
ASSISTANT PHYSICIAN, INSANE ASYLUM. BLACKWELL'S ISLAND. N. Y.
It is hardly necessary to remind one of the differences of
opinion as to the cause of fever. Most eminent authors dif-
fer as to whether it is due to increased production or de-
creased dissipation of heat. Any one who asks the ques-
tion what fever is clue to will find ample field for theorizing
by reading MacAlister's comparison of fever as quoted by
Dr. Isaac Ott in his work on Modern Antipyretics, which
reads thus :
Suppose a tall vessel containing water, the level of the wa-
ter representing temperature. Let two pipes be connected with
this vessel, one conveying water, the other carrying it off. Let
the irdet and exit tubes be each provided with a stop-cock, and
let the two stop-cocks be connected by a rigid link which insures
that they always turn together and by the same amount. If, to
start with, the inflow and outflow are equ:d, then, however ,1
move the linked stop-cocks, the height of the water will be the
same. Now remove the rigid link, and connect the stop-cocks
by a spiral spring. If you move the inflow stop-cock so as to
increase the inflow, the outflow one will not at once follow, and
the balance being broken, the level of water will rise But
shortly the elasticity of the spring comes into activity, the out-
flow is equal to the inflow, and the rise will cease, but the new
high level will be maintained. Every movement of either stop-
cock will affect the level, which will fluctuate accordingly, but
its height at any moment will not be an index of the amount of
inflow at that time. The inflow may be slight while the level is
high. If, now, you substitute heat production for inflow and
heat dissipation for outflow, the rigid link will represent the
healthy thermotaxic mechanism; then when this is weakened or
relaxed or broken the steadiness of the normal level is impos-
sible.
Dr. Isaac Ott, in his work on Modern Antipyretics, and
Dr. William A. Carter, in his prize essay on Heat Produc-
tion and Heat Dissipation in the Normal and Febrile States,
have proved abundantly that temperature, heat production,
and heat dissipation are independent of each other, and that
all are governed by special centers in the nervous system.
Dr. Ott gives very convincing graphic tracings of his ex-
periments, showing a case of induced septic fever where the
heat production reaches its height some hours before the
temperature curve, and the curve of heat dissipation is " lag-
ging," as he styles it, behind that of heat production, al-
though it follows it in its ascent. Another case was that
where, after a starvation period, a high temperature took
place while both heat production and dissipation had fallen
below the normal. A third case was one of malarial dis-
ease, showing that heat production was at its height during
the chill, that heat dissipation was not so great as at other
times, and that after the fever had reached its height the
previous rise was succeeded by an enormous fall of heat
production; and it illustrated well how high temperature
was not an index of the height of heat production. Heat
dissipation is at its maximum during the stage of defer-
vescence. He concludes by stating that the basal thermo-
taxic centers are the most important factors in the tempera-
ture phenomena of fever, and by his experiments urges the
inference that the thermogenic, thermotaxic, and thermo-
lytic centers are reflex in their activity.
In face of the enthusiasm of some physicians as to thei
use of the cold-bath treatment for reducing temperature, it
is very convenient to stand by this statement. By reason of
the intimate connection of the heat centers with the periph-
eral nerves, as has ably been shown in Dr. Ott's last work,
the tonic influence of the water is conveyed to the thermic
centers, which become again enabled to govern the body
heat, whatever was the cause of disturbance of harmony be-j
tween those centers.
Dr. Mary Putnam Jacobi reports a severe, case of typhoidH
fever {Times and Register, 1890, p. 34) which was treated!
by cold baths. After the second day of treatment and the!
tenth day of the disease, the temperature reached its maxi-fl
mum, lOG^0 F., and never reached that again ; from 10.">r V.
it was reduced to 98*8 by a cold bath, and it never reache
any alarming degree till recovery took place, the latter hav
ing come at an earlier period than is usual even in a mil
case.
The cold-bath treatment is contrafebrile and not antipy
Starch 19, 1892..)
T&ABINO VITCH: THE REDUCTION OF FEVER.
3;
relic, Dr. Jacobi says, and she remarks that it is difficult
to sec, without serious reason, why the beneficial effect is
brought about by diminishing the temperature 2° or 3' F.
w hen the latter result always implies performance of work
in and by the nervous system, which is already overtaxed
bv work. The question is very interesting. Perhaps it can
be answered, if, as represented above, the thermogenic, ther-
(notaxic, and thermolytic centers are intimately related in
their action with the peripheral nerves. From Dr. Ott's
standpoint, fever is due -to lack of harmony between these
centers, whatever may cause it. Fever does not necessarily
imply either increased heat-production or diminished heat-
I dissipation, and it may manifest itself when both the latter
arc below the normal. Water acts as a sedative on those
centers through the peripheral nerves, restoration of har-
mony between them follows, and pyrexia is reduced without
involving the nervous system in the work for new produc-
tion of heat.
To come nearer the subject of the cold-water treatment,
; Brandt advocates free nutritious feeding of the patient sub-
jected to his method of treatment, in order to enable him
to sustain the enormous drain of his vital forces; with this,
and by strictly carrying out the rules which he gives for
bathing a typhoid case, recovery must ensue.
Dr. L. Bouveret [Lyon med., 1891, lxvi, 531, 565 ; lxvii,
I 113) treated two hundred typhoid cases by Brandt's meth-
I od, and says that it is his experience any antipyretic agents
used with the cold-water treatment protracted the course of
the disease. In one set of a hundred cases he had 7'5 per
cent, of deaths, and in another hundred cases only '■'< per
l cent., though some cases were of severe type. He corrobo-
,1 rates Brandt's statement by saying that if a young patient
dies of typhoid fever there was probably an imperfect point
in the treatment ; the patient was not treated by cold baths,
1 was not bathed from the beginning, or was not bathed after
| Brandt's method.
Dr. J. E. Graham (Canad. Pract., Toronto, 1891, xvi,
53-01) collected a large number of statistics on the subject
I and thinks that high temperature can always be controlled
by cold sponging, and agrees with Dr. H. C. Wood that
i cold baths are much safer than are antipyretic drugs.
Antipyretic drugs in typhoid fever always remind the
writer of this paper of a very severe case of typhoid fever
in a girl, twelve years of age, who was admitted to the
< medical wards of Philadelphia Hospital.
She was nursing her mother in typhoid fever, and was taken
m ill with the same. She was cared for by a trained nurse at
home. The temperature during her first day of illness (the day
when she complained to the nurse of feeling sick') was 103*8° ;
J pulse, 100 ; respiration. 2-1. The temperature, pulse, and res-
piration were increasing progressively during the seven days of
her illness at home. On admission to the hospital, her appear-
ance was that of the severest type of typhoid fever. Tempera-
1 ture, 104"4° ; pulse, 102; respiration, 2(i. She was stupid and
at times in active delirium. This condition continued through-
'lifi out the period of her illness, and the temperature, pulse, and
, respiration were increasing progressively, with some fluctuations
jjl only, which were due to frequent doses of acetanilide (two grains
< at a time), or occasional sponging. There were no typhoid
spots, and she had a soft, blowing, mitral regurgitant murmur.
From the seventh to the fifteenth day of her illness the teL
perature was between 105° and 102° F., with two exception
(101-8°) ; on the fifteenth day reached 99-8° F., remained so foi
two hours, and ascended to 103-4° ; from the fifteenth to the
eighteenth day remained between 101° and 104°; fluctuated be-
tween 100° and 105° F. till the thirty-first day of her illness,
when she died. The fluctuations were invariably caused by the
frequent, and repeated use of two-grain doses of acetanilide,
which always reduced the temperature about 2° F., but the re-
duction was always of very short duration. The pulse was be-
tween 96 and 148, respiration between 24 and 60 a minute,
throughout the course of the disease.
Several days after admission peculiar spots made their ap-
pearance on the body, apparently due to capillary embola. This-
view was held by all of the physicians who saw the case, and
with the presence of the soft mitral regurgitation it was thought
to be a case of typhoid complicated by septic endocarditis, the
latter being the cause of the capillary emboli. On the twenty-
ninth day of the disease the girl had a profu-e intestinal haemor-
rhage, she became more delirious than before, the haemorrhages
which followed were very large, from one to two pints at a time
and too often repeated by day and night till the thirty-first day /
of the disease to give her a chance to recover.
The post-mortem examination revealed the most intensely
engorged, infiltrated, and ulcerated lower bowel that the writer
ever saw in the course of several hundred autopsies. There
was no endocarditis, and no other pathological condition except
profound anaemia of all the tissues and a very small cicatrix in
a pulmonary apex.
Acetanilide affects the heart by depressing it profound-
ly ; it causes cyanosis, aud increases arterial tension. \\ hen
a heart is beating at a rate of from 96 to 148 per minute it
has already an immense amount of work to do. To depress
such a heart and to increase the arterial tension seems really
poor therapy. Had we used cold-water treatment the child
would undoubtedly have made a good recovery.
In the subsequent cases of typhoid fever the writer
never used antipyrine or acetanilide as an antipyretic. Cold
water, either in the form of irrigation, cold pack, sponge
bath, or plunge bath, was the stand-by as an antithermic.
While in charge of the men's medical wards at Philadel-
phia Hospital the writer had under her care nine typhoid
patients which included her own and Dr. S. M. Taylor's, who
was sick at the same time. Three of them had pneumonia,
and one left pleurisy with effusion, which extended to the
third rib, and pericarditis with effusion; the hearl was dis-
placed almost entirely to the right, and for three days the
cardiac sounds could not be heard, although the pulse was
perceptible.
This case was of special interest. It was that of a young man,
twenty-one years of age, tall and robust in appearance. He
became delirious and violent and attempted to jump out of the
window ; his friends thought he was insane and sent for the am-
bulance. The physician diagnosticated the case at once as one of
typhoid and assigned him to the medical wards. On admission,
he was in profound stupor and had a high temperature and rapid
pulse and respirations. The plunge bath could not conveniently
be used, but we gave him cold-water treatment by either irri-
gating him, keeping him in a wet pack, or sponging him almost
every hour. Aside from the above-mentioned severe complica-
tions, he had intestinal haemorrhages and double acute otitis
media with perforation of both drums, lie did well under the
322
VAN ALLEN: A CASE OF CONGESTION OF THE LUNGS. |N. Y. Mei». Jo
a]
eatment. The effusion in tlie left chest and pericardium
gradually disappeared, and lie made a good recovery in a much
•horter time than he would have under acetanilide treatment.
The three patients that had pneumonia were treated lib-
erally by the cold water in whatever form it was most con-
venient regardless of that complication, and in no case was
a cold bath administered without reducing the temperature
at least two degrees. The patients always felt better, and
usually enjoyed a long and refreshing sleep after it. All of
the nine cases yielded well to the treatment, and at no time
was there room for regret as to the use of the cold water.
In 1871 Dr. "Wilson Fox (London) used the plunge bath
liberally for reducing high rheumatic fever. lie narrates
two cases — one of a woman whose highest temperature
was 109-1° F. and who had pericarditis as a complication;
another, one of a man, whose highest temperature was 107-3°
F. and who had double pneumonia, double pleurisy with
effusion, and pericarditis with effusion. In this latter
case the cold applications were at one time used continu-
ously for eight days, and both cases made a good recovery.
Dr. Wilson Fox remarks that the pulmonary and cardiac
complications tend to resolution under this treatment.
There is a very excellent article On the Treatment of
Typhoid Fever by Prolonged Immersion in Water [Lancet,
1890, pp. 633, 690), by Dr. James Barr. He has bath-
tubs in his hospital specially arranged so that the patient
can remain in the bath for days, not to be removed until
the temperature is reduced to the desired degree — 100° to
99° F. He has treated all his cases by this method since
accommodations were made for it, and records most fortu-
nate results. The high temperature is broken up at an
earlier time than with any other treatment ; complications
— such as intestinal ulceration, hemorrhages, diarrhoea, etc.
— make their invasion far less frequently than under any
other treatment, and pulmonary and cardiac complications
yield well to the same water treatment. The death-rate is
much below that of ordinary antipyretic treatment.
The highest temperature the writer of this paper ever
had to deal with was 109° F. It was in a case of puerpe-
ral septicemia. The woman was delivered outside of the
hospital, and, on her admission, pieces of membrane and
placenta came out after the routine intra-uterine douche
which is usually administered to women who come to the
hospital after having been confined at home. It was a very
alarming case. Quinine, acetanilide, antipyrine, cold spong-
ing, and intra-uterine douches were used, but it never oc-
curred to us to put the patient in a cold plunge bath, as she
was a puerperal and not a medical patient. After a pro-
tracted illness the patient recovered; but any patient with
marked fever that comes under my treatment hereafter,
especially with a temperature of 109° F., whether of puer-
peral, rheumatic, or typhoid nature, will be put into a cold
plunge hath.
Only recently I had a severe case of typhoid fever com-
plicated by pneumonia and acute nephritis, the highest tem-
perature reached being 106° F. Two grains of acetanilide
were given in the morning; the patient became cyanosed,
and her pulse was almost imperceptible for the following
i welve hours.
A fatal case of acetanilide poisoning in typhoid fever is
reported by Dr. Granville Macgowan {Southern California
Practitioner, 1890, p. 379), and he now condemns entirely
the use of antipyretic drugs in typhoid fever.
To conclude, the following tables may be found of in-
terest :
VbffPt Tablets of 8,325 Cases, as quoted by Dr. Simon Baruch (Jour,
of the Am. Med. Assoc., 1891, xvi, ,'
Combined
treatment.
Pure bath
treatment.
Mortality
6 • 7 per ct.
2 • 7 per ct.
Average hospital stay
40 days.
47-3 days.
102
65-2
Average daily number of stools for each person.
19
0-7
The following table is given by Dr. J. C. Wilson, of
1'hiladelphia (Medical News, vol. lvii, 1890, p. 588), the
cases of which treated at the German Hospital were his
own :
Hospital.
Year.
Number of
cases.
Average num-
ber of days in
hospital.
Number of
deaths.
Percent, of
deatlis.
Pennsylvania.
1889
31
38 .
5
1ft- 1
Pennsylvania .
1890
46
37
6
13-4
Episcopal ....
1889
69
44
9
13-04
Episcopal ....
1890
40
51
5
12-5
St. Agnes. . . .
1889
19
36
2
10-5
St. Agnes ....
1890
15
34
4
26-6 1
German
1890
50
36-9
1
1889
41
36-5
4
9-75
Treatment.
Expectant.
Symptomatic.
Intestinal antiseptics.
Mixed internal and ex-
ternal antipyretics; no
baths.
Expectant-symptomatic.
Ten of these were treated
with carbolized iodine,
and 40 strictly by cold
baths.
Expectant-symptomatic. ■
A CASE OF CONGESTION OF THE LUNGS.
TREATMENT BY PHLEBOTOMY.
By H. W. VAN ALLEN, M. D.,
SPRINGFIELD, MASS.
As the time of congestion of the lungs, pneumonia, and
pleurisy is upon us, I am constrained to report the follow-
ing case, especially for the benefit of the younger portion
of the profession, some of whom, Hare justly fears, " would
hardly know how to bleed if called to do so at a crisis."
The case occurred at the Springfield Hospital during my
service as house physician, and is reported that it may be
an aid in bringing the profession to a more kindly feeling
toward venesection :
A. A., aged nineteen years, single, Canadian, a laborer, o
good previous health, employed at the hospital. He was thor-
oughly drenched in a rain storm during the evening of January
18, 1891. I saw him at 11 p.m., when he complained of noth-
ing. At 7 a. m. the next day I was called to see him where he
had been found in bed, gasping for breath, by another employee.
He was removed to one of the wards for examination and treat-
ment. His efforts were given so entirely to respiration that
the subjective examination was limited. It was as follows:
Severe pain over the heart, constant and cutting in character;
cough absent; no expectoration. He said he had had a chill at
March 19, 1892".]
LEADING ARTICLES.
323
3 a. M Objective examination : Temperature, 98-2° F. ; pulse,
7<i, full and bounding in character ; respirations, 52 a minute ;
nervous system unaffected. Examination of the chest : (a) In-
spection : Form, normal ; respiratory movements very labored
and shallow and at times of the Cheyne-Stokes character; the
apex-beat of the heart was in its normal place and very strong ;
the veins in the neck were pulsating, (b) Palpation : Vocal
fremitus normal, (r) Percussion: No dullness; at least the
same on each side, (d) Auscultation: Suberepitant rales, espe-
cially over the left chest; vocal resonance normal.
Examination of the abdomen was negative.
The patient grew worse rapidly. In an hour the respira-
tions at one time would reach 76 a minute and at others would
cease entirely, so that it was needful to stroke the chest with a
wet towel and use artificial respiration. Death seemed almost
unavoidable. It was decided to do phlebotomy, and this was
done by the attending physician, Dr. C. P. Hooker. The relief
from the abstraction of four ounces of blood was almost imme-
diate, as the patient thought he was entirely cured. He laughed
with the attendants and complained of being hungry. Later,
as his heart showed some signs of weakness, he was ordered
ten grains of ammonium carbonate at hour intervals, but it was
soon discontinued. The paroxysms of dyspnoea increased again
in severity and frequency until it became needful to abstract
four ounces more of blood, with a repetition of the former result.
Later there wa6 a return of the dyspnoea with lessened severity.
Hypodermic injections of an eighth of a grain of morphine with
one two-hundredth of a grain of atropine were given with good
results. These were continued during the night.
During the next two days the dyspnoea gradually decreased.
All physical explorations of chest were negative, and at no time
did his temperature rise to 100° or his pulse to 90. A two-by-
three-inch blister had been drawn over the heart.
On January 21st the patient began to expectorate large
quantities of thin, bloody fluid. From this time he made an
uninterrupted recovery, and was able to resume his usual occu-
pation in a week from his time of admission.
An International Periodical Congress of Gynaecology and Obstet-
rics.— The Belgian Society of Gynaecology and Obstetrics, under the
patronage of the Belgian Government, has taken the initiative in or-
ganizing the International Periodical Congress of Gynaecology and Ob-
Stetrics, the first session of which will be held in Brussels, September
14 to 19 inclusive, 1892. Three leading questions will be offered for
discussion : Pelvic Suppurations (" Referee," Dr. Paul Segond, of Paris);
Extra-uterine Pregnancy ("Referee," Dr. A. Martin, of Berlin); and
Placenta Praevia (" Referee," Dr. D. Berry Hart, of Edinburgh).
All communications pertaining to this congress should be mailed
directly to the American secretary, Dr. F. Henrotin, 363 La Salle
Avenue, Chicago, who will promptly furnish all information. All noti-
fications to be forwarded should be received by August 1st.
The Eleventh International Medical Congreis. — The congress that
is to meet in Rome in 1893 has undergone preliminary organization by
the election of Professor Guido Baccelli as president and Professor
Edoardo Maragliano as secretary general. Communications, if not
personal to the president, should be addressed to Professor E. Mara-
gliano, Istituto di Clinica Medica, Ospedale Patnmatone, Genoa,
Italy. As at present arranged, the congress is to meet in September.
Changes of Address.— Dr. Robert H. M. Dawbarn, to No. 1 \5 West
Seventy-fourth Street; Dr. P. J. Leviseur, to No. K4o Madison Ave-
nue; Dr. Max Rosenthal, to No. 130 East Eighty-second Street; Dr.
Sebastian J. Wimmer, to No. 129 West Sixty-first Street.
The Conviction of an Unlicensed Practitioner. — Recorder South
has sentenced one Max S. (Jiiggenheim to suffer two hundred days' im-
prisonment and to pay a fine of SI 50 for practicing medicine without
a license or a diploma.
THE
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by Edited by
D. Appleton & Co. Frank P. Foster, M. D. •
NEW YORK, SATURDAY, MARCH 19, 1892.
A BILL TO PREVENT THE ADULTERATION OF FOOD AND
DRUGS.
The United States Senate has just passed a law providing
for the organization of a food section of the chemical division
of the Department of Agriculture, having for its duty the
analysis of foods and drugs offered for sa\e in any State or
Territory other than that in which they are produced. The
bill prohibits the introduction into any State or Territory
from any other State or Territory or foreign country of
any article of food or any drug that is adulterated or incor-
rectly branded ; and violation of this provision is a misde-
meanor punishable by a fine not exceeding two hundred dollars
for the first offense and three hundred dollars for each subse-
quent offense, and by a year's imprisonment.
The term food is defined as including all articles, whether
simple or compound, used as food or drink by man. The terra
drug includes all medicines for internal or external use; and
they are considered to be adulterated when they differ from the
standard of strength, purity, or quality recognized in the
United States Pharmacopoeia or other standard works, or when
they are sold in imitation of or under the specific name of
another article, or when they are mixed, colored, powdered, or
stained so as to deceive the purchaser, or when poisonous or
injurious ingredients have been added to them, or when, in the
case of foods, the article consists in whole or in part of a dis-
eased, filthy, decomposed, or putrid animal or vegetable sub-
stance, or of any portion of an animal that is unfit for food.
If the label or brand on the package containing the food or
drug plainly indicates that it is a mixture, compound, combina-
tion, or blend, or if it is unavoidably mixed with some extra-
neous substance in the process of collection or preparation, or
if a substance is added so as to fit the article for carriage or
consumption, and not to increase the bulk fraudulently, it shall
not be deemed to be adulterated.
The law further provides that the manufacturer or seller of
any drug or article of food must furnish samples to the agents
of the Secretary of Agriculture, and refusal to do this is pun-
ishable by a fine; also that these persons shall, in the case of
adulteration, in addition to the fine, pay all the costs of inspec-
tion and analysis.
While this act will probably be opposed by those who
deprecate the assumption of prerogatives of the States by the
National Government, still it need not interfere with the exer-
cise of police power by any State having existing laws relating
to the adulteration of food and drugs. But, as so many of our
States have no laws on this subject, and as the enactment of
such laws is opposed by interested persons, and fails in con-
324
sequence of their opposition, the community at large must wel-
come this measure as calculated to farther the welfare of its
citizens.
WILL-TRAINING AS A THERAPEUTIC MEASURE.
Education as a preventive and cure of disease is a subject
of special interest and wide import. To the strong education
is a fortune ; to the weak it is a necessity, like bread and air.
Without it the weak easily become the vicious, the unbalanced,
and sometimes the insane. The training of the will is the vital
part of education. It has already effected remarkable results
among the mentally deficient and among the insane. The
work begun at the Bicetre in Paris by the late Dr. Edward
Seguin for the amelioration of idiotic children is now carried
on with success by Bourneville and Sollier.
Teaching the insane is also an idea by no means new.
From the Utica Asylum Dr. Brigham wrote of its great ad-
vantages in 18/44, and classes were started there, but were
shortly afterward abandoned. Similar brief experiments were
tried by Dr. Earle and Dr. Kirkbride. In Dublin, however,
superior energy and zeal, or some fortuitous circumstance,
made it possible for Dr. Lalor to elaborate and carry out a
scheme of education for the insane that for over thirty years
has been attended with the happiest results. A paper in The
Popular Science Monthly for September, by Dr. Charles W.
Pilgrim, gives an account, of the Richmond District Lunatic
Asylum, the scene of Dr. Lalor's former labors, where nearly
every patient, except those incapacitated in the hospital depart-
ment, is engaged either in school or in industrial exercises, and
about a fifth take part in both. The object of the school, as
formulated by Dr. Lalor, is, first, to provide occupation for a
large class who would otherwise be unemployed; secondly, to
vary the occupation of the patients; thirdly, to apply a system
of education to the relief of mental disorders; and, fourthly, to
promote the happiness and welfare of all the inmates. Object-
teaching prevails among the more stupid ones ; reading, writ-
ing, arithmetic, and geography among those more advanced.
Music occupies a most important place in this system. When
the patient's attention can not be gained in any other way, it is
possible to get him interested in the singing-class and afterward
in other classes. Singing is accompanied by instrumental
music, and even the theory of music is not neglected. Music
naturally' leads to drilling and marching. By placing the less
active patients here and there in the line, even the most inert
can be induced to take part in the exercises, and thus obtain an
amount of physical training that it would be difficult to give
them in any other way.
In this Irish asylum Dr. Pilgrim reports signs of activity
everywhere, and a gratifying absence of the gloomy monotony
that so often pervades asylum life. Here lives and nourishes a
rational plan for the education, training, and uplifting of the
insane, and for their health and happiness.
Three years ago, in the Utica Asylum, the earlier experi-
ment of instruction was renewed. It is now in successful
operation on a somewhat limited scale. Two patients who
[N. Y. Med. Jouk.,
could not read and write before becoming insane, learned to do
both before returning home. One woman is the terror of the
ward until ten o'clock in the morning, w hen she goes quietly to
school, and for two hours is the most docile and interested
pupil of all. Only fear of being kept away from classes makes
her at all controllable at any other time. Is it unreasonable to
hope that the day is not far distant when, in every well-organ-
ized hospital for the insane, a school will be considered one of
the essential features in ministering to the mind diseased,
since the training of the will is of first importance in all dis-
eases of personality, in all conditions characterized by insta-
bility of the nervous system? This is a matter in which the
life is more than meat, the body than raiment, and the human
mind than any huge stone building, whatever its grandeur and
architectural beauty. In the prevention and cure of disease
education is the physician's most powerful ally, and one of the
many duties of the modern doctor is to indicate the kind of
mental and moral training best suited to individual needs.
LEPROSY IN BOGOTA.
From British consular reports some interesting information
has been published regarding the prevalence of leprosy in the
United States of Colombia. Although the first introduction
of the disease probably dates back two hundred years, there
has been no very rapid spread until within the last two decades-
A medical monthly published at Bogota by Dr. Pio Rengifo
contains an estimate that of the one million population of the
States of Santander and Boyaca, about one tenth, which would
be a hundred thousand persons, are lepers. The lazarettos of
these sections contain not far from 30,000 patients, according to
the statement of a medical officer having charge of one of the
largest of them. No actual enumeration has been made,
and the reticence observed by the affected and their friends
would militate against a systematic census, although there is
very little dread among the people regarding the contagious
aspect of the disease. The influence of the climate over it is
stated to be peculiarly potent at certain localities having an
elevation of 1,400 feet above tide-water. One such place, hav-
ing a mean temperature of 82° F., is specified in the district of
Tocaima, about fifty miles southwest from Bogota, at a place
called Agua de Dios. There is an asylum for lepers at that
place, and there is a tradition extending back over a hundred
years to the effect that the climate can stay the progress of lep-
rosy. It has been asserted that lepers who went to that resort
in good season, and remained there, have seldom died of lep-
rosy, but from other causes. There are sulphur springs at the
place which are resorted to by others than the lepers, but the
latter do not use them. The different classes mingle together
without restriction, and marriage of the leprous with the non-
leprous is not uncommon. The offspring of these marriages
generally show the effects by inheriting the disease or contract-
ing it in childhood. Children of tender years are to be seen
with well-marked leprous manifestations. The death-rate
among the lepers is believed to be higher than among others.
LEADING ARTICLES.
March 19, 1892T]
LEADING ARTICLES.— MINOR PARAGRAPHS.
325
Their stamina seems to be so far reduced that they fall easy
victims to fevers, dysentery, and pulmonary troubles, although,
if these diseases are eluded, the leprosy alone will spare them
for a long term of years. One leper is said to have spent
nearly forty years in the locality above named, and for the past
eighteen years to have had very little pain or annoyance from
his malady. As a rule, the people are [callous and careless
about the spread of the trouble, and seem to be averse to giving
any attention to its repression. A species of fatalism seems to
rule their thought, so'that restraint and preventive legislation
are not to be looked for among them.
GOUT OF THE PENIS.
Sir Dyoe Duckworth gave the clinical history of a case of
gout of the penis before the Clinical Society of London on Janu-
ary 8th, as reported in the lancet.
A man, forty-two years of age, a glass-cutter, was admitted
into the hospital with gouty arthritis of several joints and mod-
erate pyrexia. For about twenty years he had led afsedentary
lifejandjdrank a quart of beer daily. Sixteen years before, he
had had lead colic. Ho occasionally had suffered from attacks
of articular gout, a disease which he had inherited from his
father.
Five days before his admission into the [hospital he was
awakened by sudden pain in the right wrist and the right great
toe joint. On the following day he awoke with pain in the
penis and firm erection of the organ, which persisted. Three
days later the left great toe joint was attacked with gout. The
various thoracic and abdominal rorgans were found healthy.
The urine was acid, of the specific gravity of U022, with no al-
bumin. The penis was erect and tense, painful, and turgid.
No points of hardness were found in its course. The testes
were natural. There was no pain or swelling in the perinaaum.
The temperature varied from 99° to 102° F. Aperients and
salines with colchicum were administered, and^the patient was
put on light diet. The priapism persisted uninfluenced by in-
ternal treatment, sedative suppositories, or lead and opium ap-
plied locally. A cage had to be placed over the abdomen to
prevent contact of the penis with the bedclothes. Micturition
was painful and the urine had to be drawn with soft catheters.
From time to time fresh attacks occurred in various joints, but
the priapism continued for twenty-one days without intermis-
sion, and then gradually subsided with the general amendment
of all the symptoms.
The noteworthy points in this extremely rare casejare the
gouty inheritance, the sedentary habits, with "exposure to lead
poisoning, and the habitual drinking of beer.
MINOR PA RA GRA PUS.
THE INCOMPLETE REMOVAL OF DISEASED OVARIES.
In the British Medical Journal for December 19th a brief
note is given concerning conservative operations on the ovaries.
At a meeting of the Surgical Society of Paris, Dr. Rontier
stated his opposition to Pozzi's method of partial removal of
sclero-cystic ovaries. Conservative surgery, he holds, is inex-
pedient when the ovary is sclerosed, whether the tube is healthy
or not. Pathological anatomy shows that in ovaries, under
these conditions, all the ova have a tendency toward cystic
degeneration. The stump left with a portion of the ovary on
it is liable to a return of the disease, with all the attendant suf-
ferings for the relief of which the original operation was under-
taken. At the same time, the patient is just as surely sentenced
to sterility as though the operation had been radical. The fail-
ure of the conservative operation has many times been due to
an imperfect removal of one of the ovaries. Unsatisfactory
results also have been due to the intentional non-removal of the
Falloppian tube. The author has had experiences of this kind.
In one case of hemorrhagic metritis failure had followed the
use of the curette. He then removed the ovaries, leaving a
healthy tube. But all the troubles returned and remained until
the radical procedure of vaginal hysterectomy was performed.
In two other cases, in women having retroflexion and metritis,
the curette was successful in curing the flooding, but not the
pain ; hysteropexy was performed, but there were left unre-
moved the almost healthy appendages on one side. A few
months later he was compelled to do a vaginal hysterectomy.
For these reasons Rontier has been led to abandon the tempo-
rizing policy of incomplete removal of the uterine annexa, even
when they are in a sound condition, in the belief that he will
thus often save time, trouble, and suffering to his patients. In
the discussion following the paper, Pozzi replied that it was by
no means certain that a woman would be sterile after the con-
servative operations on the ovary of the kind he had recom-
mended.
THE KNEE-JERK IN THE CONDITION OF SUPERVENOSITY.
In a preliminary note in a recent number of the British
Medical Journal, Dr. J. Hughlings Jackson reports the absence
of the knee-jerk in some cases of emphysema with bronchitis
in which the blood had become very venous, and also in a case
of diphtheria in which tracheotomy was performed for dysp-
noea producing cyanosis. When the cyanosis disappeared the
knee- jerk could be elicited. At his sugge-tion Dr. R. Russell
asphyxiated dogs by clamping the trachea, and found that the
knee-jerk became exaggerated until knee-clonus was produced,
but that in the third stage of asphyxia no reaction could be ob-
tained. As asphyxia diminishes, and in an extreme degree an-
nuls, the excitability of the motor cortex, the prelim in ary ex-
aggeration of the jerk was probably due to loss of cerebral con-
trol over lumbar centers, which subsequently succumbed to the
poisonous influence of supervenous blood. It is worth while,
in all cases of apoplexy or coma, to note the degree of super-
venosity, and to investigate, in regard to it, the state of the
patients as to tendon reactions and superficial reflexes.
EPIDEMICS AND THE CONVULSIONS OF NATURE.
In Le Progres medical for February 27th we find a paragraph
recounting that an English gentleman, Mr. Harries, recently read
before the Meteorological Society of the United Kingdom a pa-
per on influenza in which he stated that epidemics of that dis-
ease generally coincided with volcanic eruptions, and suggested
that volcanic dust from the depths of the earth, being suspended
in the air alter the eruption of a volcano, was the principal factor
in the propagation of infectious diseases. The recent prevalence
of influenza Mr. Marries is said to have attributed to an erup-
tion of Krakatoa, in the Straits of'Sunda, in 1883. If the date
is given correctly, it must be remarked that a long period elapsed
before the volcanic dust did its work. The general question of
326
MIX OR PARA GRAPHS.— ITEMS.
[N. Y. Med. Jour.,
the connection of epidemics with violent meteorological phe-
nomena is not a new one, as those who feel an interest in it may
learn — and at the same time be made acquainted with many
curious facts and theories — by consulting a work on Epidemics
written many years ago by our great lexicographer, Dr. Noah
Webster.
A CURIOUS INJURY BY A STROKE OF LIGHTNING
There is an account in the Archives of Otology for January
of a case in which a man was struck by lightning on the left
side of the head. It passed down the ear and along the neck
and breast to the right arm, where it burned through the flesh,
leaving the bone exposed, and then passed out into the metal
work of the buggy in which he was seated. Some days after-
ward he applied to Dr. Clark fur relief from an otorrhcea which
had supervened, when it was found that the external ear and
the meatus were burned superficially and the tympanic mem-
brane ruptured, either by the direct stroke of the lightning or
by the cauterization of the surface of the meatus, followed by
suppuration which afterward penetrated the middle ear. From
the history and the appearances present the former hypothesis
was considered the more probable.
THE CEREBRAL CORTEX AS A DRUG.
The 'Wiener klinische Wochenschrift for February 25th con-
tains an abstract of a communication made at a meeting of the
Paris Academy of Medicine, held on February 16th, by Dr.
Oonstantin Paul, from a report published in La Semaine medi-
cale, 1892, No. 9. Dr. Paul spoke of decided benefit in cases of
neurasthenic chlorosis, typical neurasthenia, persistent slowness
of the pulse, and tabes dorsualis as the result of subcutaneous
injections, of five cubic centimetres each, of a sterilized ten-per-
cent, solution of the gray matter of the sheep's brain in the
lumbar region. No untoward results are mentioned as having
occurred even after numerous injections.
ASAFCETIDA AS A REMEDY FOR HABITUAL ABORTION.
The Centralblatt fur Gynakologie for March 5th contains a
summary of an article by Dr. Guido Turazza, of Padua, who
gives his own testimony, together with that of several other Ital-
ian physicians, in favor of the efficacy of asafcetida as a prevent-
ive of abortion. A pill containing about a grain and a half of
the drug is given once in two days at first, and gradually at
longer intervals until finally one is given only every tenth day.
The author regards asafcetida as a good remedy in the nerv-
ous derangements of women, and remarks incidentally that it
has the advantage of regulating the action of the bowels.
CORNUTINE AS A PELVIC HEMOSTATIC. •
In the Centralblatt fur Chirurgie for March 5th we find a
brief abstract of an article by Dr. A. Meisels, published in the
Pester medicinisch-chirurgische Presse, 1891, No. 39, on the
use of cornutine in cases of haemorrhage from the urinary and
genital tracts, given in the amount of fifteen one-hundredths of
a grain daily. The results are said to have been excellent.
FOOTBALL CASUALTJ ES.
The L'mcet continues to catalogue the results of rough play
at football in England. In one of its latest issues five cases of
injury are mentioned, in three of which death resulted. Rupt-
ure of the kidney and laceration of the intestines were among
the causes of death, as determined by inquest. One youth was
dead within twenty-four hours after the receipt of his injuries.
ITEMS, ETC.
Infectious Diseases in New York. — We are indebted to the Sanitary
Bureau of the Health Department for the following statement of cases
and deaths reported during the two weeks ending March 15, 1892 :
DISEASES.
Week ending Mar. g
Week ending Mar. 15.
Casei-.
Deaths.
Cases.
Deaths.
Typhus
20
3
4
12
Typhoid fever
8
4
7
2
S:arlet fever
219
38
231
31
2
4
0
0
Measles
337
21
328
20
Diphtheria
119
43
98
32
Small-pox
6
1
1
1
Erysipelas
0
0
0
0
Varicella
12
0
0
0
1
0
0
0
Mumps
2
0
0
0
The New York Academy ot Medicine. — The order for the meeting
of Thursday evening, the 17th inst., was a discussion on The Varieties
of Pneumonia and their Treatment.
At the next meeting of the Section in Ophthalmology, on Monday
evening, the '21st inst., a paper on Unilateral Albuminuric Retinitis and
its Significance is to be read by Dr. W. B. Marple, and one entitled Re-
marks on the Pathology of Albuminuric Retinitis, by Dr. John E.
Weeks.
At the next meeting of the Section in Laryngology and Rhinology,
on Wednesday evening, the 23d inst., Dr. Charles A. Powers will show
a modified oral speculum, Dr. Beverley Robinson will read a paper on
Diseases of the Upper Air Passages during and resulting from In-
fluenza, and there will be a continued discussion on Hvpertrophied
Tonsils, with special reference to Methods of Treatment and the Ques-
tion of Hemorrhage after Excision.
At the next meeting of the Section in Obstetrics and Gynaecology,
on Thursday evening, the 24th inst., Dr. F. Forster will read a paper
entitled Clinical and Microscopical Analysis of Twenty-five Extirpated
Ovaries, with special reference to Haematoma, and Dr. S. Marx will
present one entitled A Case of Accidental Haemorrhage during Labor,
with Remarks.
A Protest against the Baby Students' Relief Bill. — At the regular
meeting of the Section in Public Health and Legal Medicine of the New
York Academy of Medicine, on Wednesday, March 16th, the following
protest was unanimously adopted :
The Section in Public Health of the New York Academy of Medi-
cine, whose membership comprises several hundred physicians of New
York and Kings Counties, hereby earnestly protests against the passage
of Assembly bill No. 513.
Its enactment would not only enable several hundred medical stu-
dents to become licensed practitioners without passing the State medi-
cal examination, but also allow these students to be graduated after
only two years of college study, instead of the three years' course pre-
scribed by law. The members of this Section deem any such attempt
opposed to enlightened public policy, which properly demands a guar-
antee from the State that a legalized practitioner of medicine shall be a
competent one.
No lowering of the present standard of requirements for a license
to practice medicine can be permitted without menacing the health of
the people. Inasmuch as two graduating classes are already exempted
(1891 and 1892), we believe no injustice is imposed upon the class of
1893 by requiring of its members the test of their qualifications re-
quired by the law of 1890, for every member of this class was ma-
triculated with the full knowledge and expectation that he would have
to pass these examinations.
In view of these facts, the honorable members of the Legislature
from New York and Brooklyn are urged to oppose with vigor the pas-
sage of this proposed amendment.
March 19, 1892.^
ITEMS. — LETTERS TO THE EDITOR.
327
The Hospital Graduates' Club. — At the next meeting, on Thursday,
the 24th hist., Dr. W. E. Lambert will read a paper on Retinoscopy as
a Method of estimating Astigmatism.
The Brooklyn Surgical Society. — The special order for the meeting
of Thursday evening, the 17th inst., was the reading of a paper entitled
A Report of Two Cases of Carcinoma of the Bladder, by Dr. H. W.
Rand.
The Medical Society of the State of North Carolina will hold its
thirty-ninth annual meeting in Wilmington on the 17th, 18th, and 19th
of May. A debate on Puerperal Eclampsia will be opened by Dr. Frank
W. Brown. After April 1st the address of the secretary, Dr. J. M.
Hays, now living at Oxford, N. C, will be No. 826 Fourteenth Street,
N. W., Washington, D. C.
The German Poliklinik. — Dr. Carl Beck has established a special
department for surgical diseases of the neck.
Army Intelligence. — Official List of Changes in the Stations and
Duties of Officers serving in the Medical Department, United State>
Army, from February 6 to February 12, 1892 :
Wales, Philip Gh, First Lieutenant and Assistant Surgeon, is relieved
from further duty at Fort Apache, Arizona, and will report in person
to the commanding officer, Fort Bowie, Arizona Territory, for duty
at that station, relieving First Lieutenant William N. Suter, Assist-
ant Surgeon.
Suter, William N., First Lieutenant and Assistant Surgeon, is granted
leave of absence for four months, from March 22, 1892.
Woodhull, Alfred A., Major and Surgeon, having completed the
duties assigned him by Par. 4, S. 0. 303, A. G. 0., December 30,
1891, will proceed from New York city to Hot Springs, Ark.,
and take station thereat as surgeon in charge of the Army and
Navy General Hospital.
A board of medical officers, to consist of Huntington, David L., Major
and Surgeon; Turrill, Henry S., Captain and Assistant Surgeon;
Kilbourne, Henry S., Captain and Assistant Surgeon ; Fisher,
Walter W. R., Captain and Assistant Surgeon, is constituted to
meet in New York city on the 1st day of April, 1892, or as soon
thereafter as practicable, for the examination of candidates for ad-
mission to the Medical Corps of the Army.
By direction of the President, the retirement from active service this
date, by operation of law, of Norris, Basil, Colonel and Surgeon,
is announced. War Department, Washington, March 9, 1892.
Naval Intelligence. — Official List of Changes in the Medical Corps
of the United States Navy for the week ending March 12, 1892 :
Brathwaite, F. B., Assistant Surgeon. Detached from Hospital, Chel-
sea, and ordered to the U. S. Steamer Fern.
Gates, M. F., Assistant Surgeon. Detached from the U. S. Steamer
Fern and granted two months' leave.
Lamotte, Henry, Assistant Surgeon. Ordered to the U. S. Receiving
Ship Vermont, at New York.
Von Wedekind, L. L., Assistant Surgeon. Detached from the U. S.
Steamer Vermont and granted three months' leave.
Kersiiner, P., Medical Inspector. Orders to the U. S. Steamer San
Francisco revoked.
Van Reypen, William K., Medical Inspector. Detached as Assistant
to Bureau of Medicine and Surgery and ordered to the U. S. Steamer
San Francisco.
Gatewood, J. D., Passed Assistant Surgeon. Ordered to the U. S.
Steamer Dolphin.
Butt, E. R., Assistant Surgeon. Ordered to the Naval Hospital,
Philadelphia, Pa.
Society Meetings for the Coming Week :
Monday, March 21st : New York County Medical Association ; New
York Academy of Medicine (Section in Ophthalmology and Otolo-
gy); Hartford, Conn., Medical Society; Chicago Medical Society
Tuesday, March 22d : New York Academy of Medicine (Section in
Laryngology and Rhinology) ; New York Dermatological Society ;
Buffalo Obstetrical Society; Medical Society of the County of
Lewis (quarterly), N. Y.
Wednesday, March 23d: New York Surgical Society; New York
Pathological Society ; Metropolitan Medical Society (private) ; Ameri-
can Microscopical Society of the City of New York ; Medical Society
of the County of Albany ; Philadelphia County Medical Society.
Thursday, March 24th: New York Academy of Medicine (Section in
Obstetrics and Gynaecology) ; New York Orthopaedic Society;
Brooklyn Pathological Society; Roxbury, Mass., Society for Medi-
cal Improvement (private).
Friday', March 25th : Yorkville Medical Association (private) ; New
York Society of German Physicians ; New York Clinical Society
(private): Philadelphia Clinical Society'; Philadelphia Laryngologi-
cal Society.
Saturday, March 26th : New York Medical and Surgical Society (pri-
vate).
fetters to tlje (Irbitor.
THE SPREAD OF SYPHILIS BY CIGARS.
23 West Fifty-third Street, March 7, 1892.
To the Editor of the New Yorlc Medical Journal:
Sir: The two following cases may not be fitted to adorn a
tale, but they certainly point a moral:
A cigar-finisher, aged nineteen, came to me on January 12th
of this year with the following history : In the beginning of
December of last year she noticed a swelling of the upper lip;
a small lump appeared, which has continued to grow until it
has attained its present size. About January 1st she noticed
some blotches on the face and body, but these, she affirms, have
disappeared. She gives an indefinite history of sore throat a
month ago. She has grown thin and pale, and lost strength
and appetite. She states that her friend, a girl who finishes
cigars upon the machine next to hers, had a similar lump upon
her lip three months ago, but is now well. She thinks she must
have acquired some disease from her friend, since she used the
same cup with her to drink tea at lunch. Stat us prasens : A
pale and anfemic girl, undersized and rather stupid, has a typi-
cal hard chancre upon the upper lip, in the middle line ; a gen-
eral macular syphiloderm in full bloom on the face and body;
diffuse specific pharyngitis ; marked adenopathy ; and moist
papules on the [labia and in the vagina, with a profuse dis-
charge.
She has worked steadily up to the present time. She "fin-
ishes " the cigars made by a machine, biting off the ends of the
wrappers and using her saliva to shape the tips. She maintains
that it is absolutely necessary to finish them in that way ; that
even if a knife were used to cutoff the redundant wrapper, the
tip of the cigar must be shaped with the finger moistened at the
lips. She has heard something of an order forbidding the biting
off of the ends; but she states that every finisher in the factory
— one of the largest in the city — does exactly the same as she
does. She refused to believe in the contagiousness of her mala-
dy. She remained under treatment but a short time, and then
withdrew from observation.
After much efforl I finally saw her friend, who gave the fol-
lowing history : She was eighteen years old. On October 2d of
last year a pimple appeared upon her lower lip, which grew to
be as large as a nut. She gives a full history of syphilis — a gen-
eral macular eruption, adenopathy, defiuvium capillorum, rheu-
matic pains, pharyngitis, etc.
Status vrasens, February 3, 1892: A tall, well-developed
girl; stains left by roseola still visible on the chest and arms;
adenopathy marked; large mucous patches on the tongue; on
328
LETTERS TO THE EDITOR.—
PROCEEDINGS OF SOCIETIES. [N. Y. Med. Joue.,
the lower lip, a little to the right of the middle line, a small, pea-
sized, distinctly indurated nodule.
She lias been working steadily. She invariably finishes off
the ends of the cigars with saliva, and says the practice is uni-
versal, as it would take too long to use knife and paste.
She has been under medical treatment, but professes not to
have been warned of the nature of her malady. In fact, she re-
fuses to believe that it is syphilis. She Remained under treat-
ment only a few days.
I certainly think that these are cases which are within the
sphere of action of our public health authorities. I am not
aware that any epidemics of syphilis have been distinctly traced
to the use of cigars. It is possible that the tobacco leaf and
tobacco juice in the mouth may render the contagious element
innocuous. But it is also possible that the long period of incu-
bation of syphilis has rendered it impossible to trace a source
of contagion so unnoticeable. It remains a fact that upon every
single cigar tip of the thousands finished by these two opera-
tives there was probably deposited a portion of the virus of the
disease. Moreover, the practice of using the teeth and saliva in
the manufacture of an article which is destined to be taken into
the mouth is not without serious objections entirely apart from
considerations of disease.
It will probably be impossible in the future, as it has been in
the past, to stop this unclean and dangerous method of cigar-
making by pressure put on the operatives themselves. The
saving time and trouble is so great as to outweigh every other
consideration. All the influence of the French authorities could
not induce the glass-blowers of that country to use the embout,
or detachable mouth-piece, in their work, though the journey-
men recognized its advantages; and Chassagny himself finally
acknowledged with sorrow the absence of any practical result
from his labors. But it is possible, I believe, to put the respon-
sibility on the employers. They and their foremen must be
aware of the methods used by their hands, and a sufficient pen-
alty would, I am sure, secure an immediate reform. I com-
mend the subject to the consideration of the Board of Health,
and would suggest to smokers the use of cigar-holders in the
interests of cleanliness, it of nothing else.
W. S. Gottiieil, M. D.
THE PRESERVATION' OF HYPODERMIC-SYRINGE NEEDLES.
North Manchester, Ihd., February 29, 1892.
To the Editor of the New York Medical Journal:
Sir : Having noticed in various medical journals different
plans of preserving hypodermic needles from rust or at least from
occlusion, 1 have thought that a means that has been iu use by
myself for the last twelve or fifteen months might be of use to
the profession generally. Accidentally I found that, if the needle
head wa* filled with ungnentum petrolei and then screwed on to
the barrel, the needle would be filled with the ointment and per-
fectly preserved for an unlimited time. All that is necessary to
do when you want to use the needle is to fill the barrel w ith
water and force out the contents of the needle, or, in case you
should forget to do so or are in a hurry, you may disregard the
needle-filling and proceed with the injection, as no harm can
come from the subcutaneous injection of so small an amount of
ointment. I have used this method of preservation for small
and large needles, have no use for the little brass plungers that
accompany the needles, and have saved a great deal of time, pos-
sibly two or three lives, and quite a considerable amount of bad
humor. If some one would construct a small bottle with a
screw cap to which a small spoon was attached for filling the
needle-head, to accompany hypodermic syringes, the outfit would
be complete. T- A- Laxcastek, M. D.
procccifmgs of Societies.
AMERICAN LARYNGOLOGICAL ASSOCIATION.
Thirteenth Annual Congress, held at Washington, on Tuesday,
Wednesday, and Thursday, September 22, 23, and 2/f, 1891.
The President, Dr. W. C. Glasgow, of St. Louis, in the Chair.
( Continued f rom page 193.)
Cyst of the Middle Turbinated Bone.— Dr. C. H. Knight
of New York, read a paper with this title. (See page 309.)
Dr. Wright: I am very much interested in the paper and
specimens. Some years ago, after I had removed a bony growth
from the middle turbinated bone, as a matter of routine, I de-
calcified it and made a number of sections of it. I was very
much surprised to find that it had really contained a cyst; the
contents were unfortunately not noted. The walls were en-
tirely bony, and were covered with remains of a grumous ma-
terial from the altered fluids. I could not distinguish an epi-
thelial lining to the cavity ; nothing but bone-cells. Shortly
after, I read Schmiegelow's paper upon this subject ; his ex-
planation was that they are congenital. I wrote to Schmiege-
low and inquired if he had found epithelium in these cysts, and
he replied that he always had found epithelium in them. I had
thought that possibly it was due to ordinary osteitis, causing
hypertrophy, and then rarefying osteitis occurred with the
formation of cysts; but, of course, if epithelium exists, the ques-
tion is settled.
Dr. Casseeberp.y : Some years ago I made reference to a
case of nasal myxoma which had apparently undergone calcare-
ous degeneration. It was hollow, and formed of egg shell like
substance, lined within by myxomatous tissue and without by
the same, and also mucous membrane. It was so large as to
totally occlude the nostril and push the sseptum far to the other
side. It could not be removed entire, as it was brittle; it oc-
cupied the position of the middle turbinated body. After hear-
ing this paper, I think that the explanation given of the mode
of formation of cysts is probable, and that my case was origi-
nally an outgrowth of the middle turbinated body, followed by
hypertrophy, and finally formation of a cyst.
Dr. Kxigiit: One of the most interesting points in cases of
this kind is the character of the membrane lining the cyst. As
represented in the drawing and as seen in the section under the
microscope, it consists of columnar ciliated epithelium. As time
passes and the lining membrane undergoes degenerative changes
the cilia disappear, and in cysts of long duration we should not
expect to find the epithelium preserved. The congenital theory
sustained by Schmiegelow — which is substantially identical with
the idea of Zuckerkandl— that the ethmoid cells may extend into
the body of the bone, seems to me untenable for the reason that
the lesion is not met with clinically in early life.
A Case of Intrinsic Epithelioma of the Larynx.— Dr.
Morris J. Asch, of New York, read a paper thus entitled. (See
page 232.)
Dr. Wright: I am especially interested in this case, because
several months before the pa'ient went to Dr. Ascli he can.e to
my office with his son. I can fully confirm the statement, made
in the record, of the irritability of his larynx. It was only at a
second sitting that I was able to see over the epiglottis at all.
At that time there was very little to recognize; the larynx was
simply covered with mucus, looking like chronic laryngitis. I
told his son that in a man of his age. who had never had laryn-
geal trouble before, the outcome might be very serious.
Dr. Asoh: In addition to what I have said, I would like to
March 19, 181*2.]
REPORTS ON THE PROGRESS OF MEDICINE.
329
lay stress on the case of performing tracheotomy with the aid
of cocaine. The injection of a few drops of a two-per-cent.
solution along the line of the proposed incision makes the oper-
ation absolutely painless. Another very interesting point in the
case is that, a few weeks after the operation, the patient was
att licked with a peculiar form ot dyspnoea, coining on in spas-
modic attacks. It was a spasmodic attack of this kind which
occurred while he was on the boat where it was impossible to
get medical assistance, together with weakness following an at-
tack of the grip, that caused his death.
Dr. Jabvis: I should like to ask Dr. Asoh why a secondary
operation involving the larynx was not indicated in his case for
the relief of the spasmodic attacks? Could he not have dissect-
ed out the carcinoma by performing thvreotomy?
Dr. Asoh: I suppose Dr. Jarvis refers to such an operation
as Lennox Browne reports, where he opened t he larynx and dis-
sected out the cancer. In my case this could not be done, be-
cause in so old a patient the cartilage is too much ossified to
permit of such an operation.
A Case of Thyreotomy in a Child Eighteen Months of
Age. — Dr. Clinton- Wagnek, of New York, read a paper with
this title. (See page 512, vol. liv.)
Dr. Clarence C. Kick: It would be exceedingly satisfactory,
in the cases referred to in this very interesting paper, if the
diagnosis could always be made before the operation is per-
formed. I recall a case somewhat similar to the one reported,
although the child was older (between three and four years of
age), where I was able to make a diagnosis by the combined use
of chloroform and cocaine. It is very difficult under ordinary
circumstances to make a laryngoscopie, examination in young
children, and impossible to make the diagnosis of laryngeal ob-
struction without such examination. Before doing an external
laryngeal section it is important to know the character of the
occlusion, its location, size, etc. In making the laryngeal ex-
amination, the plan followed was to paint the posterior wall of
the pharynx and fauces with a two-pei -cent, cocaine solution,
and to spray the larynx with the same; then I gave the child a
few inhalations of chloroform while it was held upright in the
arms of its father, and in this way I was able to make a satis-
factory examination with the laryngeal mirror and to discover
the multiple papilloma attached to the sides of the larynx, which
were removed by endolaryngeal methods. In another case of
apparent laryngeal obstruction in a child, seen within a few
days, I was not able to make a satisfactory examination, and I
intend using cocaine and chloroform in the manner described
on my return. 1 think that by this method, which requires
care and patience, we can make the exact diagnosis and can re-
move a growth or foreign body from the larynx in a case where
a general surgeon would perform laryngotomy. In a case of a
girl, five years old, in which I had the assistance of Dr. Joseph
O'Dwyer, of New York, we removed several papillomatous
growths from the larynx by the following method : The larynx
was so thoroughly closed by these growths it was found neces-
sary to introduce a tube and allow the patient to recover respira-
tion before giving the anaesthetic. After slight anaesthesia was
produced the tube was removed, the forceps was quickly in-
troduced into the larynx, and as much of the growth as possi-
ble was removed before it again became necessary to introduce
the O'lKvyer tube. The bleeding caused by the introduction of
the forceps increased the dyspnoea. Both the forceps and the
tube were carried into the larynx three times before enough of
these numerous growths could be removed to allow the child
to breathe without the tube. The growths returned, and a thy-
reotomy was eventually done. Two points I wish to make: (1)
It is possible to make tin examination in young children by the
combined use of cocaine and chloroform, and (2) by the aid of
intubation we can introduce forceps into the occluded larynx
of a child, and perhaps remove obstructions without opening
the larynx.
Dr. J. C. Mdxhall : There is one instrument much used by
general surgeons which lary ngologists should more frequently
use; I refer to the index finger. The finger with its nail attached
forms an instrument which may be very successful in removing
papillomatous growths from the larynx. There is no difficulty
whatever in reaching the larynx in young children, and with the
aid of chloroform there should be no trouble in making the di-
agnosis. In one case that I recall I was enabled to effect a re-
moval and a cure by the use of the finger-nail alone.
Dr. E. Fletcher Ingals : In examining young children, if
the tongue is drawn well forward by a tongue depressor, like
that devised by Mount Bleyer, we are often enabled to make a
diagnosis by inspection. When the papilloma projects above
the vocal cords it can often be detected by the finger. As the
larynx is relatively high in children it can be reached without
difficulty. I have several times detected papillomata in this
way.
Dr. Wagnek: With regard to the use of ether or chloro-
form in these cases, I would say that for my own part I am
afraid to give ether merely for diagnostic purposes, because of
the danger of death by asphyxia. In three of the cases of chil-
dren upon whom I operated I was compelled to perform rapid
tracheotomy in order to avoid death on the table from asphyxia
produced by the ether.
With regard to the use of cocaine in these cases, I might
mention that my three cases previously reported occurred be-
fore the discovery of the drug. In one of them, that of a boy
five years of age, I was enabled to make a thorough examination
with the laryngoscope, and discovered a large papilloma, but in
addition to the growth there was a membranous web stretching
from cord to cord and probably more directly concerned in
causing the dyspnoea than the growth; it was not possible to
remove this membrane by the mouth.
In the case that forms the subject of my paper I think death
from spasm of the glottis would have taken place had an attempt
been made to make an examination with the mirror, either with
or without cocaine.
(To be continued.)
gcjiorts on % progress of Htcbtc'mc.
PAEDIATRICS.
By FLOYD M. CRANDALL, M. D.
Common Errors and Fallacies in the Treatment of Children. — Dr.
Cheadle contributes an exceedingly interesting paper upon this subject
to the Practitioner for July. One of the most common and dangerous
errors is the belief so prevalent, both among physicians and the people
at large, that a moderate amount of diarrluea is beneficial. Upon this
assumption a looseness of the bowels is of ten allowed to run unchecked
until it has assumed dangerous proportions. It is not true that diar-
rhoea is a safeguard against convulsions. It is precisely those children
whose vitality has been drained by diarrhoea and vomiting who are most
liable to them. Young children bear purging badly, and the younger
t be child the greater the importance of gel tine a diarrhoea quickly under
control. Nothing should be given us food that is not sterilized, and
either predigested or easily digested. The author believes that opium
is essential in severe cases even in young children, and that it is an
error to withhold it. In later stages lie believ es the most ellicient reme-
dies bismuth in lull doses and opium in small doses.
330
Night terrors is a most ttoublesome and' at times alarming disorder,
occurring, as a rule, between the second and sixth year. It usually oc-
curs in delicate, sensitive, neurotic children. The direct source of irri-
tation is frequently undue stimulation of the brain, as by exciting
stories, rough and unkind treatment, over-study, or some serious acci-
dent. By far the most common cause is constipation, often slight but
persistent, the passages being hard, dry, and often light-colored. The
point of error in the management of these cases is the use of mere
sedative treatment. The neurotic element alone is recognized, and bro-
mides are prescribed, often with good effects for a time. Unless the
cause of irritation be discovered and removed, the bromides alone, while
most valuable if properly used, will give but temporary relief.
Among the drugs most heedlessly used at the present day are anti-
pyretics such as aconite, antipyrine, and acetanilide. Pyrexia is not
the cause or essence of disease, but a symptom. The temptation, how-
ever, to reduce temperature when elevated above the normal is very
strong, especially when it can be accomplished by the simple adminis-
tration of a drug. It must be remembered that these are powerful
agents having, in addition to their antipyretic power, other active prop-
erties. They are all powerful cardiac depressants. In most diseases
marked by high temperature danger is to be apprehended from heart
failure, not from pyrexia. That a high degree of fever is an element of
danger can not be denied, but in no case is it the sole danger. This is
true of pneumonia to a marked degree, and the results of antipyretic
treatment in that disease have not been satisfactory. Children espe-
cially do not bear vigorous antipyretic treatment as well as adults. It
is futile to attempt to cure the disorder that gives rise to a febrile state
by the mere forcing down of temperature, and it is often extremely dan-
gerous.
The cruel and useless practice of swabbing out the throat in diph-
theria has nearly died out ; but this method of applying astringents,
antiseptics, and solvents still survives. After long observation of the
effects of various methods of local treatment, the author has no hesita-
tion in condemning as injurious the system of brushing out the throat.
It is easy to do serious harm to the throat by such treatment and by
abrading healthy surfaces to cause an extension of the membrane. Jt
usually involves a severe struggle. The terror, excitement, heart strain,
and physical exhaustion are most unfavorable conditions in a disease
which tends to death by asthenia.
Other errors are the oppressive poulticing of the chest in pneu-
monia, which obstructs respiratory movement and tends to increase tin'
body heat ; the administration of emetics in diphtheritic croup, which
is less effectual for good than for depressing the patient ; their fre-
quent repetition in bronchitis and whooping-cough, when there is no
extreme mucous obstruction of the air passages to justify it ; and the
too free purging of rhachitic children suffering from convulsions, under
the belief that irritant matter in the alimentary canal is the sole cause
of evil.
Hydrocele in Infants. — Sejournet {Rev. mens, des mal. de Venf.,
August, 1890) employs the term hydrocele in this paper because it sug-
gests the idea of a collection of serous fluid in the tunica vaginalis, but,
as it also implies the idea of being chronic, it is not as appropriate. As
it appears in infants it is usually due to the extension of a cutaneous
erythema. This red eruption about the buttocks is very common, and
usually results from disordered digestion, the toxic materials contained
in the fasces being the active cause. The author has seen this erup-
tion advance gradually to the urethra, which it has evidently invaded, as
shown by the pain and cries of the child during urination. This has
been followed by tumefaction of the spermatic cord, and this irr turn by
hydrocele. He believes that all cases of acquired hydrocele follow this
course. This disease is most comrrron from fifteen days to six weeks
after birth. It is always confined to one side, and has a peculiar tense
but elastic feel, and is transparent by the light test. It is not a chronic
affection, but passes away irr from two to six weeks in most cases. It
may remain after' the erythema has been cured, and in rare instances
becomes chronic, having all the characteristics of the disease as it ap-
pears in the adult. When it appears without a preceding erythema,
as the author admits that it may, it is far more prone to become
chronic. In treatment, the chief point is the improvement of the diges-
tion by every possible means. Indigestion should, as far as possible,
[N. Y. Med. Jouh..
be removed, and diarrhoea should be checked by restoring the digestive
power. Erythema should be treated by the application of suitable
powders or ointments. The hydrocele should be treated by astr ingent
applications or by an iodide ot-potassium ointment.
Prolapse of the Rectum in Children. — Logan (Liverpool Medico-
chirurg. Journal, July, 1891) advises that the bowel before being re-
turned should be washed with a strong solution of alum or dusted with
tannic acid. In extreme cases reduction is difficult, but may be aided
by the passage of a small rectal bougie. Arr anaesthetic may be re-
quired. The actual cautery is very effectual, or nitrate of silver may be
applied in longitudinal lines, but in some cases wedge-shaped pieces of
mucous membrane may have to be removed. For retaining the bowel
in position the author employs a perforated celluloid tube four inches
long and three eighths of arr inch in diameter. It is retained in posi-
tion by a flange at its lower end. In mild cases a pad and T-bandage
may be applied with advantage.
The Idiocy of Myxoedema.— Bourneville contributes a series of in-
teresting articles upon this subject to Le Progres medical, vol. xii, Nos.
26 to 34, an abstract of which appear s in the Medical Chronicle for
December, 1891. The disease is known as cretinoid idiocy, cretinoid
pachydermia, and sporadic cretinism. It is usually due to congenital
absence of the thyreoid gland. The exact relation of heredity irr its
production is uncertain. Alcoholism seems to have some influence
and it has been attributed by Down to intoxication of one or both par-
ents at the time of conception. Tuberculosis and cancer would also
seem to have an influence in the production of the disease. Insanity
hysteria, apoplexy, and migraine are often seen in the relatives of these
patients. Females are more subject to the disease than males. The
symptoms are rarely present until infancy is past.
These patients all bear a striking resemblance to one another, the
symptoms being nearly identical in all cases. The intellectual develop-
ment is interfered with and also that of the body, which shows pro-
found alterations in the nutritive functions. The head is large behind,
but low, narrow, and compressed in front, while the anterior fontanelle
may persist for thirty years. The lower lip is everted, the mouth
large, the tongue thick and protruding, the nose flattened, the cheeks
swollen, the teeth imperfect, the chin small, the ears thickened. The
neck is thick and short, with no trace of the thyreoid glarrd. The belief
that the primary cause of the disease lies in the absence of the thyreoid
gland is confirmed by the autopsy of mvxeedematous adults in whom
serious lesions of that organ are found: by the appearance of the
symptoms of pachydermatous cachexy in individuals whose thyreoid
gland has been removed by operation ; by the appearance of myxoedema
in monkeys after thyreoidectomy, according to Horsley's experiment ;
and by the absence of the disease if, dining the operation of thyreoid-
ectomy in monkeys, a small portion of sheep's thyreoid is implanted in
the peritonaeum, according to Schiff's experiment
It is important to distinguish the idiocy ol myxedema from cre-
tinism. In the following particulars they are similar : Tire face and
body are hairless, the nose is flat, the lips are thick, the mouth
is always gaping, the tongue is large and protruding, aird the thorax
is deformed. Both are thick-set and heavy and subject to rickets and
scrofula.
In the idiocy of myxoedema the head is long, flattened from the
forehead to the ver tex, wide at the base, and square. The hair is
coarse, rough, long, ol brown or reddish color, with partial baldness.
In cretiuism the head is flattened from before backward, wide at the
base, contracted at (he vault, with no occipital protuberance. The hair
is thick and abundant, and neither baldness nor white hair is ever
found. In idiocy there is spurious oedema of the eyelids, cheeks, and
ears. The ears are projecting and yellowish. There is no strabismus,
retinal sensitiveness, or blepharitis. In cretinism there is true oedema
of the lids with blephar itis. Strabismus is common and the retina is
insensitive. In idiocy the saliva dribbles in infancy only, the lower lip
is sometimes pendulous, and mastication is difficult. In cretinism the
lower lip is pendulous, the saliva constantly dribbles from the mouth,
and mastication is impossible. In this form of idiocy pseudo-lipoma-
tous tumors are found irr the supraclavicular regions, axilla, arrd some-
times in other regions. The neck is thick and short with no goitre;
the breasts are absent and small. In cretinism there is goitre, but no
REPORTS ON THE PROGRESS OF MEDICINE.
March 19, 1892.] -
REPORTS ON THE PROGRESS OF MEDICINE.
331
pseudo-lipomata. The neck is thick and short, and in true cretins the
breasts are small, but in serai-cretins large and pendulous. In idiocy
the genital organs are usually atrophied. In cretins they are rudi-
mentary, but in semi-cretins often enormous. In idiocy the extremities
are large, thick, and deformed. In cretins they are disproportionate,
being either very short or very long, with deformed joints. The hands
are large and thick, the feet large and flat with the toes overlapping one
another. In idiocy the special senses are normal ; the appetite is mod-
erate with choice of food ; the habits are cleanly. In cretinism the
special senses are blunted, the appetite is voracious with no choice of
food; the habits are filthy. Idiots of this class are modest ; there is no
onanism. The same is true of cretins, but in semi-cretins the direct
opposite is seen. In idiots the movements are slow and the walk is
difficult, but may be prolonged. Cretins are semi-paralytic and unable
to walk. In idiots the vocabulary is limited as a rule, but is sometimes
free. The voice is harsh and characteristic. Cretins are often mutes
and never have a full vocabulary. The voice is normal.
The life of the idiots of myxoedema is short, but the condition is
capable of amelioration. Treatment should be by tonic drugs and by
all the pedagogical means usually employed in the education of idiots.
A Case of Bromoform Poisoning. — Sachs (Ctrlbl. f. Mm. Med., Aug.
8, 1891) reports the case of a child, four years old, who took a gramme
and a half of bromoform, the dose as prescribed being three drops.
The child soon went into a state of collapse, the face being cyanotic,
the extremities cold, and the pupils dilated. He was placed in a tepid
bath and treated by injections of ether and rapidly recovered.
A Case of Santonin Poisoning. — J. A. Smith (British Medical Jour-
nal, June 6, 1891) reports a case of poisoning by a dose of three grains
of santonin in a girl of three years and a half. The temperature was
normal, the pulse 80, heart and lung sounds normal, pupils equal and
slightly dilated, there being no diarrhoea, prostration, or eruption. She
was said to have been delirious, but no true delirium could be noted.
The majority of articles about the room were said by the child to be
green like grass. While this was the predominant color, other colors
were seen, but always false. Red appeared green ; her mother's eyes>
which were blue, were also called green. White was changed to yel-
low. Incontinence of urine occurred, the mine itself being of an in-
tense saffron color, staining everything with which it came in contact.
The symptoms subsided after a lapse of twelve hours.
Vulvo-vaginal Inflammation in Children.— Comby (Bullet, el mem.
de la Soc. mid. den hopit. de Paris, July 23), in an excellent paper upon
this subject, expresses the belief that the disease is rarely venereal in
its origin. He reports one hundred and fifty-one cases, in eighty-four
of which the patients were between the ages of two and ten years.
The author has seen it in infants, but it is far more common in child-
hood and usually appears in the children of the poor, who occupy the
same bed as older persons. While not gonorrhoeal in character, it is in
many instances contagious, and may result from a simple leucorrhoea.
As the author has no belief in the gonococcus as a specific germ, this
statement must perhaps be taken with reservation. The method of in-
fection is readily explained in most cases. Clothing, handkerchiefs, and
sponges soiled by leucorrhopal discharges of older persons may come in
contact with the vulva of the child, especially when they occupy the
same room or bed.
Besides the ordinary acute inflammation, the author has seen an
aphthous variety associated with certain eruptions, especially chicken-
pox and impetigo. In anaemic or strumous children it may assume a
chronic form. It is also in some cases traumatic in its origin, and may
be caused by irritation or injuries.
Of these varieties, the typical contagious form is the most persist-
ent and least liable to disappear spontaneously. The treatment should
be local and should consist of thorough cleansing of the parts twice a
day with a warm solution of bichloride of mercury (1 in 2,000). A
boric-acid solution, of the strength of four per cent., may also be used.
The parts are then to be dried and dusted with salol and absorbent wool
ipplied.
If the vagina is involved, a slender bougie or pencil composed of
ialol and cacao butter should be carefully passed through the hymeneal
)rifice. If the disease has assumed the chronic form, cod-liver oil and
syrup of the iodide of iron should be prescribed.
Intubation in Croup. — Escherich (Wicn. klin. Woch., No. 1, No. 8,
1891), in considering the merits of tracheotomy and intubation, reaches
the following conclusions :
1. Intubation can not in all cases replace tracheotomy.
2. Gross statistics do not properly show the actual value of intuba-
tion. Each case should be considered with regard to its peculiarities
and the location of the disease.
3. The advantage of intubation is the ease and rapidity with which
it may be performed, no anaesthetic and but few instruments being re-
quired, and no wound being left which will require treatment when the
tube is removed.
4. The disadvantages are the ulcerations of the mucous membrane
which are occasionally formed, the difficulties in feeding, the difficulty
of removal of secretions and membranes, and the less perfect aeration
of the lungs.
5. Tracheotomy is preferable to intubation when the membrane is
extending rapidly into the bronchial tubes, or when the diphtheria is of
an especially septic type. The same is true in weak children with slight
respiratory power.
6. When the disease does not present special septic characters
and the membrane is limited to the larynx, intubation should be per-
formed.
7. After four or five days, if feeding becomes difficult and the mem-
brane is extending into the bronchial tubes, the tube should be removed
and tracheotomy should be performed.
Jaundice in Children accompanied by Temporary Enlargement of
the Liver. — Enlargement of the liver is not generally regarded as of
common occurrence in connection with simple jaimdice. It is expressly
stated by some authors that such enlargement does not occur. That
this statement is erroneous is proved by twelve cases reported by Dr.
Carpenter and Dr. Syers in the Lancet of September 12th. The authors
believe that the condition, though frequently not recognized, is compara-
tively common. Several cases are reported in detail, all being unques-
tionably examples of simple catarrhal jaundice. They were all of the
same character. Jaundice appeared in previously healthy children,
lasted a few weeks and passed off, the liver in each case being more or
less enlarged. In only a few had the enlargement wholly disappeared
when the patient was lost sight of. In one instance the increase in size
took place while the child was under observation. On September 23d
the edge of the liver was felt an inch and a sixth below the costal mar-
gin and gradually descended until on October 31st it was two inches and
a half below the ribs. These cases, unfortunately, throw no light on
the causation of jaundice, neither is it apparent why the liver should be
enlarged.
The Treatment of Infantile Syphilis by the Subcutaneous Injection
of Mercurial Salts.— Moncorvo and Ferreira (Revue mens, des mal. de
Ven.fance, July, 1891) report a large number of cases of syphilis in
young children 'treated by hypodermic injections of various salts of
mercury. Of the soluble salts, corrosive sublimate is the best tolerated
and most efficient. It is not proposed as the treatment for every case,
but it offers a method to which we may turn with confidence if other
methods fail. The following^ conclusions are drawn :
1. The value of the hypodermic method of treatment must be ad-
mitted.
2. Of the various salts, the corrosive chloride gave the best results
as used with forty-seven children who received two hundred and fifty-
nine injections.
8. The tolerance of this salt by very young children is perfect, and
the effects are marked.
4. The injections should always be made with the most scrupulous
antiseptic precautions. They may in some instances lie repeated even-
four days.
5. The results obtained by means of mercurial injections are gener-
ally favorable, and the efficiency of the process does not seem to be in-
ferior to that of other methods of administration.
(>. The cutaneous lesions are more quickly influenced than the
glandular.
7. As a rule, mercurials by hypodermic injection are well tolerated
by young children, there being little tendency to salivation, stomal itis.
and intestinal symptoms.
332
MISCELLANY.
[N. Y. Med. Jo he.
Eucalyptus in the Treatment of Scarlet Fever. — Bond (Lancet,
June 6, 1891) reports forty-seven cases treated by oil of eucalyptus,
both internally and as a spray or lotion for the throat. In view of cer-
tain glowing reports that have recently been made, the conclusions of
the author are interesting. As a curative agent he believes it possesses
no value, having no power to mitigate the severity or modify the
course of the disease, and failing to prevent serious complications and
sequelae.
Induration of the Sterno-mastoid in New-born Children. — Dr. W.
R. Parker, in the British Medical Journal of June 20, 1891, reports
two cases which seem worthy of record on account of the infrequency
of the complaint, its omission from most text-books on obstetrics, and
its liability to be mistaken for inflammation of glands of the neck. The
first patient was delivered artificially, some force being necessarv in
extracting the head. It was a dorso-anterior breech presentation.
Twenty-six days afterward the child presented a marked induration
about the middle of the right sterno-mastoid, drawing the chin over to
the left shoulder. A few weeks' treatment with gentle frictions with
a simple liniment resulted in a complete cure.
In the second case much force was also used in delivering the head,
the breech being the presenting part. Twenty days afterward indura-
tion of the right sterno-mastoid appeared, sufficient to draw the head
well over to the left shoulder. Six weeks' treatment was required for
its removal.
In both cases there was doubtless sufficient force used in delivery
to tear some fibers of the sterno-mastoid, causing inflammatory
effusion and subsequently cicatricial contraction. In neither case
was there the slightest suspicion of syphilis or other constitutional
taint.
Rickets in Australia. — Dr. Muskett, in the Australasian Medical
Gazette of July 15, 1891, says that in Australia rickets is a not uncom-
mon disease, though it is the prevailing belief that it does not occur
there. As the disease is desciibed, the type is mild and the symptoms
are not peculiar. It is interesting to observe that the disease is found
by one who appreciates the symptoms and looks for them. The condi-
tions favorable for the development of the disease are unquestionably
present in Australia, and where such conditions are present the disease
will certainly appear. As those conditions increase, as they are evi-
dently doing in Australia, the disease will become more marked in
character and more prevalent.
Encephalocele.— Broca (Rev. des malad. de Venfance, June, 1891),
in a paper upon this subject devoted chiefly to treatment, condemns
pressure, puncture, and injections of iodine. Meningitis is the usual
result of such operations, and when it does not occur the tumor rarely
decreases in size. Incision leads to the danger of draining away of the
cerebro spinal fluid. Excision, with a ligature placed as low down at
the base of the tumor as possible, offers the best promise of success.
There is but little danger of removing brain substance, for the mass of
the tumor is composed of other matter. As yet it is impossible to
form an opinion as to the mental capacity of children who have been
operaled upon by excision.
Laparotomy in an Infant. — Schmidt (Deuts. med. Woch., xii, 1891)
reports a laparotomy in a child, six months old, for the removal of a
tumor. It proved to be a sarcoma of the kidney and was the size of
an infant's head. A complete recovery followed in three weeks. In
cases of this character examination of the urine often fails to give any
assistance in diagnosis. Renal tumors are far less movable than those
of the spleen.
Aprosexia and Headache in School Children. — Dr. Guye, of Am-
sterdam, presents another contribution upon this subject in the Sep-
tember number of the Practitioner. This term was applied by him
several years ago to the condition marked by feebleness of memory,
headache, and inability to fix the attention on any abstract subject,
seen in certain children suffering from disease of the nose and naso-
pharynx. Relief of such nasal disease is quickly followed by marked
improvement in the mental condition. These children are always
mouth-breathers, they have a dull, stupid look, and often suffer from
headache, which is usually constant and persistent. The mental condi-
tion is explained by the fact that the abnormal growths obstruct the
cerebral circulation, especially the lymphatic. Attention is drawn to
the importance of mouth-breathing as a symptom, especially in children
who remain backward in intellectual development.
A Case of Myositis Ossificans. — Macdonald reports a remarkable case
in the British Medical Journal of August 29th. The patient was a girl
four years old, brought for treatment because of inability to raise the
arms from the sides. This was found to be due to a semi-ossified con-
dition of the muscles surrounding the shoulder joints. The muscles of
the neck were also becoming ossified, the sterno-mastoid of the rigid
side standing out like a rod of iron. There were also nodes scattered
over the head, scapuhe, spines of the vertebrae, ribs, and sacrum. These
nodes appeared and disappeared and seemed to be influenced by treat-
ment and were strongly suggestive of syphilitic taint. But no other
evidence of that disease could be obtained either in patient or parents.
There was no suspicion of rheumatism. The condition was first ob-
served when the child was two years old.
Treatment seemed to have no effect except upon some of the nodes.
An attempt was made to gain more motion by removal of the bony
material from the tendons of some of the muscles. Though the in-
cisions healed readily, the results were not satisfactory.
A British View of American Surgery. — Mr. Rutherford Morisonj
who says he has recently spent eighteen days in America, has con-
tributed to the March number of the Edinburgh Medical Journal an
article in which he says :
In crossing the Atlantic I was fortunate in meeting Dr. Draper,
physician to Roosevelt Hospital, New York, and Dr. Kelly, gynaecolo-
gist to the Johns Hopkins Hospital at Baltimore, who were returning
after a holiday in Europe. Armed with introductions from these
gentlemen, 1 was enabled in a short time to see a good deal of surgical
work, and met with a very agreeable reception. An introduction is,
however, not essential. The American surgeon is a good fellow, and it
will be a Britisher's own fault if he can not get along with him.
I arrived too late to attend the Washington Medical Congress,
where the attendance of several distinguished British surgeons (Pro-
fessor Chiene among them) at the meetings was much appreciated.
The first hospital I visited was the Roosevelt, in New York, with
about 250 beds. This hospital is an excellent one, but cramped for
ground space, and not built in accordance with the latest views on
hospital construction. It will soon, however — for the building is nearly
completed — be possessed of the finest operating theatre in the world,
erected at a cost of £80,000. The sum was left by a wealthy bene-
factor, with the express stipulation that the whole of it should be ex-
pended on this object. The area is to be wholly marble, and the diffi-
culty of disposing of so much money is being met satisfactorily by
making it quite an extensive building. There are to be isolated ward-
rooms at the top ; the operating room, porter, and nurse are to have
quarters there. Photographic, bacteriological, and pathological rooms
are to be provided, and a number of special rooms are to be set apart
for instrument sterilizing, and disinfecting apparatus, dressings, and
the special appliances for preparing them, and consulting and other
rooms for the staff.
In the hospital, among several interesting cases, I noticed a boy
who had recovered after an operation for perforating ulcer of the
vermiform appendix with general peritonitis. The abdomen had been
opened and cleansed and the vermiform appendix removed by Dr.
Hartley. This was the only case known to have recovered after such a
lesion in New York.
Another youth was recovering after an operation for intestinal ob-
struction, due to a band and adhesions; and the interesting feature in
his case was that a year before he had been laparotomized for tubercu-
lar peritonitis.
Dr. McBurney had several cases on which he had performed an
operation of his own for the radical cure of hernia. He ligatures the
sac at its neck, removes it, slits up the whole length of the canal and
March 19, 1892. J.
MISCELLANY.
333
the skin covering it, sutures the upper skin margin to the conjoined
tendon, the lower to Poupart's ligament, draws the inverted skin mar-
gins toward each other by deep sutures, and packs the resulting ditch
with dressing, from the bottom, till the wound is healed. The object is
to secure a firm fibrous barrier against the descent of another hernia.
The large gash, held by button sutures, looks formidable, but the re-
sults are said to be excellent; and I had the opportunity of examining
a young man who turned up three months after operation, meanwhile
having been at work, and in him the site of operation appeared to be
much the strongest and most resistant part of a strong abdominal wall.
The genito-urinary cases are kept in a separate ward, and have
male attendants. A considerable number of buboes wrere under treat-
ment during my visit ; and, judging by what I saw, I think it would be
fair to assume that bubo in America must be a much more serious dis-
ease than with us. It is the rule to dissect out all the infected glands,
and to remove all infiltrated skin. The result necessarily is, in some
| cases, a huge granulating surface in the groin. One man I saw had
had the misfortune to have the glands and skin on both sides affected,
and when seen by me, had a granulating area on each side quite the
size of my outspread hand. The same treatment was adopted in Vien-
na when I was a student there in 1878.
There were several eases of urethral stricture under treatment, and
I was surprised to learn that all strictures are dealt with by internal
urethrotomy. Those in the penile port'on are cut only ; those behind
are cut, and in addition the bladder is drained through the perinaeum.
Dr. MeBurney has invented an ingenious instrument for making a
small perineal opening just large enough to admit a drainage-tube, in-
stead of the larger incision necessary when the bladder is drained in
the ordinary way.
The bougies used in the after-treatment are terrible-looking weap-
ons, and " bougie day " did not appear to be anticipated by the patients
with feelings of unmixed satisfaction. Surgical principles are not elas
tic enough to allow of such a radical difference of opinion and practice
i as I saw there and see with us. If they are right we are wrong.
I had the opportunity of examining some cases recovered after
operations for the removal of malignant growths. The operative treat-
S ment adopted is much more radical than is the rule with us — c. g., in
an ordinary case of scirrhus of the mamma it is usual to remove a large
.area of skin covering and surrounding the growth, to take away the
I pectoralis major, divide the pectoralis minor, and dissect out from the
axilla everything except vessels and nerves. The skin gap is filled up
by a Thiersch's graft — an excellent method, not sufficiently used here.
II had the opportunity of seeing that the usefulness of the arm was but
| little impaired by the loss of the pectoralis major.
In cancer of the tongue an incision is made through the center of
the lower lip, down through the middle line of the chin and neck to the
hyoid bone. A second incition crosses this, running along the lower
edge of the body of the jaw from one facial artery to the opposite.
The flaps so marked out under the chin are reflected, the glands dis-
sected out, and the lingual arteries tied. The lower jaw is now sawn
through in the middle line, and the floor of the mouth and tongue re-
moved. In one case, I think a patient of Dr. Halsted's, of Baltimore,
the upper part of the larynx and a considerable portion of the pharynx
had been removed in addition, and a year alter the patient was in ex-
cellent condition and free Irom recurrence.
In all operations the most strict aseptic and antiseptic precautions
were used, here as in all other hospitals I visited ; the operator, his as-
sistants, and the operation-room nurse, all wore special clothing; but 1
will enter more fully into detail on this point later in connection with
the Johns Hopkins Hospital at Baltimore.
Ether was the invariable antesthetic. It was administered on a
simple stiff cone covered by a towel. At Boston it was given on a
large, thick, cone-shaped sponge, without accessories of any sort — a
safe, efficacious, cleanly, and simple method. Chloroform is mostly re-
garded as unsafe, and ether is in general use.
The catgut for ligatures was prepared here in a simple way. It
looked well, and was said to be satisfactory when tested clinically and
bacteriologically The gut, bought dry and unprepared, was first put
into ether from two to four hours, depending upon its thickness, then
into 1-to-l, 000 corrosive lotion for the same time, and from this into
alcohol, where it was permanently kept till required for use. All in-
struments were sterilized before use in a special hot-air or steam
sterilizer.
Hagedorn's needle and needle-holder were used for the introduction
of sutures, and a needle-holder had two arguments in its favor — first,
convenience; and, second, it was more readily and surely sterilized than
fingers. A large number of sutures were used in wounds. Tier upon
tier of catgut sutures held the deeper structures in apposition until the
sides of the wound were so closely opposed that there was no space for
and no need of drainage. Cheap sponges, made use of only once, w ere
employed during operation. The dressings were gutta-percha protective
dipped in weak corrosive lotion, and torn into small patches, next the
wound, and either sterilized gauze and wool, or corrosive gauze and
wool heaped outside of this and retained by an ordinary roller bandage.
Bellevue. — Bellevue is an old-fashioned large hospital (eight hun-
dred beds), with a medical school in its grounds. There I saw a lapa-
rotomy performed by Dr. Polk, gynaecologist to the 1 ospital. The
operating theatre is a very large one, much resembling the theatre of
the old Edinburgh Infirmary in its arrangements and appearance.
Prom one hundred and fifty to two hundred students were present, and
waited comparatively quietly lor Dr. Polk and the patient.
On Dr. Polk's arrival he was greeted with enthusiastic cheers, for
he had just returned from a holiday in Europe. The patient was im-
mediately wheeled in on a couch, under the influence of ether, and her
case briefly discussed. She was then stripped and placed on a low,
short operating table, only long enough to hold her body. The legs
rested on a stool. The operator explained that he had brought her un-
prepared to show the methods adopted preliminary to operating, and an
assistant proceeded to smear the abdomen with an alcoholic solution of
soap, and with the vigorous use of a nail-brush and hot water soon pro-
duced an abundant lather. The pubis was now shaved with a razor
and the lather washed off by pouring a hot solution of corrosive subli-
mate from a jug over the abdomen. While the abdomen was being
attended to by one assistant, a second was cleansing the vulval orifice
and interior of the vagina by directing the flow of lotion over and into
these parts by his hand and fingers. The cleansing process finished,
the patient was entirely covered by antiseptic moist towels, excepting
a portion of the abdominal wall of parallelogram shape, reaching irom
the umbilicus to the pubis. Dr. Polk and his assistants, having thor-
oughly washed and disinfected, got into their respective places. The
former seated himself at the lower end of the table, between the thighs
of the patient, with a leg on either side of him, and his abdomen rest-
ing against the patient's perinaeum. This, he said, was Martin's (Berlin)
position, and had many advantages. An assistant stood on each side
of the patient ready to help the operator. A variety of matters were
discussed and explained during the proceedings, and an occasional halt
made when any particular point required emphasizing. The operator,
taking a long-bladed bistoury, and commencing the incision just below
the umbilicus, with one skillful sweep cut through all the structures at
once, down to either fascia transversalis or peritonaeum, for the next
step was to seize the tissues at the bottom of the wound on either side
with two pairs of artery forceps, between which a nick was made, open-
ing the peritonaeum. The finger was now introduced and the perito-
naeum slit up the length of the wound. The uterus and appendages
were then drawn forward, the extent of disease, a double hydrosalpinx,
ascertained, and the operation completed by the removal of the diseased
appendages in the most approved fashion.
I have not yet shaken off a feeling of being in sacred ground when
my hand is in the peritoneal cavity, and it was somewhat startling to
me to see the unceremonious way in which this operation was per-
formed at Bellevue. The impression conveyed to my mind was that
the operation was as exciting to the operator as the operation of trim-
ming the nails is to an ordinary mortal, who is occupied in conversation
w hile doing it, and does not feel the least need of hurrying over the
performance.
I have never seen an operation more skillfully performed ; but the
advantages of the position adopted would have to be very clear before,
a British surgeon could be persuaded to adopt it. It is not an elegant
one.
The New York Hospital. — This is a very handsome building, outside
334
MISCELLANY.
[N. Y. Med. Jock.,
and in. It is built on the pavilion principle, and each individual ward
is a model of what a perfect hospital ward should be. Unfortunately,
it has been built on a limited space, and is five stories high, with a very
limited interval between each block. The consequence is that the natu-
ral lighting and ventilation of the lower wards especially is consider-
ably interfered with.
Dr. Weir, one of the surgeons to the hospital, kindly conducted me
round, and [ had the opportunity, after the visit, of seeing Dr. L. A.
Stimson excise the vermiform appendix for perforating ulcer and peri-
tonitis. The patient was a young man of about eighteen, who, six
months before, had an attack of perityphlitis, from which lie recovered
under medical treatment. He was now suffering from a relapse, with
urgent symptoms, and though his abdomen was much swollen and
tender, a large resisting mass could be felt iu his right iliac fossa. An
incision about six inches long was made in the right linea semilunaris,
and a quantity of foetid pus welled up as soon as the peritonaeum was
opened. On further opening the peritonaeum it was seen that the pus
was well localized and shut in by adherent coils of intestine, with the
exception of a small place at the upper part, where a communication
might possibly exist with the general peritoneal cavity. The pus was
very carefully sponged out with small sponges in long forceps, wrung
out of l-to-1,000 corrosive lotion, particular care being taken not to dis-
turb any of the adhesions toward the cavity of the abdomen. The
vermiform appendix was then seen projecting from the end of the
caecum into the cavity, like a thick reddened spur, and alter tying and
dividing its mesentery it was ligatured at its base and removed close to
the caecum. The exposed inteiior of the divided appendix was then
touched with pure carbolic acid, and afterward seared with the point
of a thermo-cautery. When all blood and pus had been cleared away
by sponging, the pus cavity was gently packed with strips of iodoform
gauze all round the stump of the appendix. The wound was sutured
and the ends of the gauze strips left projecting through a small gap, to
be taken away later, when further adhesion had made it safe to do so.
To see this operation was a great tieat. The consummate skill with
which it was performed, the careful attention to every detail in the per-
formance, and the scientific way in which possible accidents were pro-
vided for, insured success, if success was possible.
The appendix was opened in my presence, and there was, near the
end, an ulcer about the size of a threepenny bit, which had perforated
near its center at oue very ndnute point.
During my visit I saw at least five«eases in which the appendix had
been removed for similar conditions. The only deduction 1 can make
is that appendicitis is more common in America than in Europe.
When discussing the condition with Dr. Hartley, surgeon to Belle-
vue Hospital, I mentioned that in three cases, at least, I had opened a
perityphlitic abscess with good result, immediate and remote, so far as
I knew. He said the appendix was always removed in America in such
conditions when it was possible to find it, as, if it was not, relapse
was not infrequent. In proof of his statement he showed me a boy
whose appendix had been removed a few days before, and his history
was that a few months ago an abscess had been opened after a severe
illness, and healed ; he got quite well, had a relapse, and had now been
admitted a second time with recurrence of similar symptoms, and had
his diseased appendix excised.
The Johns Hopkins Hospital at Baltimore, on its completion, will be
the most perfect large hospital in the world. It will be double its pres-
ent size, antl will then have four hundred beds. Possibly this state-
ment may give the impression that it appears unfinished at present.
This is not the ca«e. Everything, so far as it goes, is complete, and
everything that medical or surgical brain could wish for and think of is
there. The appointments on the staff are the best in all America, for
they secure to their fortunate possessors an income of £1,000 a year,
with no restrictions whatever. Could any conditions be better calcu-
lated to secure for the citizens of Baltimore the best medical services?
Dr. Hurd, superintendent of the hospital, showed me round. He
had the whole working of the hospital at his finger ends, and appeared
to know all that was going on equally well in every department — medi-
cal, surgical, gynaecological, pathological, and bacter iological. He knew
every instrument, recent and late, and could explain its advantages and
disadvantages ; every dressing, new and old, he had considered, and
what things were necessary, good, and indifferent in the hospital he
was clear in pointing out.
The out-patient department was the most perfect working arr ange-
ment I have seen. No time was lost, and with very little trouble a good
record of each case was kept.
There is a good opportunity at Baltimore, as at Liverpool, of com-
paring the circular ward (or more correctly at Baltimore, octagonal; with
pavilion wards, as each hospital has wards on both systems. I could
get no expression of opinion at either Baltimore or Liverpool as toi
which was considered best, except that Dr. Hurd told me that patients
preferred the circular, as feeling more private, from the central pillai
hiding one third of the ward from the remaining two thirds, and that
nurses liked the ordinary ward best for the opposite reason — that they
could see all that was going on in the ward from any one part of it.
My own feeling — after seeing Antwerp Circular Hospital, Johns
Hopkins, and Liverpool — is in favor of the circular ward. After the
first strange appearance has worn off, it is not difficult to see that on a
limited ground space ventilation can be more efficiently secured, and
aspect, of such prime importance in pavilion waids, where those with a
northern frontage always appear colder and darker, may in the circu-
lar be almost neglected.
The private wards at Johns Hopkins Hospital are so well patron-
ized that last year they produced an income of £8,ono for the hospital.
Nearly all the public hospitals in America have private apartments
attached for paying patients, who are taken in at fees ranging from £2
to £10 a week ; and private hospitals are much more common than with
us, as it is fully recognized that a patient's chance of recovery, espe-
cially in surgical cases, is much better in a properly equipped institu-
tion than at home.
The pathological and bacteriological laboratories form a part of tut
building ; and though this arrangement was made temporarily, it has
been found to work so satisfactor ily that it is now agreed thai the\ shall
remain permanently.
After going round the hospital with Dr. Hurd I accompanied Dr.
Halsted through the surgical wards. There was a dearth of interesting
cases, but what I did see was novel and good.
Dr. Halsted has written on the Treatment of Wounds, with especial
reference to the value of Blood-clot in the managemerrt ol Dead Spaces,
and showed me an interesting case bearing on this. A middle-aged man
had necrosis of the lower end of the femur, for which he had already
undergone three unsuccessful operations in good hospitals during an
illness extending over twenty-five years. Dr. Halsted dissected away
all sinuses, and thoroughly scraped out a large cavity in the lower end
of the femur. Taking the view that this large cavity could not heal, he
cut down on the anterior part of the femur, and removed an elongated
portion of the middle of the bone, opening up the cavity from the front.
He transplanted into the hole a flap of the vastus internus muscle, and
this, together with blood-clot, filled the cavity completely. An asep-
tic dressing completed the proceeding; and at my visit, a few weeks
afterward, the leg was healed without a trace of suppuration.
I saw also a novel method for the radical cure of hernia, which was
said to be giving excellent results. Dr. Halsted's operation is based
on the opinion that the presence of the spermatic cord in the inguinal
canal is an important factor in the causation of hernia and the pre-
vention of a radical cure. He consequently makes a new passase for
the spermatic cord in the abdominal wall higher irp than the internal
ring. The incisiorr begins at the anterior superior iliac spine, and ends
internal to the inner pillar of the external abdominal ring: dividing
skin, external oblique aponeurosis, internal oblique, the part of trans-
versalis muscle exposed, and transversalis fascia, the whole length of
the skin incision. The spermatic cord is then separated to the uppei'
level of the internal ring. The sac is isolated and drawn forward with
the exposed peritonaeum through the wound. The opposed peritonea'
surfaces are then brought together along the line of incision by a series
of quilted sutures, and the redundant per itonceum and sac clipped away
close to the line of sutures. The cord is now brought through between
the muscles near the upper end of the wound, and the divided muscles
are brought into apposition by a second row of quilted sutures. The
aponeurosis of the external oblique may be included in this or sepa-
rately sutured. Finally, the skin wound is carefully sutured, leaving
March 19, 1892.]"
MIS CELL A NY.
335
the spermatic cord between skin and aponeurosis. No drainage-tube is
required.
I next went to Dr. Howard A. Kelly's gynecological clinic, one of
the most interesting medical sights in America. Dr. Kelly is a young
man — on]v thirty-five — and has attained his present position solely by
his own work and ability, which count, I fancy, more in the New than
ia the Old country. His results in abdominal operations can scarcely
be surpassed, and I was much impressed by the thoroughness of all
his work, lie has a special theatre and wards of his own, and has
described those and his method of working in full in the Johns Hop-
kins Hospital Reports for 1890. The combination of asepsis and anti-
sepsis described is such as is employed at most of the surgical clinics
with a strictness not frequently to be seen in this country, and I have
purposely left distinct mention of this important subject till I could do
: it full justice.
[The author then makes copious extracts from Dr. Kelly's writings,
and continues as follows :]
Such are Dr. Kelly's directions, and they give me the impression
of carrying out surgical principles, according to our present lights, in
a practical manner and one approaching perfection. American sur-
geons do not forget that all recent advances in wound treatment origi-
nated with Sir Joseph Lister, and admit without hesitation that his
researches have revolutionized surgery.
They claim that their hospitals and nurses are better than ours,
and the first I can not deny. The American nurse, though, is a copy —
1 m costume, manners, everything — of the Nightingale sister, but to my
mind there is no nurse so perfect as a good English one.
Before leaving the subject of the Johns Hopkins Hospital it will
be well to mention that it has the reputation in America as a training
school for nurses, efforts being made by means of lectures to give
them a sufficient amount of information. The syllabus of lectures
includes elementary anatomy and physiology; hygiene, with special
reference to ventilation, heating, and drainage; bacteriology, espe-
cially in its application to surgery and medical practice ; all the sur-
gery required to insure a certain amount of appreciation of what is
being done, and enough of medicine to make the reasons for certain
1 lines of treatment intelligible. A satisfactory examination must be
passed on the sub jects included in the lectures and on cookery — theo-
retical and practical — before a certificate of efficiency is given.
I' Is this too much, or are we doing too little for our nurses? I
I think the fault is on our side. The nurses are interested in such work
* for its own sake, and the smatter ing of knowledge so gained helps
them to take a more intelligent interest in surgical methods, and
naturally increases their efficiency.
The City Hospital at Cincinnati is an old building, but does a great
deal of good and useful work. I spent a pleasant and profitable
1 morning with Dr. Conner, surgeon to the hospital, who showed me
several simple fractures put up in plaster-of-Paris bandages. Here, as
jn most American hospitals, it is the rule to put the limb up at once
in a plaster bandage over a thick layer of cotton wool. About the end
of the first week, all being well, the bandage is taken off, the position
of the limb examined, and another bandage firmly applied. This is
left on for the remaining five or six weeks of treatment. This prac-
tice also obtains in all the German hospitals I have visited, but is
» adopted only partially in the British Islands. Dr. Conner told me there
was now a rage on the radical cure of hernia by different methods, but
that he thought possibly ligature of the neck of the sac and its re-
moval were sufficient and as satisfactory in result as more elaborate
proceedings.
He also took me to a large Catholic hospital in Cincinnati, with over
200 beds. It is managed by Srsters of Mercy, and there is no resident
surgeon. The wards are small — in fact, it is a large ordinary house,
the private rooms of which have been converted into small wards. It
1 is remarkably clean arrd comfortable, and has air air of homeliness
about it which is wanting in the ordinary hospital ward. Is this not
the model hospital of the future ?
In Chicago I saw Dr. Senn, who has recently removed there from
Milwaukee. I had no opportunity of seeing him operate, but learned
from him in conversation that he had given up the use of dry decalci-
fied bone plates, as or iginally recommended by him, for irr oire case of
gastro enterostomy the patient vomited the plates, and in a second
case the plates had escaped from the abdominal wound. Both patients
recovered, but, in spite of tlris, he now prefers plates kept in a mixture
of eqiral parts of spirit, glycerin, and water.
The Massachusetts General Hospital, Boston. — Owing to the kind-
ness of an old Vienna friend, Dr. Williams, physician to the City Hos-
pital, I spent a most pleasant and profitable morning with the staff, to
whom he gave me an introduction. Everything, including hospital,
staff, nurses, and all else, is decidedly English at Boston. It seemed
none the wor se for that.
I first saw Dr. Cabot, surgeon to the hospital, do an ovariotomy.
The operation was performed in a special theatre, as all laparotomies
are at this hospital, which was quite isolated from the main building,
and had special wards in connection with it, much the same as at
Johns Hopkins Hospital.
Worsted quilted in gauze bags took part of the share in the spong-
ing, though sponges were used too. The case I saw operated on was
a tumor of large size, and several vascular adhesions were torn through,
so that some blood necessarily got into the abdomen. The majority of
surgeons in this country would have washed out that abdomen and
drained it. Dr. Cabot did neither. He, however, sponged it dry and
clean before suturing. So far as I could judge, a reaction has com-
menced in America against drainage and washing in abdominal sur-
gery, as I several times heard both condemned as mischievous.
Dr. Cabot also showed me two hysterectomies for fibroid, clamped
outside, convalescent, and a bad case of double pyosalpinx doing well
after operation. The results of abdominal surgery in the hospital are
excellent, as one can well believe, after seeing the care taken of the pa-
tients, and the strict attention to every detail enforced. In this hospi-
tal and at the City Hospital the general surgeons do all the operative
gynaecology, and all over America the general surgeon dees a great
deal, possibly the greater part, of this work. It is settled on the other
side of the Atlatrtic that abdominal surgery, at all events, is a branch
of surgery, not of gynaecology.
A case of excision of the ankle of Dr. Cabot's interested me. We
would call it erasion or arthrectomy, for the old formal excision is not
what was performed. The ankle joint was opened by a semilunar in-
cision on each side, curving round either malleolus and missing all ten-
dons, vessels, and nerves. The astragalus was found diseased, and
excised ; for, as Dr. Cabot explained to his class, if any disease at all
exists in the astragalus the whole bone must be removed, its defective
vascular supply making repair difficult. The os calcis was extensively
diseased, but the tubercular foci were scraped and gouged out of it
with u'ood hopes of success, for its vascular supply is so good as to favor
healing. Tl ralleoli were left intact, and it was considered fortunate
that this could be allowed, as they form an important buttress and sup-
port to the foot. Some loosened cartilage was scraped from the ends
of the tibia and fibula, and all granulating tissue and infiltrated struct-
ure removed. The wound was then filled loosely with iodoform gauze,
and dressed in the ordinary way. Excision of joints is somewhat of a
specialty at Boston. Dr. Scudder has published some excellent results,
but all over America this is a common operation, and leaves an excel-
lent and serviceable foot. Sixteen years ago my brilliant and revered
teacher, Dr. Heron Watson, frequently excised the astragalus in such
cases ; since then I had not seen it done, or heard of it again, till now.
In such a case nine out of ten surgeons in this country would have
done Syme's amputation, and I venture to say so in the operating thea-
tre. Imagine my surprise at being told that, if amputation had been
necessary, Syme's would not have been the operation selected ; that
Syme's was perhaps the best operation for a wretchedly poor person ;
but there were few such, who could not afford a proper artificial limb ;
and that, where money could be obtained for' an artificial substitute,
amputation at the lower one third of tire leg was the operation of elec-
tion. This was said by one of the distinguished surgeons of the hospi-
tal, and all my remarks, even quotations from Mr. Cathcart, failed to
make any impression oir his opinion.
Bigclow was a great benefactor to the hospital, arrd his name ap-
pears more than once in goirrg round it. A n operating chair in the
theatre, devised by him, is a marvel of complicated ingenuity.
Attached to the operating theatre is a room for examining patho-
33H
M ISC ELLA NY.
|N. V. Meo. Jock.
logical specimens, with a pathologist in attendance. Within five min-
utes from the time a tumor is removed, a stained section of it is mount,
ed ready for examination. A fresh piece of the tumor is frozen by
means of carbonic acid, an easier and cheaper method than ether, cut,
and stained in methyl green, and, if wanted as a permanent specimen,
mounted in glycerin.
Dr. Mixter has invented an ingenious tumor punch, which is in gen-
eral use in the hospital. It is a cannula with sharp internal edges,
which in doubtful cases he inserts into the tumor, painlessly under co-
caine, and removes a portion of it for examination.
I will conclude this desultory paper with my general impressions.
American much more resembles German than English surgery. The
Germans have an indescribable way of taking possession of an anaes-
thetized patient, giving an impression that he is entirely their own, and
that they mean to do just what they like with him.
German instruments are large, artery forceps like tongs, scissors
like sheep shears, retractors like garden rakes.
The German surgeon is seldom in doubt, and has an excellent em-
bryological, bacteriological, and pathological explanation of all his cases
and results. If there is any mistake, something is to blame, not the
BU rgeon.
Then there are other German specialties, such as metal-handled
knives, the invariable introduction of needles by a holder, the wearing
of special operating apparel, the strict attention to asepsis anil antisep
sis, and the selection of only such operations as can be performed with
deliberation and in open daylight. All have more or less influenced
American surgery.
Results are, after all, the test, and on these a judgment must be
formed, and from this standpoint my belief is that, if English surgeons
do not wish to be overtaken, they must put their best foot foremost.
Mortality in Cities in the United States. — The following table
represents the mortality in the cities named, as reported to Dr. Walter
Wvman, Surgeon-General of the Marine-Hospital Service, and pub-
lished in the Abstract of Sanitary Reports for March 11th :
New York, N. Y
Chicago, 111
Philadelphia, Pa ..
Brooklyn, N. Y
St. Louis, Mo
Boston, Mass
Baltimore, Md
San Francisco, Cal . .
Cincinnati, Ohio
Cleveland, Ohio
Pittsburgh, Pa
Detroit, Mich
Milwaukee, Wis
Louisville, Ky
Rochester, N. Y
Rochester, N. Y
Kansas City, Mo. . .
Kansas City, Mo
providence, R. I
Denver, Col
Toledo, Ohio
Richmond, Ya
Nashville, Tenn
Fall River, Mass
Fall River, Mass
Portland. Me
Binghamton, N. Y. . .
Altoona, Pa
Mar.
Feb.
Feb.
Mar.
Mar.
Mar.
Mar
Feb.
Mar.
Mar.
Feb.
Feb.
Mar.
Mar.
Feb.
Mar.
Feb.
Feb.
Mar.
Feb.
Mai-
Mar.
Mar.
Feb
Mar.
Mar.
Mar.
Jan.
Altoona, Pa Jan. S
Altoona, Pa Jan. Hi.
Altoona. Pa Jan. 93.
Altoona, Pa. . Jan. 30.
Galveston, Texas Feb. 26.
San Diego, Cal Feb. 27.
Rock Island, III Feb. 14.
Rook Island, 111 Feb. 21.
Bock Maud, III Feb. 28.
Rock Island. Ill M ir. G.
Pensacola, Fla Feb. 21.
Pen-acola, Fla Feb. 27.
1,515,
1,099.
1 .il-lll
800,
451.
448.
434
2!IS,
286.
261,
238.
205.
204
161,
133,
133,
132,
132.
132.
I ui I,
81,
81,
76;
74,
74,
3fi,
3b,
30.
30,
30.
30.
30.
20,'
16.
13,
13,
13,
13,
11
11
.3(11
,850
,964
,343
7;o
477
430
!»97
9i is
353
017
■>•>
468
129
800
81,6
It;
16
146
713
434
<?8«
108
308
398
425
11115
337
337
337
337
337
I is I
159
63 1
634
681
6 '4
o
753
DEATHS FROM-
— .2
■- *s
= 1
5
103
35
50
49
*
13
5
/
a
h
o
IS
3
28
20
'/.
37
8
13
2
8
11
0
35
21
'.'1
4
10
8
5
3
2
5
17
7
14
"z
4
4
2
1
2
22
23
20
5
8
2
1
1
1
3
2
i
2
■
i
12
8
8
3
2
4
1
2
1
g
5
2
1
l
1
6
1
1
4
4
1
6
1
1
l
15
1
2
1
1
1
1
1
1
'i
l
1
1
1
Dr. Lewis A. Sayre's Birthday, says the Medical Record, occurred
on February 29th, and consequently he has but one every four years.
Now that the secret is out, we are not surprised that he is still so
young, alert, and full of ardor. Many happy returns. All of his nu-
merous friends, here and abroad, will join with the rector of Gram
Church in tendering him their best wishes as exptessed in the follow-
ing charming sentiment:
"Grace Church Rkctoky,
" New York, February 2U,
" Dear Dr. Sayhe :
" And is it true.
That Nature set her clock for you
Some four-and-fifty years too slow ?
How clever of her to foreknow
That you would keep yourself so young,
So firm of heart, so sound of lung,
That she would never be detected,
Nor you so much as once suspected
Of being older by a day
Than leap-year records seem to say !
Eighteen, dear friend, or seventy-two,
Whiche'er it be, good luck to you.
"William R. Huntington."
To Contributors and Correspondents. — The attention of all who purjxme
favoring us with communications is respectfully culled to t/ie follow-
ing:
Authors of articles intended for publication under the head of "original
contributions " are respectfully informed that, in accepting such arti-
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dressed to the publishers.
THE NEW YORK MEDICAL JOURNAL, March 26, 1892.
(frijpfmal (f o m m it n t r a t i o n s .
A CASE OF SCLERODERMA.
By JOHN DUNN, M. D.,
RICHMOND, VA.
J. W. II., aged thirty-four, negro, gave the following his-
tory : When he was between eleven and twelve years old there
appeared on the right ala of his nose a small, hard growth re-
sembling a wart. It began to grow larger and he picked it,
and then tried various wart remedies to "carry it away." At
times it bled quite profusely when parts of it were scratched off.
He then sought a physician, as this growth increased continu-
ally. "Blood remedies " of all descriptions were taken inter-
nally, until, after years of trial, his physician said "blood reme-
; dies were useless." Numberless ointments were used ; in spite
of these, the affection spread. At times it would disappear par-
tially, only to reappear in the same places. The process re-
mained for years confined to the region about the right ala of
: the nose, choosing rather to spread to the right than to cross the
nose. Finally it attacked the left ala, and thence spread across
; the left side of the face. When about twenty-two years old
> the process had extended up the nose as far as the eyelids.
• Then followed a history of immense swelling of the lids, with
discharge from between them. The eyes were very painful.
As the lids went down, there remained a sensation as of grit
in the eyes. Some sight remained, although, as the irritation
was permanent, the sight grew dimmer, and at the end of three
I or four years he was totally blind. He suffered intensely with
' his eyes during this period. About four years ago the process
had reached his ears. About five years ago it began to " work
its way " into the nose and to attack the gums. At no time has
the facial affection been painful, nor has there been any itching,
i except when the diseased surface would break down, and even
i then the itching was slight. More itching at the corner of the
i month than elsewhere. Occasionally the "eyes" itch. Such is
the negro's account of his case, which, though far more accu-
rate than could be given by most of his race, must not be con-
' sidered as exact, both because of the long years during which
it has existed and because the power of exact description in the
negro is not over- well developed.
The accompanying cut, from a photograph taken at the time
of his coming to the Richmond Eye Clinic in 1891, gives a fair
1 idea of the negro's appearance. The photograph is at fault in
many details, which the following description will endeavor to
correct: The skin of the face, from about an inch and a half
above the eyebrows to two inches below the chin and extend-
ing laterally on both sides to the back of the ears, is thickened,
, infiltrated, and has a hard, elastic feel; in places the infiltration
is denser than at others; the skin is immovable over the surface
beneath, consequently the expression never changes. The pa-
tient is unable to shut his mouth, to such an extent has the in-
filtration affected the skin of the lips. Most of the surface of the
.affected area is black and has a shiny look ; in parts, however,
apparently where there has been at some time more or less irri-
tation with ulceration — perhaps an eczematous condition — the
i| pigment of the skin has to a great measure been destroyed, and
the surface here resembles patches of leucoderma, a disease aol
uncommon in the negro race. The places showing the loss of
pigment are two patches extending downward from either cor-
ner of the mouth, the probable cause of irritation being the more
oi' less continuous dribbling of saliva from the mouth, ami a
similar patch below the right nostril, irritation from the nasal
secretion, also the parts of the skin over which the lacrymal
secretions flow, just below the " eyes." All of these places are to
a certain extent ulcerated, and secrete more or less clear serous
matter. The fibers of the orbicularis oris still retain some pow-
er, as a slight movement in the lips can be detected when the
Fig. 1.
patient is told to try to shut his mouth. An endeavor to open the
mouth wide causes the glands situated along the mnco cutaneous
boundary line — and these glands must be greatly developed — to
secrete profusely, so that there appear in the upper lip two or
three lines of beads of clear mucus, about two mm. apart, the
whole length of the upper lip. The same thing occurs in the
lower lip, only here there appear three or four irregular lines.
These beads of mucus attain the size of a millet seed, and re-
main, with no inclination to spr.ead over the surface of the lips,
for minutes at a time. The lips from time to time crack and
bleed, as do the gums of the upper jaw, that part above the
eight central teeth. This part of the gums is swollen and hard,
and presents the appearance of a disposition to bleed easily.
The appearance presented by the gums here is not unlike that
seen in a case of hare-lip, where the gums have been exposed
for years to the action of the atmosphere and have not received
the proper covering and the influence of the mucous moisture,
though they are more swTollen in this case, and somewhat
resemble epulis in its earlier stages. The question arises, then,
naturally, whether this condition of the gums has resulted
merely from a lack of the protect ion the upper lip affords, for
in the above case the upper lip is so thickened an<l infiltrated
that it is pulled away from this part of the gums and does not
furnish them a covering, or are the gums infiltrated by the same
process which has attacked the lip- '. This hypertrophied con
dition of the gums does not extend beyond the first molar on
either side, and is confined to the anterior aspect of the gums.
Were this all, it would be fair to suppose that the process had
not extended to the gums, but that the swollen condition of the
gums was due to exposure and lack of normal moisture. There
are fount], however, in the region of the rows of glands, just
behind the front upper teeth, distinct evidences that some ab-
normal process has attacked them, for in two or three places
338
DUNN: A CASE OF SCLERODERMA.
[N. Y. Med. Joint.,
the mucous membrane is drawn together and puckered as if
there had been some ulcerative process which, in healing, had
drawn the immediately contiguous tissue into itself. The mu-
cous membrane, however, does not here appear to be thickened,
nor does this process seem to have extended to the whole of
this region. The appearance presented by these drawn spots is
very peculiar and unlike anything I have ever seen.
The entrances to the nostrils are very small ; it is highly prob-
able that, as the process extends, they will be entirely closed.
The entrance to the right nostril is circular and has about the
diameter of a lead-pencil ; that to the left is also circular, but
not more than half the size of that leading into the right nos-
tril. These holes present the appearance of being punched
out of the face. Perhaps it would be more correct to say that
these holes lead directly into the nose, since the aire are so in-
filtrated, thickened, and stiff that all the functions of the nos-
trils are utterly done away with. The cutaneous and movable
cartilaginous part of the sreptum dividing the nostrils below
has been destroyed down to the permanent cartilaginous plate
of the true sreptum, so that the partition between the two nos-
trils, as seen from below, is not more than the diameter of a lead-
pencil in length, and is formed by a part of the cartilage of the
true sreptum. There is, however, no ulceration here. The skin
at the angles and sides of the nostrils is so infiltrated as to ob-
literate all folds at the side of the nostrils and make the whole
on a gradual slope with the cheek bones. (This is not well shown
in the photograph.) As far as examination of the nose anteri-
orly can be made, the intranasal cavities appear to be free, and
to show no hypertrophies.
The " eyes " present the most remarkable part of the picture.
There remains not a vestige of a lower lid on either side, skin
and mucous membrane alike having been entirely destroyed. On
the right side there remains a part of the upper lid with about
half a dozen coarse lashes in a clump near the external angle.
The eyeball has disappeared, and where there should be an eye,
is only an oblong, fiery-red raw surface. This red surface, ex-
cept at the outer corner, where it makes a slight furrow, is al-
most level with the cheek, so that one says: " Were that ulcer
to be covered with skin, no one could say there had been an eye
here." On the left side the same condition obtains, except that
the upper lid remains and the raw surface is much deeper, and
there is clearly some mucous membrane which is bound down
to the central part of the raw surface. This raw surface, as on
the right side, is deepest at the external corner. There remains
some little power of motion in the levators, and on the left side
it can be plainly seen that the straight muscles of the orbit have
not been destroyed, as the patient can at will contract the mu-
cous membrane puckered at the central part of the raw surface.
The secretion from these raw surfaces is, for the most part, clear
tears, which run in some profusion over the cheeks. This secre-
tion comes chiefly from the external corner, where a probe will
show that in either "eye" there exists a fistula leading to the
lacrymal gland, which must have remained, in great measure at
least, uninjured. At the internal angles of these raw surfaces
all evidences of the once existence of lacrymal puncta and ca-
naliculi have been destroyed. The skin in the region of the
eyebrows is infiltrated, and the greater portion of the eyebrows
has disappeared. The process has extended across the face to
the ears, which are only in part infiltrated. The parts thus far
attacked are the lobules, which are much thickened, and the
outer edges of tin- lobes. The process has reached the tragus
and antitragus, though it has not attacked the canal. The ears
show evidences of superficial ulceration of the infiltrated parts,
probably due to the pressure to which these parts are subjected
when the patient is lying down. There can he but little tend-
ency for the affected parts to break down of themselves, as these '
superficial ulcerations heal with rapidity. The skin of the face,
-aid above, is infiltrated and hard, and in most places has a
shiny look, and to the touch resembles rubber. It is not, how-
ever, every where infiltrated to an equal degree, as there are areas
where the infiltration is thicker and denser than at others. About
the center of either cheek are several more or less contiguous
areas where the skin is so densely infiltrated as to be knotty.
These areas are slightly elevated above the adjacent skin, and
the total space occupied by them on either side is about a quar-
ter of an inch by an inch and a half. These areas are distinctly
nodular. Beneath tlie angle of the jaw on the right side are two
hardened areas which are, most probably, enlarged lymphatics.
On the forehead the skin is as yet but slightly attacked, and
while the process is the same as that below, the skin has not
been infiltrated to the same degree. At almost all points the
line of demarkation between the healthy and the infiltrated skin
is accurately defined. The affected parts are not painful or sen-
sitive on pressure. During the few weeks the negro remained
in Richmond a wash of warm bichloride (1 to 2,000) was kept,
for varying intervals during the day, applied to his face. The
only noticeable change following this was that the infiltrated
skin, especially over the forehead, lost much of its leathery feel-
ing and shiny appearance, and became more or less wrinkled
and movable, as though these parts were undergoing an involu-
tion to their normal condition. This, however, the negro said
it would do from time to time without any treatment, but after-
ward it would get dense again and spread further. This being
the case, it is impossible to say whether the bichloride solution
had any real effect upon the process. The change following the
use of the solution was. however, a marked one. The teeth are
well preserved. The skin covering the other parts of the negro
is healthy. Nor does the negro's general health seem to be im-
paired by this condition. Appetite is good. At one time he was
liable to colds in the head, but rarely suffers from them now.
Is a married man and has several healthy children, one of whom,
a girl about twelve years of age, leads him about from place to
place. Examination of the throat shows the tonsils to be greatly
hypertrophied, with marked evidences of adenoids of the naso-
pharynx. The application of the palate retractor shows the pos-
terior nasal picture to be normal, showing that the process had, at
least, not extended through the nose so far as to attack the pos-
terior parts of the turbinates or sreptum, while examination of
the nose anteriorly, as said before, makes it doubtful whether the
process has at all extended into the nose proper. One of the
tonsils was removed pretty thoroughly with a snare. A severe
inflammation of the pharynx, pillars, and soft palate of the side
from which the tonsil had been removed followed, and with it
immense oedema of the uvula. For a few days serious conse-
quences were feared; under treatment, however, the inflamma-
tion subsided and the wound healed perfectly. The cause of the
inflammation is, probably, to be sought in the negro's being un-
able to properly expel the accumulated secretions from his
mouth, owing to the stiffened condition of the lips and cheeks.
Remarks. — While the case has many characteristics
which make it, in all probability, a case of scleroderma, 1
there are certain features pertaining to it and to its history
which at least suggest a rhinoscleroma. The negro states '<
that a " hard, warty " growth appeared about twenty-two
years ago at the external edge of the right nostril : that it
remained years in this region, showing little or no tendency
to spread beyond it ; that in his endeavors to remove it he
made it bleed; that this growth then, finally, began to ex-
tend up the side of the right nostril and then crossed ever
and attacked the left nostril. Owing to the length of time
March 26, 1892.J
DUNN: A CASE OF SCLERODERMA.
339
that has elapsed since then it is impossible to determine the
nature of this hard localized growth. The nose now shows
DO evidence of a circumscribed nodular growth, but its skin
is equally infiltrated, so that one may not say that one part
is more infiltrated than another. It can not now be said
whether this originally circumscribed, nodular growth had a
tendency per se to bleed, or whether this tendency to bleed
was developed under the various attempts to cause it to
disappear by " wart remedies." The growth, however, was
not syphilis, as proved by the treatment to which the negro
has been subjected, nor was it epithelioma. Nor does the
present condition of the skin at all suggest cicatricial keloid,
a condition common enough in the negro race. Whatever
the original growth was, it has left no trace of itself behind ;
but whatever it was, it proved to be the starting point of a
sclerodermatic process, which has involved nearly the whole
face. The tendency to, at times, partially resolve is char-
acteristic of scleroderma ; but I can find no record of a
case where this seeming repeated tendency to involution to
recovery proves to be followed by an extension of the pro-
cess even beyond the limits from which the beginning in-
volution began. The fact that it is symmetrical points to
scleroderma. What the hardened, circumscribed areas in
the cheek mean it is difficult to say. It is possible that at
some time there may have been ulcerations in the places
now occupied by these nodular areas, the process of healing
giving rise to a cicatricial keloid condition ; on the other
hand, their general appearance is not at all suggestive of
keloid as seen in the negro. I cut into one of these areas
to see if there was any broken-down tissue beneath. It was
firm, elastic under the knife, cutting like scar tissue. Again,
if these infiltrated areas represent scar tissue, some process
different from simple dermatitis must have existed at these
places to have given origin to them, since at the other
places — e. </., beneath the corners of the mouth, where there
has existed superficial inflammation — no such result has ap-
peared. The process seems to have been unwilling to at-
tack the mucous surfaces, unless the swollen condition of
the gums show that it has invaded them. I think it more
probable, however, that, as above stated, this condition of
the gums has resulted from their exposure. What the
small, contracted areas in the mucous membrane behind the
upper front teeth mean I do not know. The tissue sur-
rounding them is, however, not infiltrated. A more inter-
esting problem is furnished us in the condition of the eyes.
By what process did the lower lids disappear? We have
here not to do with a severe case of ectropion, or entropion,
or partial destruction of the lower lids, such as might result
from an inflammation or a circumscribed ahseess, hut with
a destruction so complete that, from external to internal can-
thus, not a vestige of t hem remains. Skin, muscle, and mucous
membrane have entirely disappeared. It is as though some
one had seized the free edges of the lower lids and pulled
them from the cheek as far as possible, and then shaved the
lids off close to the cheek. There remains not one shred of
sear tissue to show that they disappeared piecemeal. A.bou1
twelve years ago, says the negro, the process, which had up
to that time confined itself to the region of the lower nose
and adjacent cheek, spread upward and reached the lids,
following which came an intense inflammation of the eyes,
which remained closed by the swelling for some time.
Much secretion from between the lids. Then followed dimi-
nution of the swelling of the lids, with great pain in the
balls, which pain remained until the sight had been entirely
destroyed. To one who has seen much of eye troubles
among the negro race this bit of history means nothing, or
very little, and even less when twelve years have elapsed.
Having seen the case only after the destruction of the lower
lids had become complete, the manner of their disappear-
ance must remain a conjecture. It may not, however, be
uninteresting to look into the cause which might have led
to such a condition. The present state of the upper lids,
except for the infiltrated condition of the cutaneous surface,
is such as might be the result of most any of the severe in-
flammations of the conjunctiva if continued for a length of
time. The history, as given by the negro, suggests puru-
lent ophthalmia, with corneal ulcers, perforation of the ball,
\
Fig. 2.
following which its gradual destruction. There are no re-
mains of the eyeball in either socket, unless there be a part
of the sclerotic, which may be left, as in the left " eye."
There are some movements at the center of the inflamed
surface, where the eye was, which suggest that the muscles
have their insertion there. How did the lower lids disap-
pear ? Could the destruction have been begun by an ab-
scess occurring at the time of the ophthalmia, and have
been completed in the course of years by the continuous
pouring over them of the mueo-puruleut , and lacrymal
secretions ? This seems little probable since these same
tears and other discharges have not heen able to destroy or
to do more than produce a slight form of dermatitis of the
skin below the orbit, and they hav< ntinued ever since the
lower lids were destroyed. The eves were three or four
years in "going out," during which period the negro suf
fered intensely. This is t he historj of perforations and their
results.
In seeking the possible causes of the destruction of the
lower lids, the following case from among a collection of
340
ROIUXSOX: AFFECTIONS OF THE UPPER AIR PASSAGES.
[N. Y. Med. Joub..
photographs of tin* rarer affections that came to the Rich-
mond Eye Infirmary presented itself, and a short history of
the case may not be out of place here : James A., negro,
aged twenty-three, had suffered every spring for several
years with some eve trouble the nature of which he could
give no better description of than that "the light hurt his
eyes " — words used by the average negro to describe any eve
affection whatever. (Probably phlyctenular inflammation
was the trouble.) In June, 1891, his eyes became much
inflamed, and in a week both eyes had assumed the appear-
ance shown in Fig. 2, except that the right eye presented
a condition exactly similar to that of the left eye in the
cut, the less swollen appearance of the right lower lid be-
ing due to the fact that a part of the tumor of this lid had
been removed by a physician before the negro appeared at
the clinic, which he did the latter part of July, 1891. The
condition of the eyes then — that is, seven weeks after the
trouble began — was as follows : Patient was entirely un-
able to open either eye ; the lower lid of the left eye was a
huge smooth, ovoid mass, covered with shining mucous
membrane; the cutaneous surface of the lower lid was bent
over by the weight of this tumor until it lay in apposition
with the skin of the cheek ; all endeavors to open the eye
resulted in a slight constriction at the base of the tumor,
caused by contraction of the orbicularis fibers; this swell-
ing of the lower lid was seemingly a true hypertrophy
of the tissues beneath the mucous epithelium, most likely
of the adenoiil reticulum of the mucous membrane; the
secretion from the eye was small in amount in comparison
with what might have been expected, and was rather sero-
mucous than purulent. The upper lid was apparently1
elongated, and responded, but in the slightest manner, to
the efforts of the levator; and, though its mucous mem-
brane was in an inflamed condition, especially in thecul-de1
sac, there was no such swelling anywhere as the lower lids
showed. The lids of the right eye were in a similar condi-
tion, except that, as stated above, a piece had been removed
from the mass in the lower lid. Both cornea? were almost
completely surrounded with superficial ulcerations, or leu-
comatous patches, showing that ulcers had once existed.
V bile no perforation of the cornea could be made out,
there had been a severe double iritis, with adhesions to the
lens. As said above, there was complete eversion of the
lower lids, which infiltration or hypertrophy had trans-
formed into helpless masses. When the negro was told to
shut his eyes there appeared a constriction at the base of
these tumors, due to contraction of the outer fibers of the
orbicularis. This condition of the lower lids I have seen
in one other case, also in a negro, the trouble being un-
doubtedly purulent ophthalmia, as was also the case in the
subject of the accompanying cut, although the stage of ac-
tive purulent discharge had passed when he came to the
clinic ; and it is not improbable that a similar trouble was
the cause of the complete destruction of the lids in the case
of the"" negro with scleroderma. The history would, then,
be about as follows : Purulent ophthalmia; great infiltration
and complete eversion of the lower lids; great stretching of
the skin at the place where the check and lower lid meet;
perhaps stasis <>f blood-current in the skin here, with ul-
ceration and destruction of the skin along the line of ten-
sion. Thus, could the entire lower lid be separated from its
attachments, while the condition of the lids would be most
unfavorable to any reunion of the parts, afterward slow,
continuous ulceration could destroy the lids entirely, espe-
cially when already a pathological process existed in their
cutaneous covering. The case of James A. has been added
here not because it answers entirely to my satisfaction the
question of how the lids in this case of scleroderma disap-
peared, but because it offers a more probable solution than
any other that suggests itself.
THE RELATION OF DISTURBANCES OF THE
MUCOUS MEMBRANE OF THE UPPER AIR PASSAGES
TO CONSTITUTIONAL CONDITIONS*
By BEVERLEY ROBINSON, M.D.
To establish the connection between constitutional con-
ditions and disturbances of the mucous membrane of the
upper air passages is at times a relatively easy matter. In
more frequent cases it is difficult to make out clearly the
interdependence of the general and local conditions. In a
certain proportion of instances, even after the most careful
repeated examinations, one can not but remain in great doubj
as to whether there be any common causation of the dia-
thetic state and the physical changes observed in the upper
portion of the respiratory tract. In order to form just ideas
on this subject it is important to investigate without preju-
dice and to scan every clinical case observed in the most
thorough and searching manner. It is also required to at-
tach due weight to the observations of learned men wdio
have preceded us in their practice of the healing art. While
this is true, we should not be over-tolerant of opinions held
in the past, if later advances in our science and art prove
that former beliefs are erroneous, or that clinical data handed
down are unreliable by reason of lack of precision in the
methods employed.
Still, there are certain judgments which have been tested
so frequently and so long that we should be very careful lest
we abandon them without sufficient reasons.
These remarks are but a prelude to the statement that
the old notion, which was widespread, of a constitutional
condition influencing every local state is fast losing ground
with the modern practitioner. To my mind, there is little
doubt that very many physicians of the present day are in-
clined to localize most human ailments to the exclusion prac-
tically of the diathetic influence. This tendency naturally
makes local treatment of primary importance whenever any
real disease is present which requires remedial interference.
In no special departments of medicine or surgery is my
statement truer than it is in those of laryngology and rhi-
nology. Just why this view of our art has arisen may be
clearly explained, as it seems to me, by the consideration of
a few facts. First, modern thought in laryngology and
rhinology, as in every special branch, has forcibly, as it
* Read before the American Larvngologieal Association at its thir-
teenth annual congress.
ROBINSON': AFFECTIONS OF THE UPPER AIR PASSAGES.
341
were, limited the mental horizon of the observer. Such an
one can not delve into general medicine. It has become too
large and also too changeable. New discoveries and new
ways of doing things are being added each day to every de-
partment. The busy and successful man — the one upon
whose judgment we most rely — can not find time to go out-
side his special field of work and see and hear things as
some others see and hear them. The result is that he is
not wholly convinced of the truth of things spoken and writ-
ten by those about him, as they do not thus come before his
mental vision. Besides, whenever the throat specialist finds
that in some instances which have come under his care a
particular line of treatment has been beneficial, he is apt to
assume that he can lay down general laws which should gov-
ern the action of others, and he does not allow enough lati-
tude to the various aspects according to which even the sim-
plest case can be regarded. These reflections do not prevent
me from fully recognizing the great strides in advance that
have been made latterly by the specialists in laryngology.
No one is more willing to admit that mechanical ingenuity
and operative interference have relieved or cured many pa-
tients in whom the outlook without their aid was well-nigh
hopeless.
And yet the human body is formed of many different
organs whose structures and functions are linked indissolu-
bly to one another, and we can not ignore any one of them
as being wholly unimportant in its influence upon the others.*
So it is that we start out with the thought that the relation
of disturbances of the mucous membrane of the upper air
passages to constitutional conditions are various and in-
tricate.
Sometimes the mucous membrane itself, by reason of its
diseased condition, which has arisen in some accidental or
wholly obscure manner, seems to be a focus for diseased
germs — the habitat in which they will flourish and propa-
gate readily — finally to end in constitutional disorder of an
acute or chronic type. Frequently the diseased constitu-
tional condition precedes, indeed, all physical or rational
evidences of local disturbance in the mucous membrane of
the upper air passages, and it is only after weeks and
months that the general disease is plainly manifest in the
alterations of function and structure which are clearly dis-
cernible.
The constitutional condition may be one of those in
which heredity or contagion plays an essential part as an
efficient causative factor, or one in which the habits, mode
of life, and surroundings are obviously the powerful agen-
cies at work, or, finally, one in which the mere development
of the individual seems to be the seed which will cause the
local disturbance to come into being and grow at a cer-
tain period of life with more or less certainty. The con-
stitutional conditions we are called upon to consider may
be acute or chronic. In the former we find the fevers, and
among these the fevers which come to mind most promi-
nently are typhoid fever, the eruptive fevers, and those due
to malarial poison. Then we have diseases of a general
and acute character, like diphtheria and acute miliary tu-
berculosis, which unquestionably produce different disturb-
ances of the upper air tract. As I understand the subject
of discussion, however, it was not intended to include in it
the affections just mentioned, with, perhaps, the exception
of the relation existing between malarial diseases and dis-
turbances of the upper air passages. Doubtless the section
had in view chronic tuberculosis, syphilis, scrofula, carcino-
ma, gout, rheumatism, lithsemia, alcoholism, etc. This list,
just as the former one, can be largely added to, but in so
doing I should be going beyond the short introductory
message that is properly expected from me. No one pres-
ent, I am sure, can doubt for a moment that the constitu-
tional condition which is shown in general chronic tubercu-
losis finds for itself a very frequent localization in the up-
per air passages. Particularly as laryngologists are we called
upon to recognize this sad fact in our diagnosis and treat-
ment of intralaryngeal disease.
Whenever laryngeal tuberculosis is distinctly evident,
the clear-cut relation between the constitutional condition
and the local disturbance is recognized at a glance. By
this statement I do not mean to say that it can be known at
once how and when the tubercular deposit has taken place
in the larynx. I simply wish to affirm that there can be no
doubt as to the precise nature of the disease. It can not
be confounded with the ordinary chronic catarrhal laryngi-
tis, which exists as a primary affection, or as a sequela of a
mild form of acute laryngitis. The ulcerations in the larynx,
the history of the patients, and the intrapulmonary condition
are all sufficient, as a rule, especially when the disease is at
all advanced, to allow us to make the differential diagnosis
with perfect ease. If, however, the laryngeal inflammation
is relatively slight in an anasmic patient in whom the chest
signs are negative and no abrasion of tissue exists locally,
it becomes a very delicate matter positively to decide what
the exact relation is between the disturbance of the laryn-
geal mucous membrane and the constitutional condition.
The general cachexia and impaired nervous nutrition influ-
ence very much the nature and course of the catarrhal in-
flammation of the larynx, and for a considerable time we
are left in doubt as to whether these conditions will be fol-
lowed or not by the local deposit of tubercle in the vocal
organ. It is probable that, whenever the ulcerative or hy-
pertrophied typical condition of the laryngeal structure is
reached, it is brought about, in part at least, by the con-
stant irritation which is occasioned by the passage of dis-
charges over the laryngeal mucous membrane and by the
efforts made by the patient to get rid of them by expectora-
tion. The additional movements thus occasioned in the
larynx unquestionably favor the local deposit of tubercle
and the development of more marked laryngeal complica-
tions.
As in tubercular disease, so in syphilis, a chronic catar-
rhal laryngitis is often greatly modified as to its course, its
symptoms, and its appearance by the underlying consti-
tutional condition. A syphilitic laryngitis presents, even
without ulceration, a deeper, more persistent coloration than
that due to simple catarrhal inflammation. Moreover, the
painful symptoms accused by the patient are not at all in
proportion with the apparent degree of the inflammatory
condition. Again, the use of specific treatment with mer-
cury and the iodides benefits the patient so rapidly and
342
JWn/XSOX: AFFECTION'S OF THE UPPER AIR-PASSAGES. [N. Y. Med. Jour.
manifestly as to leave no doubt in the mind of the physi-
cian as to the distinct causal relation of the syphilitic dis-
ease to the disturbance of the laryngeal mucous membrane.
In many cases the acknowledgment of the patient in regard
to previous syphilitic infection will enable us to reach a
decision in some very obscure cases. Of course, if the intra-
laryngeal congestive condition advances to ulceration, this
of itself is sufficient to distinguish it from chronic simple
catarrhal laryngitis. The irregular outline, yellowish exu-
dation, and red areola of the syphilitic ulcer are readily dis-
tinguished from the ashy-gray hue and raised, thickened, pale
borders of phthisical ulcers. Its march is more rapid and
its symptoms are less painful. In secondary syphilis espe-
cially hyperemia often attacks the nasal mucous membrane,
and in these cases occasions the symptoms of ordinary nasal
catarrh. The tendency to the formation of ulcers or mu-
cous patches on the erythematous surface is tpiite marked,
and particularly so among the poor, or with patients who
are smokers or take snuff. The syphilitic erythema is
sometimes in patches or punctate. It is difficult to differ-
entiate from ordinary catarrhal inflammation of the pitui-
tary membrane, except by the fact that the hue is more
dusky and there is less apparent irritation than there would
be from a hypenemia dependent upon a cold. Mucous
patches are occasionally seen in the larynx and trachea, but
they rarely become extensive in these situations, and disap-
pear after a few weeks of mild treatment. The diffuse con-
nective-tissue hyperplasia, without ulceration, which occurs
in the larynx in the tertiary stages of syphilis is accompanied
by a dark-colored mucous membrane and a general thicken-
ing which affejts the soft tissues of this organ.
Among the disturbances of mucous membrane of the
upper air passages which are obviously connected with
scrofula, an inflammation of a low type is the one most fre-
quently encountered. In this form the exudation is
markedly thick and sticky, and the tendency to the forma-
tion of dry scabs is most pronounced. Concomitantly we
have different eruptions on the skin which manifest the
diathetic nature of the lesions. Impetigo of the scalp,
face, and eyelids, eczematous eruptions around the ears,
in the auditory canals, and upon the upper lip and at the
nares, are commonly met with. The bones, periosteum,
and synovial membranes may also show evidences of scrofu-
lous development which, taken with the affection of the
mucous membrane, leave no doubt as to the nature of the
underlying dyscrasia. The more destructive ulcerative
lesions of scrofula as affecting the pharynx and larynx
are rarely seen in this country as compared with many
parts of Europe, and notably with Germany. Unfortu-
nately, we do occasionally meet with them in the throat in
the form of those ravaging lupoid conditions which occa-
sion such deformity and interference with normal function.
The patients thus affected are often the offspring of in-
temperate, syphilitic, or phthisical parents. The hereditary
influence is, however, not always well marked, and the
scrofulous diathesis appears to be acquired by reason of
poor food, lack of sunlight, and unhygienic surroundings.
The alternation in these cases between a corvza, catarrhal
conjunctivitis, otorrhea, and ulceration of the cornea is fre-
quently one of the most evident marks of the constitutional
relation to the disturbance of the mucous membrane of the
upper air tract. The inflammations of the larynx and
bronchi are frequent and obstinate. Not seldom they ex-
tend to the pulmonary alveoli, and tuberculous deposits in
the lymphatic ganglia and lung structure are prone to take-
place sooner or later. The diagnosis of the scrofulous dis-
turbance of the mucous membrane of the upper air tract
usually is determined in great part by its low grade of re-
action, by its singular obstinacy or duration, and by the
peculiar, characteristic changes w hich appear concomitantly
and give evidence of the presence of the constitutional
condition. One statement must be graven in the mind of
the observer, because in regard to this subject there arise
great and lamentable errors — viz. : that those chronically
seamed and scarred throats, with distorted pharynx, the
result of former destructive ulceration, which are not in-
frequently met with both in youthful and adult subjects,
are not of scrofulous origin, but unquestionably syphilitic
in the very large majority of cases. Koch's late discovery
of tuberculin appeared at first to be of very great value in
making, through injections of it, the differential diagnosis
particularly in instances in which a syphilitic history or
parentage could not be traced. Unfortunately, it has
failed to accomplish this end in just such cases, and we are
again obliged to fall back upon the results obtained, when
cases are seen soon enough, by pushing the treatment by
means of an iodide rapidly increased to large, repeated doses.
Of course, w hen great ravages are already made we can
only hope to prevent further destruction and remedy, it
may be, alterations in the voice and difficult deglutition by
operative interference. Gout and scrofula often exercise a
decided influence on the course and manifestations of
syphilis as it appears in disturbances of the mucous mem-
brane of the upper air passages. "Whenever gout is pres-
ent the hypenemia of the mucous membrane of the upper
air tract presents a drier, more glazed appearance than
when the syphilis is uncomplicated. When ulcerations
form in the nasal passages or in the pharynx they are cured
more slowly and show a tendency to return which is quite
disheartening at times. Finally, the gouty diathesis tends
unquestionably to cause nervous symptoms in syphilis, as
shown by pains in the throat upon swallowing or in using
the voice, which are not always sufficiently accounted for
by the evident lesion which is present. "Whenever scrofula
complicates syphilis the cicatrices of ulcer in the throat
take on a more irregular, puckered, and ridged appearance,
and are less smooth, thin, and glistening than those dis-
tinctly characteristic of syphilis. No doubt, therefore, in
many instances the syphilis is really complicated with
scrofula, and the resultant ulcerations have about them all
the appearances of struma, not unlike what often occurs in
cutaneous ulcerations. The type of the syphilis is apt to
be more inveterate and often attended by destructive bony
lesions. The relation between chronic malarial infection
and disturbances of the mucous membrane of the upper air
tract has been noted by competent observers for a long
period of time. In a paper read before this association in
June, 1890, in Boston, I made known my experience in
March 26, 1892.]
ROBINSON: AFFECTIONS OF
THE UPPER AIR PASSAGES.
this connection. Frequently a malarial attack is ushered
in, not by chills and fever, but rather by repeated sneezing
or an obstinate, paroxysmal cough. Upon inspection with
the laryngeal mirror or with the nasal speculum, we may
only find the usual catarrhal appearances indicative of an
acute laryngitis or rhinitis. When we come to inquire into
the history of these patients we shall find that these attacks
come on periodically, are followed by fever and chills at
times, resist ordinary remedies for cold, and are brought
into subjection after a short treatment with quinine or
Warburg's tincture. Frequently the spleen is enlarged, and
occasionally pigmentary deposits or 'different forms of the
Hcematozoon malarice are found in the blood upon careful
microscopic examination. In view of these facts, I believe
that we can scarcely doubt the relation which exists between
the blood dyscrasia and local attacks of the disease on
mucous membrane of the upper air tract. Many cases of
spasmodic asthma, apparently of the nature of a bronchitic
asthma under the immediate dependence of an inflammatory
condition of the bronchial tubes, have been signally relieved
by anti-malarial agents used remedially, when cauterization
of the nasal membrane and sawing the saeptum had obvi-
ously been of little or no benefit. In any case to-day of
obscure disturbance of the mucous membrane of the nose,
throat, larynx, or bronchi, with a history of possible mala-
rial exposure, and after eliminating other complicating con-
ditions, it is wise to think of blood poisoning from Hcema-
tozoon malarice as being the efficient cause of the morbid
symptoms. Judicious treatment, after proper physical and
blood examinations have been made, will frequently con-
firm an uncertain diagnosis in just such cases. It is also
true that quinine and Warburg's extract will occasionally
fail to be curative in these attacks after a time, and we
shall be of greater service to these patients by prescribing
for them phosphorus and strychnine in moderate, long-con-
tinued doses.
The relation of carcinoma to one of the disturbances of
the mucous membrane of the upper air passages has been
shown in a detailed and graphic manner before this associa-
tion last year. It would seem as if in the earlier stages at
least of malignant disease of the larynx, some value should
he attached to the infiltration of the soft tissues which in-
terferes notably with the movements of the vocal cord on
one side, to the existence of a ring of reddened infiltrated
tissue around the new growth, and to the cloudy area in the
vicinity of the growth which can be demonstrated by the
use of transillumination. Of course the lancinating pains,
swelling and induration of the glands near the cornua of
the hyoid bone, the character of the secretion, and well-de-
fined deformity will be of much value, whenever they arc
present, in fixing a diagnosis. The appearances of the
growth and the general history of the case are often help-
ful. The absence or presence of syphilis or tuberculosis
and the effects at times of more or less prolonged antisyphi-
litic treatment aid our judgment frequently as to the nature
of the case with which we have to do. In like manner the
microscopical examination of a portion of the tumor re-
moved before or after death is occasionally of the highest
diagnostic importance.
No doubt one of the determining factors in producing
malignant disease in the larynx is the frequent occurrence
of infiammatory conditions in this organ. The constant use
of the voice seems to become a source of local irritation in
many instances, and thus the professions of singer, teacher,
public speaker, all appear to promote the local deposit of
cancerous tissue. The constant inhalation of irritating va-
pors and dust is also a predisposing cause in occasioning a
local hyperaemia which so frequently precedes or accom-
panies the presence of malignant growths. Apart from all
local changes, however, there is always apparently in opera-
tion the underlying constitutional dyscrasia which gives the
specific character to the morbid lesions. We all know that
when the chylopoietic syrstem is out of order or performing
its functions imperfectly, repeated and often obstinate pha-
ryngeal and laryngeal irritations are apt to occur. It is
only by due attention to this knowledge and by proper direc-
tion of treatment in view of it, that we are able to effect
cures in cases otherwise intractable.
Chronic alcoholism is often made evident by the con-
gested, excessively irritable pharynx or larynx, and a diag-
nosis otherwise obscure is thus sometimes readily made..
An annoying naso-pharyngeal catarrh, with marked enlarge-
ment of the tonsils, is occasionally very distinct proof of the
process of second dentition in the young lad or girl. A
disordered emotional temperament or a well-marked neuras-
thenic state is not seldom the underlying cause of recurrent
attacks of coryza which have defeated our best-directed ef-
forts at successful local treatment. Luxurious habits and
surroundings, sedentary occupations with accompanying
chronic dyspepsia and constipated bowels, will sometimes
produce irritability of the reflex centers of pose and throat
which can only be cured by the exposures of an outdoor life
and their accompanying hardships. While this is true, it
is also a fact that once the catarrhal inflammation of the
upper air passages has taken place, it frequently aggravates
very much the pre-existing dyspepsia and the adjoined lith-
a>inic state. Indeed, it is no uncommon thing to hear a
patient say that it is the violent hawking and constant spit-
ting from which he suffers every morning on rising that un-
settles his stomach at that time, and may continue to cause
inappetence or disgust for food during several hours of the
day. It is an observed fact, not very infrequent, that pa-
tients who have never previously suffered in the smallest
degree from any evidence whatever of one of the recognized
forms of dyspepsia have developed this condition in a dis-
tinct form subsequent to the appearance of a catarrhal in-
flammation of the nose, naso-pharynx, or the pharynx and,
larynx. It is probable in such cases that some of the se-
creted mucus from these organs works its wav down the
back of the throat and is swallowed, thus starting gastric
disturbance. It is also clear that the current of inspired
air, or rather the air which is swallowed after passing over
masses of mucus or muco-pus, more or less in a state o£
putrefaction, must be very injurious to the healthy functions,
of the stomach, or stomach and bowels. It is well known,
that the " condition of sulfoxidation and overcharging of
the blood and excretions with excretory matter in a state of
faulty elaboration " is but too prone to occasion disturb-
3U
SOUS- < 'OH EN : 1NFL UESZ. I .
[N. Y. Meu. Jock.,
ances of the mucous membrane of the upper air passages.
The patchy congestion of the pharynx, the epiglottis, ary-
epiglottic folds, and ventricular bands is often indicative of
this condition. The throat is extremely irritable and the
patient suffers from a harsh, dry rough. There is often
marked dysphagia referred to the sides of the larynx. Ap-
propriate g&neral medication and hygiene generally bring
these attacks to a close in a short time, and thus the thera-
peusis of the case seems to establish the correctness of the
relation between the constitutional condition and the local
manifestations.
THE SYMPTOMS AND PATHOLOGICAL CHANGES
IN THE UPPER AIR PASSAGES IN INFLUENZA.*
By J. SOLIS-COHEN, M. D.
I n presenting a summary of the symptoms and patho-
logical changes in the upper air passages in influenza, let
7ne at once refer to the remarkable paper presented to us
in 1889 by our present president, in which he seemed to
have recognized a precursor of the recent pandemic in a
series of cases which had come under his observation for
the previous three or four years. If we carefully peruse
this paper and compare it with half a hundred or more of
the reports of ordinary and exceptional lesions which have
been noted during the pandemic of 1889-'90 in the most
diverse portions of the globe, we can not fail to be impressed
with the accuracy displayed in Dr. Glasgow's observations.
A few such confirmative records will be referred to in foot
notes when these remarks are printed.
To confine the subject to the limits assigned for the
present discussion, we find from various sources records of
a mucoid or, as I would call it, a lymphoid oedema of the
palate and pharynx, of the intranasal structures, of the epi-
glottis, and of the larynx, top and interior. We find rec-
ords of patches of exudation on the tonsils and on other
portions of the throat, much resembling the patches of diph-
theria ; we find records of oedema of the glottis and death
therefrom, analogous to Dr. Glasgow's cases of oedema of
the vocal bands, and of sudden death from spasm of the
glottis or from sudden laryngeal stenosis. f
We find records of purpura spots on the mucous mem-
brane of the structures already named, and even in the
trachea, with recurrent haemorrhage therefrom ; \ and we
rind records of mycosis of the tonsils.
There are a few additional manifestations in our imme-
diate domain which have doubtless been observed by Dr.
Glasgow during the late prevalence of influenza. These are,
as extensions from the nasal passages, inflammation and sup-
puration in the frontal and maxillary sinuses, in the eth-
moidal cells, cerebral abscess, inflammation of the Eu-
stachian tube leading to otitis media, and other lesions of
the auditory apparatus; as extensions of the laryngitis,
* Head before the American Laryngological Association at its thir-
teenth annual congress.
•| l)e Lostalot. France mid., March 28, 1890. Bavaehi. Gaz
med. d'Orient, April 15, 1891.
% Caverhill, Senion. Edinb. Med. Jour., August, 1890.
haemorrhage * and abscess ; + and as sequela-, paralysis of
the palate \ and paralysis of the larynx.*
I should likewise call attention to a paper by another
fellow of our association, Dr. Seiler, read in the same year
before the Laryngological Seel ion of the American .Medical
Association, in which he presents a summary of some five
hundred personal observations of cases similar in character
to those described by Dr. Glasgow and with which he had
been familiar for about the same period.
Although the aetiology of influenza is not included in
the subject of the present discussion, it may be permitted
here to remark that the various local but extensively sepa-
rated telluric disturbances of several kinds that have taken
place in the United States within the period comprised in
the clinical observations of Dr. Glasgow and Dr. Seiler, and
of a few others of like character, link their cases to those
which have recently occurred pandemically throughout the
globe, and which have not altogether ceased to appear en-
demically, and that they thus justify the surmise of Dr.
Glasgow that the epidemic described by him was to be re-
garded as influenza — a surmise, under the circumstances, of
most discriminative acumen.
The symptoms of influenza as manifested in the upper
respiratory tract are not at all characteristic, and are recog-
nizable as due to that disease only from their endemic char-
acter and the peculiar prostration of the nervous system
which attends them, and which in its turn is characterized
by suddenness of onset and by great debility of the circu-
latory system.
These symptoms comprise sternutation, coryza, paros-
mia, nasal dyspnoea, epistaxis, sore throat, dysphagia, im-
paired articulation, cough, expectoration sometimes haemor-
rhagic, dysphonia, aphonia, laryngeal dyspnoea, spasm of
the larynx.
The lesions, mainly catarrhal, giving rise to more or
less of these symptoms are not universal. They exist proba-
bly in about one fourth of the cases, the remainder pre-
senting the nervous, pulmonary, and gastro-intestinal dis-
orders without catarrhal complication.
The pathological lesions observed in the upper respira-
tory apparatus comprise catarrhal, hemorrhagic, and puru-
lent rhinitis ; inflammation and suppuration of the eth-
moidal, frontal, and maxillary sinuses ; acute phlegmonous
and cedematoid sore throat ; simple acute pharyngitis and
cedematoid pharyngitis, general amygdalitis, and lacunal
amygdalitis ; inflammation and tumefaction of the lymphoid
nodules at the vault of the pharynx and in the base of the
tongue ; pseudo-membranous exudation of the tonsils, pal-
ate, pharynx, tongue, and larynx ; superficial, cedematous,
hemorrhagic, fibrinous, subglottic, purulent, and ulcerative
laryngitis ; abscess of the larynx ; simple and haemorrhagic
tracheitis — all this but an exemplification of the general
Protean characters of influenza in general.
To these must be added submaxillary and cervical infil-
tration of the connective tissue with lymph, simulating the
* Marano. Arch. ital. di lar., May, 1890.
f Scbaffer. Devi, med, Woch., No. 10, 1890.
\ Heymanu. Dcut med. Ztg., March 1, 1890.
* Krakauer. Deut. med. Ztg., March 17, 1890.
\ .
March 26, 1892.] SOLIS-COHEN :
more serious lesion known as Louis's or Ludwig's angina,
and sometimes compressing the larynx. On incision into
this tumid mass there is no evacuation of pus either imme-
diately <>r a day or two after, but only hlood and serum or
a serolymph exude, as occurred in a few cases I have seen
in consultation during the pandemic.
These lesions occur but in a small proportion of the ca-
tarrhal eases.
It is to be hoped that some member of the profession
with sufficient leisure will study the records of these mani-
festations with a view of learning their proportionate fre-
quency.
The congestion of the mucous membrane is passive
rather than active, due to venous stasis rather than arterial
congestion. The color is a violet-red rather than a carmine.
The membrane looks sodden, tumid, and pasty from lymph
stasis, and from exudations of lymph on the surface. Ec-
chymoses take place in irregular numbers and distribution,
and haemorrhages, for the most part slight, in a certain pro-
portion. In the cedematoid cases muco-lymph, rather than
sero-mucus, is discharged from incised wounds, and the re-
lease of serum, as in ordinary oedema from venous stasis, is
seen but exceptionally.
At a later date fibrinous accumulations are noted at va-
rious points upon the mucous membrane. In some cases
there is profuse glandular secretion, and in some laryngeal
cases the secretion may be seen exuding from the ducts of
the glands.*
The morbid process may proceed to suppuration and ul-
ceration, while in some cases abscesses are formed. These
manifestations do not subside with the actual attack of in-
fluenza, but often continue for a number of weeks after ces-
sation of all characteristic constitutional symptoms.
In some cases of laryngeal complication, paresis of the
laryngeal muscles takes place, chiefly in the domain of the
constrictors, and occasionally in the form of paralysis of the
recurrent, f
Paralysis of the palate and other paralyses sometimes
occur in the domain of the upper respiratory organs which
bear considerable resemblance to the paralysis occurring in
diphtheria.
I have seen a number of examples of the tumid, puffy,
pasty condition of the mucous membrane of more or less of
the mouth, palate, and pharynx, so well described by Glas-
gow, much resembling ordinary oedema on first inspection,
but not fluctuating or pitting under pressure. The tume-
faction is often so great as to impair articulation, respira-
tion, and glutition. The rhinopharynx, the interior of the
nose, the epiglottis, the borders and the interior of the
larynx, may be similarly affected. At the same time, in
some instances, there is an analogous tumefaction of the sub-
cutaneous tissues under the lower jaw and in front of the
neck, similar in appearance to that of diffuse cellular infil-
tration, widely known as Louis's or as Ludwig's angina, and
giving rise to dyspnoea by compression.
Incision into the tumid portions of mucous membrane
* B. Frankel. I>< nt. me'd. Woeh., No. 23, 1890.
f Krakauer. Loc. eit.
INFLUENZA. 345
show that the infiltration is not serous but seems lymphous,
and the viscid liquid will exude in long strands. During
paroxysms of gagging after incision I have seen thick strands
reach from the mouth of the seated patient to the spittoon
on the floor in unbroken streams. In other cases there is
nothing but venous hajmorrhage from the incision, but con-
siderable mucoid or lymphoid material will be expectorated
later.
Before the cedematoid condition is reached, the lymph
will have made its appearance on the surface of the mucous
membranes, whence it is expectorated in thinner viscid
strands. The known connection of the lymphoid spaces of
the nasal mucous membrane with the subarachnoid and
subdural spaces affords a clew for accounting for some of
the terrible meningeal and cerebral complications, if we
admit that the disease is one affecting the lymphatic circu-
lation as well as the sanguinous circulation. It is probable
that both are impaired by paretic conditions of the vaso-
motor system as a direct consequence of the poison of in-
fluenza, just as its poisonous influence upon the pneumo-
gastric nerve has long been held to account for the frequent
pneumonic congestion and the cardiac debility. The tume-
faction of various lymphatic glands and of the spleen noted
in many cases still further indicates the lymphatic apparatus
as a chief seat of lesion.
I must therefore regard the immediate anatomico-patho-
logical lesion of influenza, as manifested in the upper respir-
atory passages, as one involving the lymphatic organs and
structures, in consequence of which the lymph accumulates
in the connective tissue.
There appears to be a paresis of the nervous system, in
partial result of which there is a stasis in the venous and
lymphatic circulations. Hence passive sanguineous con-
gestions, ecchymoses, and haemorrhages from the one, and
passive lymphous congestions and lymphous or mucoid exu-
dations from the other. Fibrinous exudation occurs in
some instances, and a typhoid grade of inflammation in
others, sometimes terminating in suppuration and in dis-
crete or in diffuse abscess.
I have had two most remarkable instances of a happy
effect of severe attacks of influenza upon malignant dis-
eases. One was a severe case of epithelioma of the palate
in a gentleman more than eighty years of age. The diag-
nosis had been confirmed by histological investigation. I
had destroyed the entire disease upon one side by partial
excision and by electrolysis, and it had cicatrized in the
most satisfactory manner. The opposite side, which was
not near as extensively diseased at first as the other side,
resisted the same treatment and also the electric cautery.
It had in places succumbed to lactic acid, but, despite all
that could be done, the disease had extended to the pharvngo-
palatine folds and to the region of the alveoli, when, in
January, 1S91, the patient was suddenly attacked with the
influenza. The brunt of the disease was borne in the cpi-
theliomatous portion of his throat ; the entire diseased por-
tion sloughed out, and he convalesced from his influenza
and his epithelioma together. A year later he called to
pay me a Christinas visit, and he was so stout I did not
recognize him until he laughingly recalled himself to me.
346
BOS WORTH: ASTHMA.
[N. Y. Med. Jock.
The other case was one of tuberculosis of the lungs and
the larynx in a lady about fifty years of age. The cough
was incessant. Rest at night could be secured but by spells,
and that with difficulty. Expectoration was extreme. It
was reported to ine by her family physician as more than a
pint in the twenty-four hours. This lady was attacked
with influenza, and that disease cured her tuberculosis.
She has not coughed or expectorated for eighteen months;
and is, to all intents and purposes, a healthy, though not a
robust, woman.
These cases present some compensation for the much
larger class in which the influenza hurries the patient to his
doom. They remind me very much of a number of cases
which 1 have observed for many years in hospital practice,
in which patients with tuberculosis, with syphilis, and with
carcinoma have become cured by the effects of an intercur-
rent attack of erysipelas. I have been afraid to inoculate
similar patients with erysipelas, lest it should get beyond con-
trol, for erysipelas of the nose and throat is a very serious
disease ; but I have again and again called the attention of
some of my bacteriological friends to the importance of the
subject, and have for years unavailably coaxed some of my
surgical friends to have some of their cases of carcinoma
of the mamma inoculated with erysipelas, as that disease
would be more manageable on the exterior of the body than
in its cavities.
I can thus confirm the observations recently recorded
from various sources, that infection with erysipelas will
sometimes cure tuberculosis and carcinoma.
THE RESULT OF
TREATMENT OF THE UPPER AIR PASSAGES
IN PRODUCING PERMANENT RELIEF IN ASTHMA.*
By FRANCKE II. BOSWORTH, M.I).
I think all of us will confess to a certain degree of en-
thusiasm in adopting new and original methods of treat-
ment for the relief of hitherto obscure and intractable dis-
eases, and, furthermore, that in recording our results we are
under the influence of a certain mental bias, which leads us
perhaps to overrate our successes. Whether this be true in
regard to the intranasal treatment of asthma seems now the
fitting time to decide, in view of the fact that a number of
years have elapsed since the remarkable observations of
Schaffer, Frankel, Brcsgen, Hack, Daly, Spencer, Todd,
and others were first put on record.
In a paper read before the American Climatological As-
sociation on May 28, 1885, I advanced the theory that an
asthmatic paroxysm is dependent on three conditions : First,
a general neurotic habit ; second, a diseased condition of
the intranasal mucous membrane, and not the bronchial ;
and third, some obscure atmospheric condition ; the former
two being the active predisposing causes, while the latter is
the exciting cause of the paroxysm. The truth of these
propositions I think is generally accepted; certainly no one
* Read before the American Laryngologies! Association at its thir-
teenth annual congress.
will question at the present day the fact that a diseased con-
dition of the nasal mucous membrane exercises a very
marked influence in the production of a paroxysm of asthma.
This being true, the further proposition must be accepted,
that in the restoration of the nasal mucous membrane to a
condition of healthy function we remove one of the very
active causes of the asthmatic paroxysm, and thereby are
notably aided in the complete cure of the disease. I should
like, parenthetically, to emphasize this point, and repeat that
our efforts in intranasal treatment should be directed broadly
toward the complete restoration of healthy functional activ-
ity in the membrane, for I consider it as a somewhat nar-
row view to regard the removal of a simple nasal stenosis
as the prominent indication.
In my former paper I furthermore argued that a parox-
ysm of asthma not only depended on the three stated con-
ditions, but that the removal of any one of them, and not all,
was ordinarily sufficient to arrest the disease. We all of
us recognize the fact that a resort to certain elevated re-
gions is almost invariably attended by immediate relief. In
this way the obscure atmospheric condition which is the
cause of the paroxysm is removed. We are furthermore
familiar with the fact that in many instances where, by our
general and specific therapeutic measures, the peculiar neu-
rotic condition is overcome, the asthmatic paroxysms termi-
nate. In the remaining cases of relief afforded by treating
the intranasal condition, clinical observations have multi-
plied themselves to such an extent that the success of this
method in a certain number of cases can not be questioned.
The permanence of the results, however, opens up an ex-
ceedingly interesting and pertinent inquiry. In a paper on
asthma, published in the American Journal of the Medical
(Sciences, in September, 1888, I analyzed the results of treat-
ment in eighty cases, thirty-four of which were instances of
hay-asthma or periodical asthma, and forty-six of perennial
asthma or true nervous asthma, as it has been called. For
our present purpose these may be grouped together. Of
the eighty cases, I reported forty-six as having been cured,
twenty-six improved, three unimproved, and in five cases
the results were unrecorded. Three years have now elapsed
since this record was made, and I regret exceedingly my
inability to report as to the ultimate results of treatment in
these cases. This report was based on a somewhat exten-
sive correspondence, and the limited time at my disposal
has prevented my hunting up the cases, the very large pro-
portion of which have passed from my observation. A few
of those patients who were reported as cured, however,
have suffered relapses, but I am confident that I do not un-
derstate the number when 1 say that in but six of them
have the asthmatic paroxysms returned, but of these the
violence and frequence of the paroxysm in no instance
equaled that which existed before the treatment.
Since this report I have recorded and subjected to treat-
ment eighty-eight additional cases of asthma in which there
was a co-existent intranasal lesion of a turgescent character.
In running over these cases I find that forty-two patients
were cured, thirty-three were improved, two were unim-
proved, and in eleven the results were unknown, the patients
being seen usually but once. The local lesion was in the
March 26, 1892.]
EELSEY: DISEASES OF THE RECTUM.
347
very large majority of instances either nasal polypi, de-
flected sseptum, or hypertrophic rhinitis.
Leaving ont of consideration the eleven cases in which
the results were unknown, we have seventy-seven patients
suffering from some form of asthma, in only two of which
did the intranasal treatment fail to afford a certain amount
of relief. If this report is correct, and I believe it to be
absolutely so, I think no stronger evidence could be adduced
of the intimate and close causative relation which exists be-
tween a diseased condition of the nasal mucous membrane
and asthma. Since Voltolini's first observation, I think no
one denies that nasal polypi may be the cause of asthma,
but hypertrophic rhinitis and deviations of the sseptum as a
cause of the disease are still seriously questioned by many.
I have reported forty-two cases as cured. Curiously
enough, there would seem to be some question as to what
constitutes a cure in asthma. I think, however, that we are
fully justified in considering a patient cured who has passed
through twelve months of immunity, subjected as he is dur-
ing that time to the various atmospheric changes which are
so prone to give rise to an attack, especially during the cold
and damp weather of the spring and fall months. In the
foregoing report I have endeavored to confine myself to
this rule, though in some of the cases the reports cover two
and three years of immunity.
The thirty-three patients reported as improved include
not only those in whom the paroxysms were notably miti-
gated, but others in whom months elapsed without an at-
tack, and in many the disease had ceased to be a source of
any very serious distress, and yet, the immunity not per-
sisting for the full twelve months, I have recorded them
simply as improved.
Coming now to the immediate topic of discussion — viz.,
the permanence of relief afforded by intranasal treatment —
I think this is fully answered by this report. This method
is clear in its indications, easy of accomplishment, and
promises, I believe, not only more immediate relief, but
more permanent relief from this distressing disease than any
method of treatment yet suggested.
While, therefore, this method affords so much promise,
for both the temporary and permanent relief of the disease,
it is to be borne in mind that we are dealiug here with but
a single factor in its causation. The neurotic habit is an
equally prominent factor, and I do not think we have done
our full duty in any case without giving our patient the full
benefit of those general hygienic measures, together w ith
internal medication, which are attended with such excellent
results in their action upon the nervous system.
THE SECOND YEAR'S WORK IN
DISEASES OF THE RECTUM
AT THE NEW YORK POST-ORADUATE HOSPITAL.
By CHARLES B. KELSEY, M. D.
At the end of this the second year of the clinic we will
devote the hour to a short review of the work done, glanc-
ing back over cases, operations, and results grouped to-
gether.
During the year 1891 we have had one hundred and
forty new cases, presenting one hundred and forty- seven dis-
tinct diseases. In these cases, seventy-four operations have
been done before the class, which we shall speak of more
in detail. These figures, added to those of the first yrear,
give us as total for the two years and one month since the
clinic was opened of two hundred and seventy-eight cases
of disease and one hundred and forty-one operations in pub-
lic. When this opportunity for seeing diseases of the rec-
tum is compared with what existed before the establish-
ment of the clinic, we can only congratulate ourselves and
thank the profession at large for sending the material.
Of the cases treated during the past year many have
been of great interest. Our mortality during the first year
came from hopeless cases ; this year it has illustrated the
risks of even trivial operations. There have been three
deaths. One was that of an apparently strong man — but, it
appeared afterward, a hard drinker — due to diffuse, septic,
pelvic cellulitis following the opening of a small abscess in
the perimeum. Another was caused by acute alcoholism,
following an operation for fissure upon a drunkard, who had
to be removed to Bellevue the following morning ; and the
third was from a very extensive extirpation. The patient
had previously been colotomized to make the operation by
Kraske's method as safe as possible, and had we stopped
there he would be alive now. The case seemed a suitable
one for extirpation until it was too late to abandon the
operation, but the shock was too great. It was one of those
to which the recently coined word "inoperable" particular-
ly applies.
Looking back over our cases, there is one which I think
is unique. It is well known that a congenital stricture of
the rectum which during early life has caused compara-
tively few symptoms may, as age advances, cause greater
annoyance and danger from the loss of suppleness in the
parts, and the final addition of ulceration to the other con-
ditions. No case has ever come within the range of my
reading, however, where such a congenital stricture first
made itself known by complete intestinal obstruction at the
age of thirty-five. The patient was a colored woman, un-
der the1 care of Dr. H. L. Richardson, of New York.
On questioning, she said she had noticed that never in her
life had her passages been larger than the little linger, but she
supposed that was natural and had never had any sickness. At
the usual site of such strictures, just fairly above the sphincters,
about two inches from the anus, there was found a perfectly
characteristic membranous obstruction with a pin-head per-
foration. The opening, which had been sufficient for thirty-five
years, had become contracted from thickening and inflammation,
and would no longer allow the escape of faces. Above the first
membrane there was a distinct congenital narrowing of the gut.
but not to a degree to cause any obstruction. The membrane
was freely divided, tho obstruction was relieved, and the patient
left the hospital in a week.
The capital operations for cancerous and non-malignant
strictures have done well. There have been fourteen coloto-
mies, four complete extirpations, and three proctotomies
with but one death — that already referred to. But few com-
paratively of our cancerous strictures have been when first
seen at a stage which rendered extirpation justifiable, and
348
KEL8E7: DISEASES OF THE RECTUM.
[N. Y. Med. Jour.,
hence the number of colotomies. The rule in operating lias
been that a cancer that was movable could be extirpated,
while one that was firmly attached to neighboring parts
should be treated by colotomy. The trouble with the re-
sults of extirpation comes from the lack of room to get clear
of the disease in many cases. In cancer of the breast we
cut clear of the disease with an ample margin, while in can-
cer of the rectum we dissect the disease carefully off from
the prostate, the base of the bladder, the vagina, and the
uterus with no margin whatever. In many cases the growth
is only just removed, if indeed it is entirely removed, and
it is not strange that there should be quick recurrence.
Of the results of the colotomies it is impossible t<>
speak too highly. In none have we failed to give great re-
lief to suffering, and in none to gain a considerable length
of life over what the patient would have had without the
operation. This you have all had a chance to see for your-
selves, not only in the cases operated upon this year, but in
those of longer standing in which the patients report occa-
sionally. There are few of you who do not come here with
your minds possessed of the natural and general antipathy
to this method of prolonging life and relieving suffering,
but none of you carry that feeling away with you after
coining in personal contact with those who have been oper-
ated upon. Instead of a lot of miserable, loathsome creat-
ures, " better dead than alive," you find a very jolly and
contented class of patients, male and female, married and
single, attending to the ordinary duties of life, none of
whom could under any circumstances be induced to change
their present condition for that before the operation.
If this clinic never does anything more than to over-
come the ignorant prejudice against this operation and
bring this remedy into universal repute for proper cases, as
the similar clinics have done in England, it will still have
justified its existence.
And yet we are very conservative in recommending and
practicing colotomy. It is never done where anything else
will give relief that is not attended by too great risk. Can-
cers we extirpate if we can, and non-malignant strictures
we treat in every other way likely to do good, including
also extirpation, before doing colotomy. But in all cancers
we either extirpate or perform colotomy as soon as the pa-
tient's consent is gained. Nothing can be gained and life
may be lost by delay. And so in the non-malignant cases,
where complete extirpation of the disease is out of the
question, and where divulsion, division, and dilatation have
been tried for years ; where acids and injections and sup-
positories have been kept up till the patient is discouraged,
and he is steadily losing ground, we do not wait long before
relieving him after we decide that all other treatment is
worse than useless.
It is well to impress this upon you again, for the idea
seems to have gone abroad that we do colotomies here in
preference to other modes of treatment. The fact is that
we never do colotomies except to prolong life when no
other mode of treatment is applicable; and thai if we did
not give relief in this way these patients would simply be
sent away to continue their sufferings and die a miserable
death. This is why I am always trying to impress upon
you that it is more important to know when to do a coloto-
my than how to do a colotomy, and why I never do one
w ithout asking several of you to come down into the amphi-
theatre and tell the class what other plan of treatment is
applicable. In cancer you suggest extirpation, and I ex-
plain to you that the disease is not suitable for extirpation,
being too extensive and attended by too great a risk to life.
In non-malignant disease you suggest all the recognized
modes of treatment, and it is answered that all have been
tried without benefit, and from the extent of the disease
none can be of benefit ; and thus in every case, having
eliminated every other proper mode of treatment, I try to
convince you that colotomy should be done, and the results
you see.
Perhaps the best argument in favor of the operation
that can be given you is that twice a patient operated upon
has, after a time, brought us a friend suffering in the same
way who desired the same treatment.
The cases in which colotomy has been performed illus-
trate many forms of disease for which the operation is in-
dicated. Six were for cancer too extensive for removal ;
three for extensive and incurable non-malignant ulceration
and stricture ; two in women for chronic intestinal obstruc-
tion due to old pelvic exudation ; and one as a preliminary
to a subsequent extirpation by Kraske's method.
In the matter of our fifty cases of piles and twenty op-
erations with the clamp and cautery we have done well,
having had nothing but the most satisfactory results. In
the one case in which we yielded to the continual demand
of the students from the West to know about carbolic-acid
injections, we were more than usually unfortunate.
The man was in fairly good condition, ''could not be oper-
ated upon," and was bleeding profusely, and the students wanted
to see the carbolic-acid treatment. Now you all know that I
consider this one of the most uncertain of all treatments, but in
this particular case I tried it for the benefit of the class. A
moderate-sized tumor was injected with five drops of a thirty-
three-per-cent. solution of carbolic acid in equal parts of gly-
cerin and water. The patient felt no pain at the time and was
told to come again in a week if he had no trouble, but to report
in forty-eight hours if anything went wrong. In forty-eight
hours he reported. On the side where the injection had been
made there was a marginal tumor of the size of a horse-chest-
nut covered with equal parts of skin and mucous membrane, and
with the mucous membrane fianprenous and slouching. On the
opposite side, where no injection had been made, there was an-
other tumor outside the anus and irreducible, almost of the size
of the former. The first one sloujrhed and shriveled, the second
suppurated and burst with two openings — one on the skin and
the other on the mucous membrane. The patient was in bed
three weeks, and they tell me went away thinking he had been
very fortunate in finding a doctor who could cure piles without
an operation.
This was an unfortunate result. In the vast majority
of cases the treatment would have been satisfactory. It is
just such exceptions as this that have led me to abandon it,
and everybody who practices the method for any length of
time will occasionally have just such a case.
By the courtesy of Dr. Boldt we have been able to
show you at St. Mark's Hospital two very rare cases. The
first was a typical case of chancroidal ulceration around the
March 26, 18»2.]
BEACH: THE OFFICE OF
CORONER IN NEW YORE.
349
anus ;iik1 within the rectum, one. of the cases that prove
indubitably the occasional causation of so-called syphilitic
stricture by chancroid, and go to the support of the classi-
cal argument of Mason, many years ago, that most of the
"syphilitic strictures" were not syphilitic but chancroidal.
You will seldom have a chance to see the causation and
follow the development of venereal stricture as in this
case.
The other case of 1 >r. Boldt's was one of sarcoma of the
sacrum, causing a distinct tumor in the soft tissues over
the sacrum, and another, of the size of an egg, projecting
into and partially occluding the rectum — a case, perhaps,
ultimately for a colotomy should the new growth advance on
the rectal side sufficiently to cause obstruction. In one of
my first eolotomies complete obstruction was caused by a
growth of tins kind from the promontory of the sacrum,
which first manifested its presence by causing the usual
symptoms of acute intestinal obstruction.
Another rare case was that of the physician who com-
plained of congenital absence of controlling power in the
sphincters. Fluid passages were always liable to escape him
without notice, and fiatus did the same. We tried to tighten
the orifice with the Paquelin cautery, but the patient has
written me since that the operation was a failure— a state-
ment that, for certain reasons, I am not quite prepared to
accept.
The remaining cases need no special comment. The
fissures, fistuhe, abscesses, both superficial and deep, the
cases of intestinal catarrh and of actual ulceration of the
rectum, need not be dwelt upon. Our object has been to
give a brief rSsume of the work done and the results.
THE OFFICE OF CORONER IN NEW YORK*
By WOOSTER BEACH, M. D.
The office of coroner in this city is filled by four men
elected on the county ticket, whose term of office is three
years.
Each coroner appoints a physician who acts as his as-
sistant at inquests and makes examinations of all dead
bodies, post-mortems should he deem them necessary. Be-
sides these officials, there is a clerk connected with the office
whose duty it is to receive the reports of cases requiring at-
tention and keep a record of the inquests. He also attends
to the proceedings in suits in which the sheriff is a party —
almost exclusively cases where property is replevined from
the sheriff.
The usual daily routine of the coroner's office is about
as follows: The cases from the various parts of the city re-
quiring the attention of the coroner during the day are re-
ported to the clerk mostly by the police, under whose notice
they generally first come.
Unless the case is known to be of more importance than
usual, the practice is for the coroner's physician to proceed
to the place where the body lies, examine it, take the state-
* Read before the Section in Public Health and Hygiene of (lie New
York Academy of Medicine.
ments of one or more witnesses as to the manner of death,
and furnish a certificate for burial.
In the important, or at least the prominent, cases the
coroner accompanies the physician in his visit to the body,
and then the formal proceedings as prescribed by the law
an' more nearly followed.
The inquests, so called, containing the statements of the
witnesses taken by the physician alone are completed at un-
certain intervals when a sufficiently large batch has accumu-
lated. This is done at the office by the coroner swearing a
jury, who finish up the dozen or more papers on hand by
affixing their signatures to them. This wholesale manu-
facture of inquests is certainly not legal, but, in view of the
unimportant character of the cases acted upon, it is perhaps
allowable.
The number of cases reported at the coroner's office in
a day runs from five to ten. One may be an accident, one
a suicide, one a case of drowning, and perhaps one of mur-
der. It may be that an ante-mortem examination may be
required. By far the larger number reported are of per-
sons dying without medical attendance, and consequently,
as no certificate of burial has been given, one must be ob-
tained from the coroner.
The average time required for holding an inquest is less
than half an hour. A few cases may consume an entire
day or more, but, taking them altogether, the above-stated
will be about the average time. As the work is divided
among four coroners, it will be seen that their labors can
not be deemed onerous.
For the entire expense of the coroner's department
$52,000 per annum is appropriated.
The defects in the present system are :
1. The choice of the coroner by election. It is scarcely
necessary to refer to the evils of this defect to a citizen of
our city. The practical working of this plan is that the
office is filled by a man totally ignorant of the duties re-
quired of him, and quite likely not to trouble himself about
them during his term of office.
2. The coroner's jury. Except, perhaps, in a few cases,
there is no necessity for such a body. If a coroner's case
results in a conviction of a criminal, it subsequently comes
before two juries — the grand and petty.
3. In the case of persons dying unattended by a physi-
cian, or where there is no suspicion of crime connected with
the death, the entire formality of a coroner's inquest is re-
quired for no other object than that of obtaining a certifi-
cate for burial.
4. If the coroner himself knows little or nothing of the
duties required of him, we can not reasonably expect that
he will choose a proper medical assistant. We may con-
sider ourselves fortunate in this city that we have physi-
cians in good standing as appointees.
5. The costs of the coroner's department are excessive.
Really good service should not cost one quarter of the
amount paid.
In any attempt at reform in the coroner's office the im-
portance of the medical service must be kepi prominently
in view.
The examination of the dead body in criminal cases fai
350
LEADING A RT1GLEH.
[N. Y. Med. Joub.,
exceeds in importance any other proceeding connected with
the coroner's investigation. The coroner may bungle, but
his actions may be reviewed and corrected. Not so with
the post-mortem examination of the body. Its position, its
surroundings, may, to a trained eye, furnish most Important
evidence which, not taken advantage of before it is dis-
turbed, may be lost forever. With the dissection it may
be even worse. The scalpel of the incompetent physician
may make sad havoc with wounded or diseased organs and
entirely destroy evidence that a proper examination would
reveal.
An autopsy, therefore, made in an unskillful manner may
actually be the means of covering up a crime instead of
bringing it to light.
In 1877 a law was passed in Massachusetts abolishing
the office of coroner and the coroner's jury, and substitut-
ing " medical examiners " in their place.
That law lias secured good results and works smoothly.
With some changes it would be suitable for New York, but
in our State the election of a coroner in each county is made
obligatory by the Constitution, and it is only by a consti-
tutional amendment that the office can be abolished. Still,
the Legislature may limit the powers or change the duties of
the coroner and provide for the appointment of medical ex-
aminers, so as to get substantially the same law as that of
Massachusetts. In that State the legal part of the investi-
gation is taken charge of by a trial justice, assisted, if ne-
cessary, by the district attorney. By the New York Legis-
lature granting the powers of the Massachusetts trial justice
to our coroner, the obstacle presented b)T the Constitution
may be overcome.
The really great difficulty in effecting the reform we de-
sire is in securing the appointment of the proper man for a
medical officer and in keeping the office free from political
influence. No matter how perfect a law we may have, if
the most careful discrimination is not exercised in selecting
a man to carry out its provisions, it will be a failure.
Nothing, then, should engage our deliberations more
earnestly in forming a plan to carry out our object than the
selection of the proper appointing power that is to furnish
us with the medical examiner.
The Section in Gynaecology and Abdominal Surgery of the Pan-
American Medical Congress has been organized by the election of Dr.
William Warren Potter, of Buffalo, as executive chairman ; Dr. Brooks
H. Wells, of New York, as English-speaking secretary ; and Dr. Ernst
W. Cushing, of Boston, as Spanish-speaking secretary. The foreign
secretaries of the section thus far elected are: The Argentine, Dr. Dn.
L. 0. Maglioni Llobet, Victoria 737, Buenos Aires ; Brazil, Dr. Dm.
Luiz da Cuuha Feibo, Rio de Janeiro; British North America, Dr. J.
V. W . Ross, Esq., Toronto ; United States of < 'olombia, Dr. Dn. Jose M.
Buendia, Oalle 10, No. 212, Bogota; Nicaragua, Dr. Juan I. Urtecho,
Calle Real, ciudad Granada ; Spanish West Indies, Dr. Dn. Gabriel
Casuso, Virtudes 37, Habana, Cuba ; Uruguay, Dr. Dn. Enrique Perey,
Uruguay 371, Montevideo.
A Death following the Administration of Chloroform has occurred
in New York during the past week. The patient was an old man with
atheromatous arteries, in whom an amputation for gangrene of a finger
was about to be performed. The anaesthetist had had two years' ex-
perience in hospitals in the city, and the coroner's inquest showed that
the patient's death had been caused by pulmonary (i;dema.
THE
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by Edited by
D. Appleton & Co. Frank P. Fostkr, M. D.
NEW YORK, SATURDAY, MARCH 26, 1892.
REFORMS NEEDED IN NEW YORK CITY INSANE ASYLUMS.
Recently the Mayor of New York appointed a commission
of five well-known gentlemen to investigate the subject of the
care of the insane in the city asylums, and to report whether it
was advisable to continue the present system or to turn the pa-
tients over to the State.
The commission lias just made its report, and those unfa-
miliar with the condition of these municipal institutions will
probably turn it over to see if their eyes did not deceive them,
and if some other place than New York city is the subject of
the report. That the commission did not favor the transfer of
both patients and institutions to the State is probably because
they believe atonement should be made in the future for the
sins of the past. For no other reason is it apparent that what
they characterize as " a reproach to humanity " should be con-
tinued, even upon the plea that the city recognizes the cura-
bility of insanity. From their inspection of both State and city
institutions they found the latter superior to the former in one
particular — that of furnishing iron bedsteads! Were it not for
the importance of the subject and the wretched condition of
affairs that is now brought prominently before the public it
might be imagined that the commissioners had desired to instill
some humor into their report. And. yet, read their present-
ment : " The condition of these insane poor is pitiable. Their
accommodations are a reproach to humanity. Overcrowding
exists in every building of every department, and their wretched
existence is rendered still more intolerable by the absence of
comfortable surroundings, of proper accommodations of every
kind, and by insufficient protection in the case of many of the
smaller buildings from the inclemency of the weather. There
is also the danger of fire, which, in the inflammable wooden
buildings, would be certain to result in large loss of life." If
these unfortunates were convicts their environment would be
better.
On January 30, 1892, there were 5,485 insane patients in
the asylums on Blackwell's Island, Ward's Island, and Hart's
Island, and at Central Islip, and the total cost of maintaining
these institutions during the year was about $700,000. In the
seven State hospitals there were 5,870 inmates, and they cost
$1,100,000 annually to maintain. In other words, this city is
attempting to care for almost as many insane patients as the
State in half the number of buildings and at two thirds of the
cost.
For the relief of the existing evils it is recommended that
the per capita allowance for the support of the insane be in-
I creased; that they should be removed from the neighborhood
March 26, 1892.]
of convicts and paupers; that the quality of the food should be
improved ; that the medical superintendent should have full
authority over his subordinates; that the old buildings should
be replaced by better ones ; and that some of the present build-
ings should be enlarged. For the sake of our reputation for
humanity alone, it is to be hoped that these necessary changes
will be inaugurated at an early date.
THE DIAGNOSIS OF DRUNKENNESS.
A lecture delivered before the Hunterian Society of Lon-
don by Dr. J. Hughlings Jackson, entitled Neurological Frag-
ments, was published in the Lancet for March 5th. The lecture
bristles with ingenious suggestions, but, on account of certain
peculiar terms coined by the author and on account of his
brevity of expression, parts of it require careful and repeated
reading to bring out their full meaning. In our last issue we
mentioned his remarks on the reflexes in connection with the
condition of supervenosity ; another matter on which he spoke
yery instructively was the difficulty sometimes felt in diagnosti-
cating drunkenness in the absence of a history of the onset of
the symptoms.
For practical purposes, he said, alcoholic intoxication had
to be studied carefully. It was well known that men fatally ill
from cerebral lesions were sometimes locked up in police cells
for drunkenness, and it needed to _be insisted on that intra-
cranial lesions that would soon result in death might give rise
not only to insensibility^but also to the manner and conduct of
a person partly intoxicated with alcohol. lie alluded to a fatal
•case of meningeal haemorrhage in which the patient was violent
and profane and, what was more striking, showed purposive
action. On the other hand, men were sometimes seen in the
hospital who, [aftei sucking raw spirits out of a cask, were
seemingly in a state of [coma as 'deep as that caused in other
men by a large and fatai cerebral haemorrhage. Without the
history of the circumstances and of the mode ot omset. the diag-
nosis of apoplexy produced by alcohol from that produced by
eerebra haemorrhage was very difficult and might be impos-
sible; for an hour or two after an injury to the head there
blight be a condition very like that of a man slightly drunk, and
the patient might act elaborately even if foolishly, while " un-
conscious"— unconscious in the sense that on his recovery he
would remember nothing of his strange doings.
When a man of Hughlings Jackson's rare acumen in'diag-
nosis makes such 'statements as" these, it seems as if the wise-
acres of the daily' newspapers, might with propriety curb the
glibness of their criticism of the occasional ambulance surgeon
who makes a mistake.
MI SOI! PARAGRAPHS.
THE QUESTION OF THE CONTAGIOUSNESS OF LEPROSY.
In the March number of the International Medical Magazine
Dr. L. Duncan Bulkley concludes a paper with the statement
that there is no warrant tor the popular terror at the name of
leprosy as a disease; that, while probably of bacillary origin,
351
it is not contagious in the ordinary acceptation of the term.
When acquired, the disease may, under favorable conditions, be
transferred from one person to another; and, while heredity
may account for a share of the cases, the disease is not neces-
sarily so transmitted. Furthermore, there is far greater reason
for the restriction of syphilitic and tuberculous persons by iso-
lation and segregation than for that of lepers. This opinion of
an American dermatologist is fortified by the recent report of
the English Leprosy Commission, in which their study of the
disease showed that it was contagious and inoculable only in a
very limited degree and not hereditary. They found only half
as many cases of the disease in India as had been estimated.
As a result of two thousand experiments, the commission con-
sidered the risk of inoculation so small that it might be disre-
garded, and concluded that a fish diet had nothing to do with
the disease.
SUPPLIES FOR THE MEDICAL CORPS OF THE ARMY.
An awkward impediment to the work of providing the
medical staff of the army with certain necessary supplies for
which a contract bad been given out seems to have come up
in the shape of a criticism by the Second Controller of the course
pursued by the Surgeon-General in the matter. It appears that
after the contract had been made it became evident that certain
modifications of the articles contracted for would render them
decidedly more useful, but that the changes would entail a
moderate advance on the prices agreed upon. The Surgeon-
General thought it proper to change the contract accordingly
without going to the additional expense of publishing a fresh
invitation for bidders. As the newspapers have it, he has done
so, and will leave the question of irregularity to be settled in the
future. This degree of latitude, it seems to us, might well be
allowed to the discretion of the head of a staff department.
GUNSHOT WOUNDS OF THE SPINAL CORD.
In the February number of the Revue de chirurgie there is
an exhaustive article on this subject by Dr. E. Vincent. M.
Vincent's conclusions are as follows: These injuries are of great
gravity, but they are not necessarily fatal, and there is reason to
believe that surgical intervention may help to save some of the
wounded. Whatever may be the nature of the injury to the
spinal cord — provided there is no mortal injury of a thoracic or
abdominal organ, and provided the wound involvesthe posterior
or lateral portion of the vertebral column at an accessible point
—the tract of the wound should be enlarged and any foreign
body that may be found should be extracted, and for this pur-
pose one should not hesitate to open into the rhachidian canal
if necessary, for such a procedure, although sometimes futile, is
harmless, with antiseptic precautions, and may prove of ad-
vantage.
THE ASSOCIATION OF THE ALUMNI OF THE NEW FORK
HOSPITAL.
On Wednesday evening of this week a meeting of ex-inem-
bers of the house start* of the hospital and its branches was held
in the governors' room for the purpose of organizing an associa-
tion having the title that heads this article. It was well at-
tended, and a number of letters and telegraphic messages were
read from gentlemen who were unable to be present, all of
w hom expressed their hearty sympathy with the undertaking
and their readiness to take part in it. It is strange that such
an association was not formed many years ago, and the older
graduates of the hospital are undoubtedly glad that the superior
enterprise of their younger brethren — especially of a committee
LEADING ARTICLES.— MINOR PARAGRAPHS.
352
Ml SOU PA RA GRAPHS. — ITEMS.
[N. Y. Meu. Jo. k..
consisting of Dr. Walter Von-ht. Dr. E. W. ( lark. :m<i Dr. 'I'.
S. Southworth — has at last made its organization an accom-
plished fact.
A MAGNETIC PHASEMETER.
In the March number of the American Journal of Science
Mr. John Trowbridge describes an instrument adopted by him
for use in determining questions of the phase of alternating
electric currents in transformers and in branch circuits. Two
telephone diaphragms are provided with mirrors, and a beam of
light is reflected in such a manner that the vibration of one
diaphragm gives a spot of light a horizontal motion, the other
one gives the spot of light a vertical motion, and the combina-
tion of the movements gives a figure that indicates the relative
amplitude of the motions of the diaphragms and also the differ-
ence of phase of the currents that set the diaphragms in motion.
This device Mr. Trowbridge calls a phasemeter.
AN UNJUST AWARD IN A MALPRACTICE SUIT.
A juky in Poughkeepsie has recently rendered a verdict of
$2,500 against a physician of that city for alleged malpractice
in the case of a man who fell upon a sidewalk of dirt and ashes
and sustained a compound, comminuted fracture of the arm. A
month after the accident he was admitted into St. Luke's Hos-
pital, New York, for septic infection, the arm was incised to
facilitate the escape of pus, and it lias been useless since lie re-
covered. He bases his suit on the ground that the attending
physician at his home did not properly cleanse the wound.
The award on this ground seems to us to be very unjust, as the
most skillful surgeon might, under the circumstances, have had
a similar result.
ANKYLOSTOMIASIS THE BERIBERI OF ASSAM.
According to the Indian Medical Gazette for February. 1892,
Dr. G. M. Giles finds that the diseases known as the beriberi
and the kala-nzar of Assam are identical, and that they are in
reality ankylostomiasis caused by the Dochmius duodenalis.
This parasite, Dr. Giles finds, develops slow ly if at all in drink-
ing-water, but develops plentifully in faeces. The ingress of the
parasite into the human system is believed to be due to the
habit of cleansing kitchen and table utensils with infected earth,
and of eating food from a mat on the ground. The symptoms
and causation of the disease are the same as those found by Dr.
Kynsey in the so-called beriberi of Ceylon.
THE VALUE OF ALBUMINURIA AS A MEANS OF DIAGNOSIS.
In a paper on this subject in the International Medical Mag-
azine Dr. F. R. Sturgis, of New York, concludes from a survey
of the literature that albumin in the urine does not necessarily
signify any renal disease; that it exists temporarily in many
diseases unassociated with any organic renal complication ; that
from the uncertainty of tests and methods of testing it loses a
ur. at deal of its value as a diagnostic sign; and that if present
in even a small quantity it is a danger-signal, and if persistent
indicates some serious organic lesion.
ANTE-MORTEM BURIAL.
Our excellent contemporary the Maryland Medical Journal
publishes in its issue for March 19th a very useful article en-
titled Studies in Plaster Jackets and how to make Removable
Plaster-of Paris Corsets, by Dr. C. C. Barnwell, of Baltimore.
The secondary title of Dr. Barnwell's article is: "After the
Method of the late Professor Louie A. Sayre, M. D., of New
York,1' meaning undoubtedly Professor Lewis A. Sayre, who,
we are glad to be able to say, is still in the flesh and shows no
signs of hastening to put on immortality.
PROMOTION EXAMINATIONS IN THE ARMY MEDICAL
CORPS.
By a recent law no medical officer in the army can be pro-
moted to the rank of captain until he has passed an examina-
tion for promotion. Heretofore the medical officers of the army
have been promoted to the rank referred to at the end of five
years' service without an examination, while their less favored
brethren of the navy and of the marine-hospital service have
had to prepare at the end of three and four years' service, re-
spectively, for an examination preliminary to promotion that
was quite as rigorous as that given for admission into the corps.
NEW TITLES FOR ARMY MEDICAL OFFICERS.
Tin-; Senate has just passed a law giving to officers of the
medical corps holding the rank of colonel the grade of assistant
surgeon-generals, and to those holding the rank of lieutenant-
colonel the grade of deputy surgeon-generals. These are new
titles in our army and are similar to those of the British army
medical corps.
ITEMS, ETC.
Infectious Diseases in New York. — We are indebted to the Sanitary
Bureau of the Health Department for the following statement of cases
and deaths reported during the two weeks ending March 22, 1892 :
Week ending Mar. 15 Week ending Mar. 22.
DISEASES.
Cases.
Deaths.
Cases.
Deaths.
Typhus
«
12
2
6
1
2
9
6
231
31
215
28
o
0
4
4
328
20
282
23
98
32
109
37
1
1
4
1
Erysipelas
0
0
2
0
0
0
10
0
0
0
2
3
Mumps
0
0
2
0
A Bacteriological Institute in Tokio. — Dr. Kitasato, who has been
in Koch's laboratory for many years, and who is so well known for his
bacteriological researches, intends to leave Berlin to open a bacterio-
logical institute in Tokio.
Changes of Address. — Dr. William R. Ballon, from New York to
the Oakland Heights Sanatorium, Asheville, N. C. ; Dr. F. J. Leviseur,
to No. 640 Madison Avenue.
The Sixth Annual State Sanitary Convention of Pennsylvania, un-
der the auspices of the State Board of Health, will be held at Erie on
the 29th, 30th, and 31st inst.
The New York Post-graduate Clinical Society. — The special order
for the meeting of Saturday evening, the 19th inst., was a paper en-
titled Points in the Diagnosis and Management of Serous and Suppura-
tive Pleurisy, by Dr. J. K. Crook.
A Society for the Promotion of Maternal Lactation has been organ-
ized in Paris, according to the (iazelli hrliilomiiilnirc <le medicine et de
chirurgie.
The Death of Dr. D. Hayes Agnew, of Philadelphia, occurred, not
unexpectedly, on Tuesday of this week. Be was in the seventy-fourth
year of his age. lie obtained his medical education at the University
of Pennsylvania, and in his later vears was professor of surgery in that
March 26, 1892.]
ITEMS.— LETTERS TO THE EDITOR.
35a
institution, having in the mean time won distinction as a teacher of
anatomv in the Philadelphia School of Anatomy. He was a surgeon
of distinction and the author of a well-known text-book of surgery.
The Death of Dr. H. Rosenthal, of Berlin, for many years the edi-
tor of the Al'getneinc medicinische Central-Zcitung, is announced in the
Wiener k/inischc \\'och< nschrift as having taken place recently.
Naval Intelligence. — Official List of Changes in the Medical Corps
of the United States Navy for the week ending March 19, 1892 :
Marsteller, E. II., Passed Assistant Surgeon. Ordered to duty at the
Naval Academy.
Arnold, \V. F., Passed Assistant Surgeon. Detached from the Ver-
mont and ordered to the Richmond.
Lowndes, 0. II. T., Assistant Surgeon. Detached from the Richmond
and ordered to the Vermont.
Dickinson, D., Surgeon. Detached from the Navy Yard, Mare Island,
and granted two months' leave.
Moore, A. M., Surgeon. Detached from the Naval Hospital, Mare Isl-
and, and ordered to the Navy Yard, Mare Island.
Norfleet, E., Surgeon. Detached from the U. S. Steamer Monocacy
and granted three months' sick leave.
Smitp, G. T., Assistant Surgeon. Detached from the U. S. Steamer
Mohican and ordered to the U. S. Steamer Hassler.
Young, L. L., Assistant Surgeon. Detached from the Independence and
ordered to the Mohican.
Schofield, W. K., Medical Director. Granted one year's leave of ab-
sence, with permission to leave the United States.
Society Meetings for the Coming Week :
TrESDAY, March 29th : Boston Society of Medical Sciences (private).
Wednesday, March 30th : Auburn, N. Y., City Medical Association ;
Bsrks'iire, Mi-ss., District Medical Society (Pittsfield).
Friday, April 1st : Practitioners' Society of New York (private) ; Bal-
timore Clinical Society.
Saturday, April 2d : Clinical Society of the New York Post-graduate
Medical School and Hospital ; Manhattan Medical and Surgical So-
ciety (private) ; Miller's River, Mass., Medical Society.
Answers to Correspondents :
No. 375. — We can not answer your first question. In regard to the
luminous signs, address Messrs. F. W. Devoe & Co., corner of Fulton
and William Streets, New York.
No. 376. — The surgeon-general of the State of New York is Dr.
Joseph D. Bryant, and his address is No. 54 West Thirty-sixth Street,
New York city. Probably he can furnish you with information con-
cerning the ambulance service.
letters to the (gbitor.
COCAINE POISONING.
Ann Arbor, Mich., February 8, 1892.
To the Editor of the New York Medical Journal:
Sir: Will you please grant me a short space in the Journal
in which to record the phenomena accompanying a case of
cocaine poisoning which recently came to my notice, and also
the results of treatment ? The patient is a young man who Cor
some time past had been suffering from rectal ulcer with
colitis accompanied with quite intense tenesmus, for the relief
of which latter he had resorted to cocaine. On the afternoon
of February 4th, upon his own responsibility, he took a sup-
pository containing rather more than three grains of the drug.
I saw him about an hour after and found bis condition as fol-
lows : Pulse 150, thready ; respirations .I to the minute and simu-
lating the Cheyne-Stokes variety; pupils dilated; bilateral
sweating; surface cold, patient conscious, and responding well
to questions; vision good; no pain; no nausea; surface
anajmic. I ordered twenty drops of tincture of digitalis with
fa of a grain of atropine sulphate bypodermically, to be re-
peated in twenty minutes; hot applications to the surface and
brandy internally. Half an hour after the second hypodermic
the patient's pulse bad fallen to 120 ; the respirations bad in-
creased to 12 and were regular; and the surface was becoming
warm and somewhat flushed. I then put him upon digitalis
and stropbantbus, three drops of each, internally, and omitted
the atropine.
At midnight bis pulse had reached 100, and the respirations
were normal. From this time be rapidly recovered.
In two cases elsewhere reported 1 obtained similar results
from the treatment pursued in this case. While digitalis, or
any of the other cardiac tonics, is strongly indicated in these
cases, there might be a question about the atropine, since the
action upon the pupil of both cocaine and atropine is mydriatic,
and this would indicate that the two agents are synergists-
Yet cocaine paralyzes respiration, while atropine stimulates
the respiratory function. Here, it would seen), is the chief in-
dication for atropine to overcome the toxic action of cocaine.
While this is true, yet it must not be forgotten that atropine
also stimulates all the vaso-motor ganglia, and, if carried be-
yond a certain limit, would overcome the cardiac inhibition ob-
tained by the digitalis — an important factor in eliminating the
cocaine poison. J. A. Wessinger, M. 1>.
BEARD AND ROCKWELL ON ELECTRICITY.
New York, March U, 1892.
To the Editor of the New York Medical Journal :
Sir: Jn a recent number of this journal a short review of
the eighth edition of Beard and, Rockwell's Medical and Swrgv?
cal ' Electricity appeared in which defects were pointed out, while
its merits were by no means overlooked.
The animus of the review was everything that could be de-
sired. Certainly no author can complain when his book, after
nearly t wo decades of uninterrupted success, is characterized as
"deserving its popularity." Butthere is one statement to which
I must demur.
The reviewer says: " Dr. Rockwell would inspire more con^
lidence if be told us candidly that there were some infirmities
in which electricity was of no use."
Now, at first sight this seems to be a very severe arraign-
ment, but that the writer did not mean to convey any impression
specially derogatory is evidenced by the general tenor of bis re-
marks.
The truth might perhaps be more nearly stated if be wTould
accept a mean between another review written by the late Dr.
Frank II. Hamilton some years ago and his own. Dr. Hamil-
ton stated that the book seemed to be given up to a discussion
of what electricity would not do rather than what it would do.
How shall we reconcile two such divergent opinions ema-
nating from fair and honest critics? A close inspection of the
detailed cases (which in some future edition I hope to entirely
recast) will clearly show that they arc neither given up to
"demonstration of what electricity will not do," nor to asser-
tions that it is a universal panacea. No one better than he who
has labored for years in the department of eleotro-therapeutics
appreciates its limitations, and I can in Ti measure sympathize
with the remark once made to me by Dr. E. L. Keyes, that he
had "broken bis heart over electricity." Now, among these cases
many recoveries in many differenl conditions are verj properly
reported; but a careful perusal of the clinical portion of the
work will show that a large proportion of cases are spoken of as
only improved or relieved, while others relapsed, and not a few
are recorded as receiving no benefit.
354
PRO* ' EEDINCS
OF SOCIETIES.
[N. Y. Med. Joub.,
Wheii electricity first came into prominence, some twenty
years ago, it was earnestly hoped that electrolysis could be made
to accomplish something for the relief and cure of cancer. In
connection with Dr. Beard, I treated a very large number of
cases of seirrhus of the breast and other parts, and indeed al-
most every variety of malignant growth. The most grateful
reliet of pain was often demonstrated, but it was just as clearly
demonstrated then, and by subsequent efforts, that electricity
was incapable to any extent of favorably influencing the prog-
ress of these seirrhus tumors of the breast. This and many
other things equally unfavorable to electricity the book states
clearly enough; and if the writer had done no more than to
demonstrate this one fact, in the face of certain well-remembered
statements to the contrary, he would regard it as sufficient to
justify all the attention given to this department of medicine.
A. D. Rockwell, M. D.
flrocccrjinqs of Societies.
AMERICAN LARYNGOLOGICAL ASSOCIATION.
Thirteenth Annual Congress, held at Washington, on Tuesday,
Wednesday, and Thursday, September 22, 23, and 24, 1891.
The President, Dr. W. C. Glasgow, of St. Louis, in the Chair.
( Continued from page 329.)
The Eadical Treatment of Nasal Myxomata.— Dr. W.
E. Casselberrt read a paper on this subject. (See vol. Iiv, page
533.)
Dr. Sajous: I have listened with great interest to this com-
munication; it is on a subject to which I have given much at-
tention. I agree with the authors whom he quotes as to the
difficulty of reaching the points from which polypi arise after
removal of the growths. It is surprising to see how easy the
operation seems to be as described in the books, but it is not so
easy in practice. Some years ago I attempted to pass a galvano-
cautery wire as far as possible behind the middle turbinated
bone ; I subsequently found that by using a rongeur forceps and
removing a small portion of the middle turbinated bone at its
anterior angle I made a convenient passage for the introduction
of the instrument. I have not found it necessary, except in very
few cases, to remove the whole bod.v, in order to introduce the
forc eps or galvano-cautery. In applying the gal vano cautery, I
have been muoh helped by using an electrode with a tip bent in
the shape of a curette. By not heating the wire too much, say
to a red heat, it retains its hardness, and can be used as a
curette, combining the heat with the scraping of the surface, if
so desired. The electrode I now show you D, as you can see,
glass-covered. It can be easily cleansed and does away with the
silk- covered electrodes, which can never be made absolutely-
aseptic. The glass electrodes are not affected by the heat of
the incandescent tip.
Dr. J. Solis-Cohex : I rise simply to say that some months
ago I read in one of the journals an article by a gentleman
whose name I can not recall, in which he recommended, after
removal of polypi, simply washing out the nose with a solution
of alcohol or of witch-hazel. I would here bear testimony to its
value; I use it in preference to the cautery. I use it in the
strength of one to four, one to three, or even one to two —
simply the distilled extract of hamamelis with alcohol.
Dr. Bobwoeth: I should like to ask if Dr. Cohen thinks
r li.it it will have the slightest effect in preventing the return of
the polypi.
Dr. Cohen: Yes, I have found it so.
Dr. Bosworth : I have used both the witch-hazel and the
cautery, and found neither of value.
Dr. Cohen: I use it in place of the application of the
cautery, using injections twice a day ; the patient can do this
for himself.
Dr. Bosworth: I (mite agree with the remarks which have
been made with regard to the galvano-cautery. I think that it
is the removal of the polyp which cures the patient; I do not
think that there is any use in applying the galvano-cautery
afterward unless some better reason can be given than has been
offered. The principal value of the hamamelis in such cases is
that it may prevent the use of something worse.
Dr. Roe : I agree with the last speaker, that the success of
the treatment of nasal polyps lies in the completeness of their
removal; but in some cases, owing to their situation, complete
removal is well-nigh impossible. In the majority of these cases
it is because the polyps lie behind an enlarged middle turbinated
body. In all such cases in which the turbinated body is very
much enlarged, and particularly where the bone is sufficiently
projecting to press against the s.-eptum, I have made it a rule to
remove a part of this projecting turbinated body. I do not re-
move the whole of it, but only sufficient to get at the base of
the polyps. The method I adopt for its removal is by means of
a saw, such as I presented to this association two years ago)
and termed the nasal bow saw. It is modeled on the plan of the
jeweler's saw, and by using one with the blade set at a right
angle with the back and with a bow at the proper height, the
amount taken off can be so accurately regulated that we can
remove just the amount desired. I formerly used scissors, but
scissors crush the bone before cutting it, and the same objection
applies to the snare. I find the method that I have described
by far the best, and it leaves the parts in a better condition for
healing. In those cases where the base of the polyp is accessible
I have for some time adopted a plan of encircling the polyp
with the wire, and then dissecting away the base with a small
knife, taking the periosteum with it; and where it is located
upon a turbinated bone, taking off a small spiculum of bone
with it. When this is done I never have a recurrence of the
polyp.
Dr. Rice: The treatment of those cases of multiple nasal
polypi which form the text of Dr. Cassel berry's paper is very
difficult. After all tangible growths have been removed by the
snare the entire mucous surface in the affected nostril is so thick-
ened, and the middle turbinated bone is frequently so much
hypertrophied, that great obstruction still exists. Even after all
hypertrophy has been removed the mueo-purulent secretions
are very abundant and exceedingly troublesome to the patient.
It is not possible with the snare to reach the tissue satisfacto-
rily which is above and behind the middle turbinated bone
without first removing a portion of the middle turbinated bone.
I do not approve of the application of the galvano-cautery to the
surface of the middle turbinated bone, where it is very closely
related to the saeptum. Both surfaces are apt to be scorched,
very little tissue is removed, and adhesive inflammation may be
the result of such burning. The only rational method of treat-
ment is to remove enough of the middle turbinated bone, so
that the thickened tissues above and behind it can be reached
and removed by proper manipulations.
A word of caution should be suggested as to the removal of
the middle turbinated bone. Only so much of it should be
taken away as will secure good drainage and allow treatment of
the cavity above. I have seen severe forms of atrophic rhinitis
following the wholesale removal of the middle turbinated bone
and the use of the galvano-cautery above the neighboring struct-
ures.
March 26, 1892.]
PROCEEDINGS
OF SOCIETIES.
355
In these cases of nasal polypi the middle turbinated bone
seems to have become so much weakened in its attachments that
the entire bone may be removed by the snare if too much of it
is included within the loop. The treatment of these cases is
troublesome at the very best, and requires careful and painstak-
ing work.
Dr. Jarvis : I am myself a great believer in the surgical
treatment of these cases ; but I also believe, in contradistinction
to what Dr. Bosworth states, that it is possible to find chemical
agents that will remove these growths. I formerly employed an
application, which I was led to try some years ago, through the
suggestion of a physician who had found it very effective.
While the treatment in most casts is purely surgical, it is not
necessary to make the nose a surgical armamentarium. For in-
stance, why should we use first a snare, then scissors, then a
saw, and finally the cautery ? It seems to me that this might all
be done with two instruments — the snare and the searching
forceps. Where small polypoid growths appear, I encircle the
base and remove part of the bone with it; the searching forceps
I use is of about the thickness of a lead-pencil. With this little
instrument these bead-like growths are seized and stripped off
one after another ; there is no haemorrhage of any account after
tearing them away. There is one point which I wish to ac-
centuate: where we remove polypi by means of the wire snare,
we use a method which is easy and simple as compared with
evulsion and the cautery, and one which is free from the danger
of producing septic symptoms. Even if the patient has to come
back again for another operation in a year or two, it is not
much trouble to repeat the procedure.
Dr. J. Solis-Cohen : I would ask the last speaker if he
knows of any medicament which, applied to a polyp, will cause
it to disappear without surgical procedure 1 If so, he should
state what it is.
Dr. Jakvis: There is no secret about it, it was simply the
injection of the tincture of the chloride of iron into the nostril.
It is not an elegant application and I am not entirely satisfied
with it ; but in some cases I have found it effective.
Dr. Mdlhall: There is nothing new about that, as it is men-
tioned in the text-books on surgery years ago. With regard to
operating upon these cases, I have a rule concerning the re-
moval of a portion, but not the entire, middle turbinated bone.
It came to me by experience. The rule is that where the Jarvis
snare can catch the end of the middle turbinated bone, it can
be and should be removed. I rise principally, however, to
speak in opposition to the views expressed with regard to the
use of the galvano-cautery. Some years ago I read a paper
condemning the use of the galvano-cautery by Lennox Browne,
who claimed that it caused erysipelas and other bad results. I
concluded that they were not due to the method, but to the
rules of operating laid down by that writer. I have used it in
many cases — I should say at least four thousand cases— and
have never met with such an accident. My rule is that the
platinum wire should be white hot before cauterizing the spot,
and it should be withdrawn in the same condition. Lennox
Browne's rule was to heat the wire only to a cherry-red heal
and allow it to cool inside of the nose before withdrawal. This
is sure to he followed by inflammation, for which the opera-
tion has been blamed, whereas it is the fault of the operator.
It is necessary in some cases to remove part of the middle
turbinated bone in order to reach a polyp in the hiatus semi-
lunaris. In one case I recommended the removal of the en-
tire middle turbinated bone for a man who had had polypi
removed for thirty years; the operation was done with entire
success.
Dr. Mackenzie: I have been very much interested in the
discussion, especially in the remarks of Dr. Jarvis, and in the
simplicity of the means to be used in the class of cases under
discussion. I can not, however, concur in his statement that
everything can be done with the snare. In these bone cases I
have found considerable difficulty in getting the snare through
the bone; when the bone was thoroughly engaged in the loop, it
was with the greatest difficulty that I got it home. Therefore, in
many cases, I have been obliged to relinquish the snare in favor of
other means. I am also completely in accord with Dr. Mulhall
in his estimate of the value of the galvano-cautery ; I keep it by
my side all the time. I use it every day, and among several
thousand cases I have never seen an accident. I use it at a heat
just bordering upon a white heat, and just whiter than a cherry-
red. I have seen a purulent discharge following the applica-
tion and lasting several weeks, and some sloughing alter remov-
ing large pieces of the turbinated bones, but no serious accident.
At the same time it must be admitted that unskillful use of the
cautery might cause sloughing and do great damage.
Dr. Roe: The main reason for the failure to get good results
after the employment of the galvanic cautery,, and the cause of
the occurrence of inflammatory and septic troubles, is that the
burned surface, after the operation, is not rendered thoroughly
aseptic. This should be done as thoroughly after a cautery
operation as after a cutting operation, and kept so until the
parts are healed. When this is done we never have any inflam-
matory or septic troubles and seldom a purulent discharge. This
fact was pointed out by me in an article read last year in Berlin
before the International Medical Congress.
Dr. A.son : My experience is thoroughly in accord with that
of Dr. Jarvis. I find that the snare fills every indication ; the
operation is a slight one and, if necessary, can be repeated
at a future time. But few growths require more than one or
two operations. With regard to the objection of Dr. Mac-
kenzie, I think that the trouble is due to defective instruments.
Where the snare and holder are made of steel, there is no diffi-
culty in cutting through bone — certainly not with an instru-
ment made as mine are. Like Dr. Jarvis, I have never seen the
use of the snare followed by septic trouble. I take the precau-
tion always to immerse the wire and snare in a carbolized solu-
tion before operating.
Dr. Jarvis: If the galvano-cautery is harmless, why is it
that we read of the case of Ziem, where total blindness fol-
lowed its use in one eye; or that of Quinlan, where meningitis
occurred? I also recall a case where erysipelas resulted, where
the operator was sued for malpractice.
Dr. Mulrall: I attribute such accidents to an imperfect
method of operating.
Dr. Roe: I should say imperfect antisepsis
Dr. Sajous: I would confirm the statements jusl made as
regards improper use of the galvano-cautery.
Dr. Cassei.behry : I feel a little guilty for calling out a dis-
cussion upon all the methods of treating polypi. My contribu-
tion was meant to limit the discussion to a newer field — the re-
moval of the anterior portion of the middle turbinated bone in
certain cases. I hardly think that the removal of a small por-
tion of the middle turbinated bone could give rise to atrophic
rhinitis. With regard to the transition of hypertrophic into
atrophic rhinitis, I would offer the suggestion thai it niay occur
more frequently in the climate of New York, as I have never seen
acase in Chicago where hypertrophic change has passed into an
atrophic. With regard to the use of chemical agents, especially
the tincture of iron, alcohol, etc., I think that where there is
general relaxation of the parts such astringents are useful as
adjuncts to surgical treatment. Alone thc\ can not often reach
the actual seat of disease. With regard to the snare, I may say
the same, concerning, however, a much smaller proportion of
cases — that one can not always reach the growth with tin
356
PROCEEDINGS
OF SOCIETIES.
[N. Y. Med. Jouk.,
snare; and the cautery also fails at times. Then I resort to the
operation described. In conclusion, I will merely refer to the
remark that has been made about removal of the normal turbi-
nated body : the turbinated body in these cases is never normal ;
It is hypertrophied, sometimes covered with polyp- buds, and
often curved over toward and crowding upon the saeptum.
Moreover, I never removed the whole body, but merely the an-
teroinferior end. In tin' case where meningitis set in, following
the use of the galvano-eautery, it was probably a case of inflam-
matory ethmoiditis, and the meningitis set in before the cauteri-
zation ; the use of the cautery was merely a coincidence, oc-
curring in an effort to relieve symptoms due to the ethmoid it is.
Various Forms of Disease of the Ethmoid Cells.— Dr. F.
H. Boswortii read a paper on this subject. (See vol. liv, page
505.)
Dr. Mackenzie: I take great pleasure in saying that Dr.
Bosworth has at last read a paper with the contents of which 1
can entirely concur. I wish to say this in opening the discus-
sion on the paper tbat we have just heard, and to thank him for
that paper. 1 agree with him in his remark about the confu-
sion of cause and effect that has been made by Woakes, whose
theory is only explainable on this ground.
Dr. Jarvis: I can confirm the remark made by the reader of
the paper concerning the dangers of removing the cap from the
turbinated bone and opening the cells, and also of removing the
bone, on account of the existence of a myxomatous growth. In
such cases the unfortunate patient may perish with meningitis,
from extension of the inflammation through the ethmoid cells.
After the removal of the posterior end of the middle turbinated
bone the nostril may be found to be occluded by a soft myxom-
atous growth. It is my rule not to stop until all this obstruc-
tion is removed. I believe we may have pure ethmoiditis. I
recall a case of blood poisoning in which I was called in consul-
tation after pyajmic symptoms had set in. I drilled away the
side of the saeptum into the body of the turbinated bone, and in
this way obtained free drainage. It required a number of
operations, but the patient made a good recovery. It is of in-
terest to note that in these eases of non-myxomatous ethmoidi-
tis we often have to deal with a condition of malformation in
which the saeptum is deflected to one side so as to completely
occlude the upper part of the naris. I recall one case, that of a
lady, who had traveled extensively without obtaining relief, in
whom the trouble was removed by chiseling away the saeptum
until the channel was clear. I agree entirely with Dr. Bos-
worth in his views upon the treatment of ethmoiditis.
Dr. Wright: I did not understand whether or not Dr. Bos-
worth referred to cases of acute ethmoiditis; but since Dr.
Jarvis has mentioned such a case I may also refer to one which
I saw last spring. My observation is that these patients
generally get well after thorough cleansing of the nose; wash-
ing it out frequently with a syringe or spray is often sufficient.
Suc h an operation as Dr. Jarvis resorted to would rarely be
necessary.
Dr. Muliiall: I subscribe to the views expressed by the
reader of the paper and to his remarks upon a class of diseases
which we all recognize and which he,, has grouped in a way
that will be of great value. I wish simply to state that I coin-
cide with his statement that in the class of cases referred to we
are tempted to radical measures for the relief of the condition
when milder ones would answer and are safer. I recall a case
coming under my observation in which the middle turbinated
bone was removed and the patient died ; however, the opera-
tion was not done aseptieally ; it was before the day of the in-
troduction of present measures into surgery. I now use the
curette, but always take the precaution to do the operation in a
perfectly aseptic manner. The danger of opening the ethmoid
cells and of lighting up inflammation is such as to make such
measures indispensable.
Dr. Jarvis : I should like to say in reply to the remark of
the last speaker, with reference to securing asepsis, that there
is no method that will equal the use of the cold wire. I have
never seen septic symptoms produced by the application of the
cold wire in operating. I have seen such symptoms after the
use of drills, but I think as long as the cold wire is used we can
proceed with impunity. I do not think that any gentleman
present can report a single case in which septicaemia followed
an operation with the cold wire snare.
Dr. Boswortii : I have nothing to say in closing the debate,
but I should not let the occasion pass without acknowledging
the remarks of Dr. Mackenzie and my gratification at having
him agree with my conclusions. With regard to the theory of
necrosing ethmoiditis of Woakes as the cause of all cases of
nasal polypus, I think he still stands almost alone in his views.
The Symptoms and Pathological Changes in the Upper
Air Passages in Influenza.— Dr. J. Sous-Cohen read a paper
in opening a discussion on this subject. (See page 344.)
Dr. Shprly: I am very much interested in the paper, espe-
cially because of having met so many cases of tuberculosis the
origin of which was apparently in an attack of influenza. An-
other point to which I would like to call attention is one
noticed by some French writer, in an article published some
eight or ten months afro, in which the idea was advanced that
the late pandemic of influenza was a modification of, or allied
to, cerebro-spinal meningitis. There is certainly a resemblance
clinically, because in our district there were neurotic symp-
toms manifested in a majority of the cases strongly resembling
the latter disease. A third point that I would mention is that
the paper formulates the belief that it is a chemical metamor-
phosis which takes place in the various cells and tissues which
constitute the original features of the disease. In our chemical
work, incident to the examination of tubercular matter, etc.,
we have been unable yet to separate a distinct ptomaine or
toxine from them. However, fluids treated with phospho-
tungstic and phosphomolybdic acids 'yield deposits which,
when injected into the tissues of guinea-pigs, gave rise to in-
tense glandular irritation and inflammation, which, in some
cases, reaches its height in three days, afterward gradually sub-
siding. In one of the animals, where suppuration took place,
examination of the pus showed no bacteria whatever, but pus
cells and broken-down lymph material only. If we had al-
lowed the animal to live, it is possible that the characteristic
lymph elements might have been developed. The observations
of the author of the paper can be borne out by the results of
such experiments. The why and wherefore, of course, I do
not know, but we shall pursue these experiments further upon
the larger animals, such as calves or goats. I think that the
chemical poisons of tuberculosis may be considered as related
to that or those of pandemic influenza, whatever it is.
Dr. Wright: I was much struck during the second epidemic
of influenza by the disproportion between the amount of actual
disorder which could be found upon examination and the
amount of suffering and constitutional disturbance. I saw a
large number of throat and nose patients in the hospital, and
could find only a slight pharyngitis or rhinitis; and the way we
usually made the diagnosis of influenza was by observing the
slight lesions of the nose or throat and the large amount of con-
stitutional disturbance.
Dr. Ascn: I think that it would be well for the representa-
tives from the different sections of the country to give their ex-
perience as to the manifestations of influenza, so that we could
ascertain whether the upper air passages were equally affected
in the different localities where it prevailed. In my own expe-
March 26, 18lJ2.J
PROCEEDINGS OF SOCIETIES.
357
rience in New York there was not a marked increase in the
number of such cases applying for treatment nor in their gravity,
nor did I remark in the cases of influenza which came under ray
notice a uniformity of lesion. There was, however, one lesion
which was frequently, though not always, present — viz.: an in-
flammation of the tonsils, attended by an extreme depression,
which 1 have noticed under no other circumstances. Though
follicular amygdalitis is usually marked by depression, I have
never seen it so severe as in these cases, it was so great that
in some cases it gave me reason to fear for the safety of my
patients.
Dr. Oasselbeert: The point raised by Dr. Asch is a very
valuable one, and in fact 1 brought it out yesterday in connec-
tion with disease of the mucous membrane of the nose. As re-
gards the climates of New York and Chicago, there seems to be
a decided difference in the number of cases of transition from
the hypertrophic to the atrophic stage of chronic rhinitis, which
transition is rarely seen in Chicago. With regard to the point
raised by I>r. Wright concerning the severity of local manifesta-
tions of influenza in the upper respiratory tract in Chicago, we
observed them often of a violent type, commencing with severe
rhinitis and naso-pharyngitis, and extending into intense de-
grees of laryngitis, bronchitis, and even pleuritis. In the nose
I have not always at first been able to distinguish between the
local manifestations of influenza and those of ordinary severe
inflammatory attacks; perhaps in the former the mucous mem-
brane had a more bluish aspect, and this appearance T had not
attributed to a specific venous congestion, but to the violence
of the attack.
Dr. Weight: I might supplement my remarks by the state-
ment that with us in New York we observed a much larger
proportion of cases of suppuration of the middle ear than among
ordinary cases of throat inflammation.
Dr. S. Solis-Cohen : The comparative frequency of special
lesions of influenza in the personal experience of any physician
will depend largely upon the character of his practice. For in-
stance, in my general wards in the Philadelphia Hospital char-
acteristic manifestations of the disease in the upper air passages
were comparatively few ; and, in fact, I can recall but two
cases, botli presenting the "solid oedema" referred to by the
reader of the paper. On the other hand, I saw a ranch larger
percentage in my private and consultation practice. I would
express my admiration of the graphic expression " solid cedema,"
used by Dr. Glasgow in his original paper. The character of
the manifestation has been fully described and I need not repeat
it. The first case of influenza I saw in 1889 was one in which
this solid cedema affected the tonsils and soft palate. Through
the knowledge gained from the paper of Dr. Glasgow, I was en-
abled to make the diagnosis, which otherwise I might not have
been able to do, as it was some months before general recog-
nition of the existence of the pandemic. I have now under care
a convalescing case which at first I was inclined to diagnosticate
as one of typhoid fever; but its further progress has led me to
think it rather a case of the peculiar pneumonia described by Dr.
Glasgow, and I mention it now only to suggest the wisdom of
greater attention to this peculiar condition. The favorable ef-
fect of influenza upon tubercular processes is, of course, excep-
tional. Hundreds of cases of tuberculosis have been hurried to
the grave by the epidemic.
Dr. S. Solis-Cohen: I would supplement my remarks with
the statement that with us, in Philadelphia, otitis media was
also very common. In some cases other symptoms were lack-
ing, and only from the prevalence of influenza and the occur-
rence of several cases among the children in a family was I en-
abled to recognize its infectious character. In many instances
it was bilateral, one ear becoming affected as the other healed.
Dr. Jakvis: The paper read by Dr. Cohen presents clinical
features of great interest which we may very well study. I
refer especially to the curability of malignant disease and tuber-
culosis. Only a few days ago a most distinguished dermatolo-
gist expressed a belief that he had seldom seen cases of lupus in
which erysipelas bad occurred where a favorable influence was
not exerted upon the course of the disease.
Dr. Robinson: I wish to simply say one thing, perhaps not
bearing directly upon what Dr. Cohen has said. In connection
with influenza, I have been witness to disturbances of the mid-
dle ear which seemed to me to be very interesting for several
reasons. I could not say precisely in what the inflammatory
condition consisted. There did not really seem to be any nota-
ble disturbance of the Eustachian tube, or inflammation of the
canal; but these patients suffered a very great deal. There was
dullness of hearing, noises, worse in one ear than in the other,
and- a sensation of a foreign body in the ear; but I could not
determine anything of a pathological nature simply by sight.
The obstinacy of these cases was something extremely remark-
able. I saw a lady only a few days a^o who has been troubled
in this way for at least twelve months, in spite of general and
local treatment. I wish merely to add this to the discussion —
that there is something peculiar hitherto unclassified in the
auditory disturbances following influenza.
Dr. Jakvis: According to my observation, the victims of this
class of affections of the upper air passages were those having
more or less pathological deviation of the sseptum ; in other
words, those who were suffering with chronic rhinitis. I would
ask if this is borne out by the experience of any other gentle-
man present?
Dr. Roe: I observed, when the epidemic first appeared, that
those who had chronic ear, nose, or throat disorders were those
who suffered most from the influenza. 1 also noticed in this
connection that the apparent cause of this cedema, which was
first described by Dr. Glasgow and now mentioned by Dr. Cohen
in his paper, was due to a vaso-motor paresis associated with
cardiac weakness. In nearly all cases I have been led to look
upon this passive cedema as not associated with any inflamma-
tory trouble, but as one due to lack of sufficient circulation, re-
sulting from weakness of the heart. In the treatment of these
affections I have obtained the best results from the administra-
tion of cardiac stimulants in addition to other medication that
may be indicated.
Dr. Shublt : We have three distinct grades of severity
among the cases of the late pandemic of influenza, and I wish to
exclude entirely instances of ordinary influenza that we usually
have in our northern climate every winter. In some cases the
general affection is light and, perhaps, only lasts twenty-four
hours, but the upper air passages seem particularly affected.
Just as in epidemics of scarlet fever and measles, there are cer-
tain persons who have nasal catarrh or rhinitis, but who do not
manifest the symptoms of scarlet fever or measles. Now I take
issue with those gentlemen who hold that a deflection of the
sseptum, or any purely local condition of the air passages, induces
the attack: or that the nervous, pandemic, general disease is
influenced by any local condition.
Dr. Jaevis : I wish to explain that I do not maintain that
the pathological process is confined to the nostril, but that it
constitutes the starting-point from which the disease may ex-
tend to the throat and lower air passages, producing more seri-
ous symptoms. I did not mean that the disease was due to a
deflected sseptum, hut that this condition might be a predis-
posing cause.
Dr. S. Sous-Coiikn : The majority of the cases of influenza
which I have seen had no chronic nasal trouble.
Dr. Sajous: 1 think that the matter is easily explainable.
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The gentlemen are looking at the matter from different stand-
points, basing their conclusions upon tlieir individual observa-
tions. Where- there is already local disease, the patient will h'nd
that there is more local disturbance during the progress of the
disease.
Dr. Roe: I did not mean to say that the local diseases that I
referred to were the cause of the general symptoms, but that
when these local disorders exist in the upper air passages the
person is predisposed to attacks of influenza. I do not, how-
ever, regard the influenza as merely a local trouble, limited to
the upper air passages, but believe it to he more severe when
the air passages are diseased.
Dr. Glasgow: The complications, or rather the pathological
changes, occurring in the upper air passages as the result of in-
fluenza have been fully described, and I can add very little to
what has been said. There are a few points, however, which
have not. been mentioned which have attracted my attention.
During the epidemic I have met with a greater number of cases
of acute suppuration of the antrum than I have seen at any
other time. I think it was also true that during the prevalence
of the disease the tendency of all inflammations of the closed
cavities was to become purulent. If pleurisy occurred, it was
empyema; pericardial effusion was purulent. In fact, according
to my experience, purulent inflammation was a characteristic
feature of the disease. My experience is fully in accord with
the writer of the paper in stating that during the prevalence of
the epidemic there was an almost complete disappearance of ca-
tarrhal inflammations of the upper air passages. The reappear-
ance of this condition was an evidence that the epidemic was
disappearing. I have not observed that local disease in the nasal
passages had any causative effect in provoking the disease.
Where pathological changes have produced obstruction, the ad-
dition of the cellular infiltration of the mucous membrane has
certainly added to the distress. There is one point in Dr. Co-
hen's paper which has gratified me, for it was upon this point
that I was criticised when I read my paper before this society
on (Edematous Disease of the Upper Air Passages. I refer to
the presence of an exudation in the throat bearing a certain re-
semblance to the diphtheritic membrane. I can heartily agree
with Dr. Cohen in believing that influenza is essentially a dis-
ease of the blood. I have always considered it analogous to
typhus or erysipelas — a general infections disease. In regard
to the connection of influenza with tuberculosis I have positive
views, which are based upon extended clinical experience. Ac-
cording to my observations, I should say that influenza rather
encourages the production of tuberculosis, instead of being a
protection against it. The interstitial cellular infiltration of the
alveolar walls — the pathological condition in influenza — seems
to be a most fertile soil for the development and growth of the
tubercular bacillus. Microscopic examination of the sputa of
cases which have become tubercular shows enormous numbers
of bacilli, and resembles rather a culture of the laboratory than
human sputa.
The weakness of the heart has been referred to by the
speaker, and I can fully indorse all that he has said. Cardiac
weakness is a constant accompaniment of the disease; it is due
to a change and weakening of the heart fibers, similar to that
existing in infectious diseases.
Dr. J. Solis-Cohen : The supposed connection between cere-
bro-spinal meningitis and influenza, which has been referred to
in the discussion, was first brought to the attention of the pio-
fession by Dr. Levick, who was then physician to the Pennsyl-
vania Hospital, I believe about 1804. I did not wish to be un-
derstood as saying that influenza will cure tuberculosis. I have
seen too many fatal cases of tuberculosis hurried off by influ-
enza. 1 thought it peculiarly interesting that I had seen one
case of tuberculosis of the larynx and one of malignant disease
of the pharynx cured by the attack of influenza.
Useful Deductions derived from the Study of a Case of
Cicatricial Contraction of the Larynx, possessing Unusual
Clinical Features, with Exhibition of Specimen.- Dr. W.
C. Jarvis read a paper with this title. (See vol. liv, page 509.)
Dr. J. Solis-Coiien : Mr. President, I have looked at this
specimen very carefully, and I can not divest myself of the
opinion that if you were to cut through this stricture in the
upper part of the larynx, you would find a normal glottis be-
neath.
Dr. Mackenzie : The paper reminds me of a case which ]
had several months ago at the Johns Hopkins Hospital. The
patient had syphilis, and suffered very much with dyspnoea. He
had been treated for eighteen months for asthma. Upon ex-
amining his larynx, I found bilateral abductor paralysis. His
dyspnoea was so great that I feared his death in my office, and I
got his father to take him to the hospital in a carriage, with a
note to the hospital resident to perform tracheotomy at once, if
another attack came on, without waiting for my arrival. The op-
eration was done at once by the house surgeon, but the expected
relief did not appear. In fact, the dyspnoea not only got worse,
but expiratory dyspnoea was added to the inspiratory difficulty,
This showed, to my mind, that there must be some obstruction
below the, seat of operation which had been overlooked. The
patient sank, and in the course of a few days died. I thought
that it might be clue to stricture of or pressure upon the
trachea. The post-mortem was made by Dr. Welch, very care-
fully. No trace of syphilis was found in any part of the body,
except in the respiratory organs. In the apex of one lung was
found a large gumma. Both recurrent nerves were compressed,
and were found in a mass of half cicatricial tissue and half en-
larged glands. There was pressure upon the nerves, and the-
trachea at its bifurcation was so narrowed by the tumor and by
contraction following ulceration, that it was with the greatest
difficulty that a very fine probe could be forced through the
stricture. There were other ulcers in a state of cicatrization in
the neighborhood. The complete examination has not yet been
made, but I may state that in the nerves we found certain
fibers of both recurrent laryngeal nerves in a state of fatty de-
generation. This case was extremely interesting to me because
of the combination of the stenosis with the degeneration of the
nerves and the external pressure of a tumor. This was all sub-
sequent to the gummatous deposit in the lungs. It is very sel-
dom that we find this location of syphilis strictly in the respir-
atory organs, without being manifested in any other part of the
body ; it is a paradoxical expression of the syphilitic infection.
The patient was in the process of cure; but the cicatricial con-
traction of the ulcers made pressure upon the trachea and upon
the nerves and caused his death. Of course there was also a
condition of hypostatic pneumonia found at the examination
after death.
Dr. Asoh: In a case like that reported by Dr. Jarvis I
think it advisable to try dilatation ; I have reported some cases
which were cured and some much improved by this treatment.
Of course the amount of dyspnoea might necessitate tracheoto-
my; but the dilatation could be practiced after the operation.
Dr. Casselberry : I am greatly interested in Dr. Jarvis's
case, and wish to speak of the danger of undertaking palliative
treatment in cases of this kind. I recall one case of my own
which in many respects is similar to the one before us. It was
a man of middle age, suffering from syphilitic contraction in the
upper part of the larynx, with attacks of dyspnoea, which were
sometimes of dangerous severity. Tracheotomy was recom-
mended and refused. It was just five days afterward that he
suffered a severe attack of dyspnoea and perished before aid could
March 26, 1802,]
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359
reach him. Now, T maintain that a man going about with such
a condition of the larynx, exposed to all sorts of influences which
might bring on an attack — such as cold or inhalation of dust or
other irritants —is every moment in much more danger of his
life than he would be from the performance of tracheotomy. I
claim that palliative treatment with O'Dwyer's tubes in such
severe cases is dangerous. We should perform tracheotomy first
and then palliation if you choose ; but first of all put the patient
in a safe condition as regards his life, and treat the stricture
afterward.
Dr. S. Sous Cohen : This specimen very much resembles the
laryngoscopy image of a case in the practice of my brother.
Upon cutting through the contracted portion of the larynx — a
therapeutic operation undertaken during life — there was found
a healthy glottis beneath. Perhaps he recalls the case.
Dr. J. Soi.is-Cohen: Yes, I remember the case you refer to.
Dr. Weight : I am interested in the specimen, but less on ac-
count of its extraordinary character than its ordinary character.
There are a large number of cases of syphilitic contraction of the
larynx presenting themselves having the same features. ] have
a case now under observation in which the inflammation, com-
mencing in the nose, extended down the throat and into the
larynx with cicatricial formation ; and it was much benefited
by iodide of potassium. I saw several cases of tracheal syphilis
last winter which lend emphasis to Dr. Oasselberry's remarks.
Take a case of this kind ; if be were to have an attack of ordinary
laryngitis he would drop dead in the street ; the slightest swell-
ing could not help but cause suffocation. The patient would die
suddenly. Certainly, in these cases it is our first duty to explain
the condition clearly to the patient; he may refuse an operation,
but it should be explained to him so that he may understand the
danger he is in without it. I am glad that Dr. Jarvis has brought
this subject before us for discussion.
Dr. Sajous : Speaking of the dangers to be encountered in
these cases, I should like to include iodide of potassium in the
list. The fact that oedema sometimes follows its use should be
borne in mind in treating these patients.
Dr. Wright : In cases of extreme stenosis I want to say that
the administration of iodide of potassium may have the result
just referred to, and if it is given, I would say, get out your
tracheotomy instruments and be ready for immediate operation.
I always treat these cases in a hospital, where I can keep them
under observation.
Dr. Sajous : I would also state that in syphilitic laryngitis
I noticed a connection between the administration of the iodide
and the appearance of the oedema ; as soon as I gave the iodide
the oedema would appear, and would disappear as soon as it was
stopped.
Dr. S. Sous-Cohen: I am glad that Dr. Sajous has brought
this matter up. Few physicians keep in mind t he possibility of
producing oedema when they give large doses of iodide of potas-
sium in syphilitic affections of the throat. It is Dot a mere theo-
retic danger. Professor S. W. Gross used to relate to his classes
a case in which he had to sit up all Hight, prepared for instant
tracheotomy. This danger is present in every case in which
large doses are given at the first, without previous gradual in-
crease, even where there is no local disease of the larynx. As
to the specimen presented by Dr. Jarvis, any physician or sur-
geon who counsels against tracheotomy in such a case is taking
a very grave responsibility.
Dr. .1. 8olis-< Ioheh : With regard to the occurrence of oedema
in these cases, I must say that I can hardly see where the oedema
is to come from on account of the dense infiltration of the parts;
but there are other dangers than those from iodide of potas-
sium. In several cases occurring in the practice of some ot the
most prominent men in the profession, in which I have urged
the performance of tracheotomy which was not done, the pa-
tients afterward died. Another point is that in cases of de-
cided stenosis there would be danger from an attack of bronchi-
tis, since a small pellet of mucus might cause strangulation. I
was surprised that any one should use O'Dwyer's tubes when I
first saw them, their caliber was so small ; I did not see how they
could possibly benefit the patient. I always make it a rule to
use as large tracheotomy tubes as possible. I afterward found
that patients could breathe very well through the small tubes of
O'Dwyer.
Dr. Jakvis : In reference to Dr. Cohen's remark that there
is a healthy larynx inferiorly. I should state that I meant to con-
vey the idea that the contraction was limited to the upper part
of the larynx. I of course knew that the cords were not in-
volved ; this was recognized during life. I was very glad to
hear the remarks made about iodide of potassium. It is a valu-
able remedy in these cases, but it is not necessary to give it in
overwhelming doses ; small doses would be safer and sufficient
to afford relief. I was also pleased with the remarks made about
intubation. I am sure that if any gentleman present had seen
the case he would have agreed with me as to the impracticability
of the O'Dwyer tubes in this case; and I think that he would
have been very glad to get off" without causing serious inspiratory
spasm during the examination. With regard to Dr. Oasselberry's
remarks, I stated that tracheotomy was indicated and that I had
urged the patient to submit to the operation, but he thought that
as long as he was relieved by the inhalations he would not have
it done. I did not feel like sending him away just because he
would not do exactly as I desired. I am glad that this report
of the case has been so well received and that the discussion
shows that the members agree as to the propriety of the meas-
ures suggested by me for the patient's relief.
The Relation of Disturbances of the Mucous Membrane
of the Upper Air Passages to Constitutional Conditions. —
The discussion of this subject was opened with a paper by Dr.
Beverley Robinson. (See page 340.)
Dr. Mackenzie : The only tiling that I have to complain of
in the paper of Dr. Robinson is the unnecessary stress which he
lays upon scrofulous inflammations of the larynx or upper air
tract. I suspect that the essayist is still under the influence of
the old French school, and it is owing to his early training in
that school that he comes to lay such stress upon scrofulous in-
flammation in contradistinction to syphilitic and tubercular
ulcers. I have read much of the literature of this subject and
have come to the conclusion that there is very little difference
between scrofula and syphilis on one hand, and scrofula and
tuberculosis on the other. I think that there is no ground for
belief in an ulcerative scrofulous inflammation of the throat.
Dr. Jarvis: I should hesitate to accept the radical view of
Dr. Mackenzie that scrofulous inflammation is always tubercu-
lous. We can not always demonstrate by microscopic examina-
tion the presence of bacilli. Many scrofulous disorders come
more correctly under the head of constitutional syphilis.
Dr. Weight: I should like to know what scrofula of the
upper air passages is if it is not tuberculosis and if it is not
syphilis. What is it?
Dr. Jarvis : I do not absolutely accept the term scrofula.
This condition might be due to inherited syphilis. 1 do not be-
lieve in making the comprehensive term "tuberculosis" cover all
these cases. I might mention a case of necrosis coming under
my observation in which the attending circumstances, clinical
history, and social surroundings make it difficult to entertain
the view of inoculation with syphilis, and there was no evidence
of tuberculosis. In this patient the manner and result of
treatment were such that we could not entertain the view that
it was a case of tuberculosis or 93 philis.
360
PROCEEDINGS OF societies.
[ X. Y. Med. Joub.,
Dr. Mulhall : What has scrofula to do with syphilis? I
remember the remark of a man with whom I had the pleasure
of being associated for three years — I refer to Mr. Hutchinson,
■of London, who knows something of syphilis. The statement
was that syphilis is not transmitted to the third generation. I
offer an explanation of what we vaguely call "scrofula." I
published a paper some seven years ago upon atrophic rhinitis,
in which I gave a definition of scrofula as a peculiarity in the
constitution or age of the parents by which one or both of them
are unfitted for transmitting healthy offspring. For instance,
the child of drunken parents may be scrofulous ; the child of
senile parents may be scrofulous; the child of syphilitic parents,
if conceived in the stage of cachectic depression, may be scrofu-
lous; the child of phthisical parents may be scrofulous. There-
fore, scrofula affects the product of conception of parents w ho
are in a profoundly depressed state of nutrition, whatever it may
be due to.
Dr. S. Solis-Cohex : I have been very glad to hear this sub-
ject brought forward for discussion, since, unless we recognize an
abnormal constitutional condition, which we may call scrofula,
we will not treat its subjects properly, either for local disease
in the upper air passages or for local or general disease else-
where. Dr. Mackenzie believes that Dr. Robinson is at fault in
paying deference to the opinions of the older French writers. I
for one would like to express my indebtedness to those French
writers, and especially to Lugol. Even with all our new lights,
if we turn to the writings of that great man we can certainly
learn something about scrofula — a disease which the elder
Gross called the child of syphilis and the parent of tuberculosis.
But syphilis is not the only cause of congenital scrofula. As
Lugol pointed out and as Dr. Mulhall has just said, it is the in-
heritance of a child whose parents are, from whatever cause,
physically incompetent to produce normal offspring, and it
forms a species of what we vaguely call " diatheses." We have
ho better w-ay of characterizing this condition, especially from
the standpoint of the modern cell doctrine, than by stating the
position thus : All manifestations of life enter this world as liv-
ing cells: every cell springs from a parent cell. If that parent
is intrinsically deficient or by extrinsic causes rendered unable
to transmit to the offspring the necessary vitality or life force,
the product will be incomplete or scrofulous. The scrofulous
state may likewise be acquired by depression, privation, or ex-
cess. Benjamin Ward Richardson says that the secret of long
life consists not so much in any peculiar endowment of the
body as in the nice adjustment of parts. Going a little farther
than this, we see throughout Nature a constant balancing of op-
posing forces. It is exemplified alike in the revolutions of the
planets, in the course of the winds, in the swing of the pendu-
lum. As in the macrocosm, so is it in the microcosm ; the heart
of man throbs as the heart of the universe. In the scrofulous
child there is not that nice balance of opposing forces. Either
there is not enough innate constructive force to repair the tis-
sues broken down in the exercise of function, or there is a
failure from incomplete development or, in the acquired condi-
tion, from incomplete nutrition, to supply energy to meet the
destructive forces of the environment. This state has been
well described by a modern French writer (Jaccoud), as one of
" hypertrophy " or " congenital dystrophy " : but names are less
important than the fact that the organism is unfitted to survive
in the struggle for life. The child under such circumstances is
not necesarily born tuberculous, but may become tuberculous.
Local expression of the disease in the upper air passages or else-
where is determined by some trauma or other accidental exci-
tant. The local expression may not differ to sight from the
local expression of other causes, but its course, its rebellious-
ness, the general condition of the patient, help the diagnosis.
I may refer to a case of scrofulous ozaena, which was neither
syphilitic nor tuberculous, that I saw ten years ago in a boy
whose brother and sister have since developed tuberculosis,
My patient himself has not yet developed tuberculosis, though
he may do so. At all events, the general history of the patient,
rather than the shape of the ulcerations or the quantity of bone
that necrosed, shows that his was a case of scrofula and not
of tuberculosis, which his brother and sister manifested. The
parents are neither tuberculous nor syphilitic, but they were,
when the children were born, overworked and ill-nourished be-
cause of their poverty. I heartily agree with Dr. Robinson that
in treatment, as in diagnosis, we must look upon the funda-
mental constitutional condition as more important than the
local accident that comes under our eyes.
Dr. Glasoow : I am a firm believer in the constitutional
origin of many of the pathological conditions of the upper air
passages — not from a theoretical, but from a clinical standpoint.
That this view is not accepted more generally seems to be due
to the fact that physicians are looking too closely to the local
processes. I came many years ago to the conclusion that many
of the cases showing congestion of the upper air tract could be
promptly relieved by proper attention to constitutional rather
than local conditions.
I am thoroughly pleased to hear the term scrofula again. I
know I am out of date, but to me it is one of the most expres-
sive terms in the medical vocabulary. The influence of my
early training, listening to the teachings of Scoda and Oppolzer,
made such an impression that it has been difficult for me to
accept the views of later German pathology. I do not see
that any addition can be made to the definition of scrofula as
given by Dr. Mulhall and Dr. Cohen. Clinically the term des-
ignates a certain condition of the mucous membrane when it is
applied to the air passages. In persons of the strumous diathe-
sis inflammatory processes are prone to take on a subacute or
chronic character. There is great infiltration of tissue with a
lessened tendency to a return to the normal condition. The
modern school would embrace all the conditions formerly
known as strumous or scrofulous under the general name of
tubercular infiltration. To me this seems unfortunate, when
we look at the condition from a clinical standpoint, for we
see uiany cases where we can certainly make a favorable prog-
nosis. The name strumous would indicate this, while tubercle
is a word of ill-omen. The confusion which is caused by the
use of the word tubercular to indicate a variety of conditions is
not justified by the fact that we often find the tubercular ba-
cillus in this tissue. The old doctrine of Niemeyer — that "the
great danger to the strumous lies in the possibility of becoming
tuberculous" — is strictly in analogy with our experience at the
present time, when we consider the infectious pneumonia ot
influenza. No one would consider this pneumonic condition as
tubercular, but we do know that the pathological condition of
the lung in this disease proves a most fertile soil for the growth
of the tubercular bacillus, and large numbers die with an ac-
quired tuberculosis. The bacillus grows and develops in the
laboratory in several culture mediums, and is it not equally
true that in the human body there exist several pathological
conditions which furnish a suitable and fruitful soil?
Dr. Boswortii : In estimating the constitutional or other
origin of any local disease of the upper air passages, it is neces-
sary to differentiate between diseases of the nose and those of
the naso-pharynx. I do not think that the constitutional state
has much to do with catarrhal inflammations of the pituitary
membrane, in a great majority of cases at least. Rut when you
come to the naso-pharynx you will find catarrhal conditions
very frequently dependent upon constitutional diseases. Dis-
ease of this region is most likely to occur between the age of
March 26, 1892.]-
NEW INVENTIONS.
361
eighteen and forty years. I have found that most catarrhal
affections locate themselves at this point in the naso-pharynx
between these ages, thus establishing conditions which are ag-
gravated by disorders in other parts of the body. This leads to
the question, What lias the lymphatic system to do with these
disorders? and, still further, to the discussion and definition of
struma. We think that we know about all there is to know
about the nose and its disorders; but we have in the lymphatic
glands existing in the naso-pharynx a subject for study — one 1 hat
we know comparatively little about. Catarrhal diseases located
in the naso-pharynx, secondary or primary, are dependent upon
disorders of the lymphatic system ; the source of the lymphatic
disturbance is in the underlying constitutional condition. I do
not like the term scrofulosis: I prefer to call it struma. I think,
if we investigate the cause of the lymphatic condition that I have
mentioned, it will lead us a step farther toward comprehending
what is described as struma. My main point, however, is that
the constitutional state has very little to do with diseases of
the nose, but has very much to do with diseases of the naso-
pharynx.
Dr. Ingals : I am particularly pleased with Dr. Robinson's
paper, as it directs us to a rational treatment of a comparatively
large class of obscure cases whose real nature is liable to be
overlooked. I can not understand why constitutional condi-
tions should not affect the nose as well as the naso pharynx, and
I can not agree with the last speaker that the nose is never
affected in cases considered scrofulous.
Dr. Wright : In answer to my question of what is meant by
scrofula of the upper air passages, I have been informed what
constitutional scrofula is, but have not been told how to recog-
nize a scrofulous lesion in this location.
Dr. Mulhall: Six months ago I wrote a paper on The Ef-
fects of Diet and Exercise upon the Cure of Simple, Uncompli-
cated Chronic Inflammation in the Human Body. I think I
proved in that paper by several new facts that constitutional con-
ditions do affect the nose. I furthermore proved that to the
dyspeptic disorders of Americans and their careless manner
of eating and lack of physical exercise must be ascribed the
cause of our national disease — catarrh — and not to our climate
or any meteorological conditions whatever. I think that I also
proved that patients, by proper hygienic treat-
ment, by careful attention to diet, exercise, CggSII~Sgl^iS^g
and clothing, can be cured without local treat-
ment. I referred, as examples, to the cases of
two pugilists who had catarrh, whose noses were stuffed and hy-
peramiic, while they were spending their time in saloons and
eating and drinking too much; they were in a state of hypermi-
trition. They used various remedies for the catarrh, both with
and without the advice of physicians, without benefit. They
then went into training for a prize-ring encounter, and two
weeks before training ceased the nasal troubles entirely disap-
peared. I also referred to other cases in which equally good
results were had from improvement of the personal habits of
patients with nasal catarrh. Without this hygienic help, I de-
nounce local medicinal treatment as utterly useless, except from
a financial standpoint.
Dr. Robinsox: With all respect to Dr. Mackenzie, who
credits me with not forgetting my early training, I would state
that I am not unfamiliar with recent French literature and Ger-
man literature also. We are not yet in a position to place an
exact value upon Koch's tuberculin in diagnosis. It is not pos-
sible to decide in every case whet her a lesion is a tuberculous
manifestation, or simply a case of so-called struma or scrofula
affecting this locality and the tuberculoid deposit still remain-
ing doubtful. All of us are aware that there are cases of this
kind in which the microscope fails to prove the lesion tubercu-
lar. What, then, shall we call them if they appear in patients
evidently scrofulous? I am glad that the president has also ex-
pressed his approval of the views which Dr. Cohen so very elo-
quently set forth in his exposition of scrofula. We must not
lose sight of the general ground of medicine, otherwise we will
lose ourselves in minutire.
I submit that, in the presence of a scrofulous manifestation
in the upper air passages, we are forced to call it something,
and, if we can not pronounce it tubercular, what can we call
it? We will have to fall back upon scrofula for the want of a
better name — just as, in speaking of "catarrh," as Dr. Bos-
worth has admitted so forcibly, in some cases we are obliged to
fall back npon general ideas and provisional names, perhaps
without expressing ourselves positively as to the case being ne-
cessarily of one kind or another. For further consideration I
will refer those interested to Dr. Reyes's last edition for the
diagnosis between scrofulosis, tubercu'osis, and syphilis of the
throat, where a part of what I have said will be found.
Lcfco Jfnij cations, etc.
SOME NEW AND IMPROVED INSTRUMENTS.
By Southgate Lkigh, M. D.,
NORFOLK, VA.,
LATE HOUSE SURGEON, MT. SINAI HOSPITAL, N. Y.
During a bousesbip of thirteen months on probably the heaviest
surgical service in the United States I found many of the instruments
in constant use unhandy or complicated. I attempted from time to
time to improve and simplify them. I take the liberty of here present-
ing a few of them. They represent but little originality, yet I hope
they may prove to be useful to the profession.
Messrs. George Tiemann & Co. are the manufacturers.
1. Sponge Holder (Fig. 1). — In abdominal surgery the sponge hold-
ers ordinarily used are unsatisfactory and unsafe, in that the sponges
are liable to come off and be lost. Some operators use ovarian clamp
forceps, but these are inconvenient from the size of their handles. The
Fig. 1.
holder here presented is intended to overcome both objections. It con-
sists of two long rods with serrated grasping surfaces and an aseptic-
lock. When closed it holds the sponge firmly and securely, and forms
a slender single rod.
2. Ether Inhaler (Fig. 2). — The Ormsbee inhaler has been clearly
proved to be far superior to the ordinary inhalers. Its chief advantages
are that it consumes less ether and that the vapor is warmed by the
expired air. It is, however, somewhat complicated and an expensive
Fro.
'nstrument. The inhaler here ligured is extremely simple. It consists
of an ordinary A His inhaler with a bag attached and with packing
ofspotiges instead of cloth. It has all the advantages of the Ormsbee,
with the addition of simplicity, smaller cost, and a licttet lilting mouth-
362
MISCELLANY.
[N. Y. Med. Join.,
piece. It can be used as an Allis inhaler by detaching the bag, and
has the advantage of simpler packing, w hich may be easily removed
and cleaned.
3. Needle Holder (Fig. 3). — This instrument is all metal and easily
taken apart. Its action is simple, convenient, and best adapted for
rapid work. The sliding catch is so nicely graduated that the operator
can exert slight or great pressure on the needle, as occasion may re-
Fio. 8.
quire. While in use its spring prevents the instrument from opening
more than a moderate distance. The grasping surface is hollowed for
curved needles, and has a groove for Hagedorn needles.
Fie
4. Artery Forceps. — Figs. 4 and 5 represent the forceps in use at
Mt. Sinai Hospital, both plain and bull-dog. They have been perfected
from time to time, and are now probably the most reliable and con-
Fio. 5.
venient forceps that are made, especially for rapid operating. They
have the same useful thumb-slide as the needle holder. They are easily
cleaned.
5. Mixeel/tinetixx. — (a) The sliding catch was found to be so con-
venient that I have adapted it to the fixation forceps for the eye and
to other catch foreeps.
(b) The forceps ordinarily used for everting the lids in "grattage for
trachoma " frequently cuts the edge of the cartilage. I have had one
made with a modification which overcomes this objection.
(r) Bandage cutter: This consists of a large, wide, thin-bladed knife
and a miter-box. The bandage is rolled wide and then cut into two or
more bandages, according to the width required. It is a labor-saving
machine.
i s c c 1 1 an v .
The Mechanism of the Mammalian Limb. — The Boston Medical
and Surgical Journal tor March 17th contains the following lecture by
Professor Harrison Allen, delivered before the Academy of Natural
Science of Philadelphia :
In all animals the limbs are adapted for locomotion in one of three
ways, and each of these is in fixed relation to the plane of support —
the first, by which movement is made through air; the second, by
which it is made through water; and the third, by which it is made on
the ground. Observe, we speak of motion in air, in water, and on the
ground. Flving and swimming mammals are surrounded by the medi-
um through which they move, whereas in terrestrial mammals the limb
is on the ground. The few exceptions that can be made to this state-
ment will not interfere with its truth in general. Again, the size of the
limb (notably the foot) in its proportion to that of the body decreases
as we pass from the flying to the walking animal.* Thus the wing of
* It is curious that we have one phrase to express motion through
the water, which is the act of swimming; one phrase to express motion
the bat in proportion to that of the body is immensely larger than are
the paddles and flukes of a whale or seal, and both of these, again, are
larger than the foot of any of the terrestrial animals. In a word, the
size of the limb disposed for progression is in direct ratio to the
density of the medium through or on which the animal moves.
Let us examine the skeleton of the dog with reference to the rela-
tion which the limbs have to each other, and to the influence which is
exerted upon them by the weight of the head and spine.
We notice, in the first place, that the anterior extremity
is supported entirely by muscle; for we do not acknowl-
edge that limbs with clavicles are better adapted for sup-
port than are those without these bones, since when the
extremity is fixed at a small movable point to the breast
bone it gives little or no assistance to the terrestrial
movement. Indeed, the clavicle does not appear until
the limb is adapted for kinds of motion with which terrestrial planes
of support have nothing to do. Now, in order that the anterior
limb be firmly supported, its motions precisely defined, its strength
as well as its mobility rigidly preserved, these muscles must be of
enormous size and power. We find that the lines of origin of this
muscle-mass are secured from a large region — namely, the back of
the skull, the side of the chest, the sternum, the vertebral aponeurosis,
and even, in some forms, the hip bones. All the muscles which thus
arise are in the forms of sheets, either simple or folded once, twice, or
three times. Often from a sheet we may have ribbons evolved, or from
a second sheet bandage-like layers, but never thong-like or cable-like
bands. These sheets are wonderfully rich in nerves, and extend to,
and partially imbed, the shoulder blade so that no part save that which
lies directly at the shoulder joint is free. They extend down along the
arm at varying distances, always reaching as far as the humerus, and
not infrequently the wrist.
How different is everything in the hind limb! The hip bone is fixed
to the line of the spine; and the limb, not being supported by muscle-
masses, has in every part an entirely different aspect from that of the
front limb, and the muscles which do arise from the line of the spirre
are confined to a surface scarcely any larger than that of the hip bone,
and act, of course, not on the part which is homologous to the scapula,
but on the lower limb segments. They show slight disposition to ex-
tend forward — for example, as in the psoas — and scarcely any to extend
backward along the caudal vertebra?, yet they preserve the same tend-
ency, as do the fleshy masses of the anterior extremity, to send bundles
down — that is, distal ly — to reach in most forms to points as far as the
knee or even the ankle. Since the nerves are more numerous in the
sheet than the spindle forms of muscles, it follows that the nerves go-
ing to the posterior extremity are relatively fewer than those going to
the anterior.
Let us retrace our steps a moment to consider the two limbs from
an entirely different point of view than the one above accepted. As-
suming that vertebrate life found its first expression in aquatic ani-
mals, and remembering that the most important feature in the life of
aquatic animals is the means by which the mechanism of respiration is
adapted to the medium of water, it follows that problems of the
mechanism of the limb in aquatic creatures will be essentially different
from air-breathing forms, inasmuch as they all possess respiratory
organs, which are fixed to the sides of the neck, or at least to the
region back of the head, since in some types, as the fishes, there is no
true neck. It will be at once seen, accepting as correct that an ante-
rior extremity demands for high degrees of efficiency an extended sur-
face for the origin of its muscles, that much of such surface is lost in
gill-bearing vertebrates, and it is probably true that this accounts for
the fact that no such forms possess large anterior extremities. Take,
for example, the proteus type of water-newt, which is the besl ex-
pression known of this phase of development. We have here the gill-
arches in front of the small anterior limb, and the chief motion is ob-
through the air, which is the act of flying; but no one phrase to ex-
press motion on the ground; the last-named motion being included in
such terms as the acts of walking, running, leaping, etc.
March 2(5, 1892. J.
MISCELLANY.
363
tained by the action (it the long flexible tail rather than by the limbs.
In the frog the gill-arohes indeed disappear, yet even here the anterior
limb remains of small size.
In mammals the relation existing between the motion of the ante-
rior extremity and the respiratory act must be remembered. It is not
accidental, I am sure, that such an extremity is placed at the side of
the front of the thorax. The act of breathing is assisted by many of
the muscles which move the anterior extremity, whereas none of the
posterior have any connection with respiration. The posterior ex-
tremity, on the other hand, is held to the line of the spine by a fixed
pelvic girdle. The exceptions to this rule are so unimportant that
they can not be separately treated. Not only is each hip bone fixed to
the side of the trunk, but is also joined to its fellow at the pubis (bats
often excepted, and seals always), and the relations of both bones are
held to be, not with respiration, but to the functions of the organs of
the abdomen, especially to the rectum and the organs of generation.
We have seen that the shape of the limb is in relation to the den-
sit v of the medium through which it is used, and now we will notice
that in terrestrial forms the motions of the limbs hold an equally exact
relation to the center of gravity of the body. In the most rapid motion
of the terrestrial type the front limb can retain its plane of support on
the ground until the trunk has passed along so far as to bring the
center of gravity in a line which will pass vertically upward through
the foot. In a subsequent attitude of support the hind limb can reach
forward as far as or even beyond this line.
It is a remarkable circumstance that both in the anterior and pos-
terior feet the ground is reached by the outer border of the foot, and
not, as one would suppose at first sight, by the foot being brought down
iu a horizontal position. In all quadrupeds the outer border of the leg
and the outer border of the foot receives distinct nerves. In the fore
limb it is the ulnar, in the hind limb it is the tnusculo-cutaneous and
short saphenous nerves. The outer border is further often adorned
with fringes of hair or other appendages either in the form of scutes,
warts, or of special folds of skin. In a word, the outer border of the
foot and leg, taken as a whole, is apt to be distinct from the rest of
the body, not only in the way it is used in progression, but in its domi-
nation of nutritive processes.
The cycle of movement of the foot in the act of walking is some-
thing as follows: The foot in the first stage — that is, before being
brought to the ground — is in a position midway between pronation and
supination. The outer border as it reaches the ground is held in this
position but for an instant, since the body surging forward by the aid
of the other three legs soon brings the main lines of weight upon the
foot, which now rests on its widest surface of contact. The impact is
somewhat gradually transferred to the inner border, along which,
when the main body weight is beyond, the foot is lifted from the
ground.
It is noteworthy that when used in any other way except for sup-
port on the ground (I mean by this, firm contact against a resisting
terrestrial surface), limbs of all mammals resemble one another; for ex-
ample, forms so distinct in systems of classification as the sloth, the
bat, the seal, and the duck-mole are associated in one respect — namely,
by the absence or diminution of impact of the several parts of the
limbs. The characters of the bones of the arm and thigh, since they
do not support the body on the ground, are almost exactly alike iu the
sloth and the bat. In like manner the general outline of the scapula in
man, the ape, the kangaroo, and the jumping mouse conform to a single
plan— that is to say, the supraspinatus fossa is narrower than the
infraspinatus — since in none of these animals is the anterior extremity
used for support. Likenesses which are due to strain, as in the bat
and sloth, are recognizable; as well as those due to adaptation of the
anterior extremity to prehension, as seen in men and the apes; or
those due to adaptation to the swimming habit in creatures so far
apart as the duck-mole and the seal; but all these, nevertheless, may
lie associated by a inciely negative character — namely, the absence of
impact .
When walking with a closed umbrella, using it as a cane, one
brings the ferrule down on the ground at every step. A leg of a living
animal periodically adjusted to the ground like the closed umbrella is
said to be modified by im/nn/. In a word, it is impact that takes place
in the umbrella every time it is brought to the ground. When the
umbrella is held in mid-air and opened, the movement is independent
of impact. An animal using its anterior extremity in a similar man-
ner (as in a bat unfolding its wings for flight), the several parts are
said to undergo strain. The difference between impact and strain in a
general way implies a difference in the method of progression — that
is to say, the difference between strictly locomotor and prehensile use.
I will now attempt to make an application of the above-stated facts,
which I fear some will think radical. I allude to the study of the
causes of certain fractures in the human body. May I venture the
opinion that without an understanding of the mechanism of the limb in
the lower animals the a;tiology of lesions of the limb in man can not
be explained ? The following is an example of a lesion through strain :
A sailor falling from the deck of a vessel to the bottom of an open
hold, catches at a rope for support ; he sustains himself but for an in-
stant ; he feels a sharp pain in the region of the shoulder ; he lets go
his grip and again falls. Examination shows that he has fractured his
shoulder blade.*
Now, the man has done exactly what a monkey will do many times a
day in the forest, as he springs from swaying vine to pendent bough;
but the animal incurs no risk to the shoulder blade or to any other
bone. The man has attempted something, in an excursive way, to
which his structure appears to be adapted, but iu the attempt he fails
and incurs injury. Unless an analysis of such a lesion can be rea-
sonably undertaken by comparing the manner in which this act can be
safely performed with that which results in disaster — in a word, of a
comparison of the parts in a monkey and in man — no exact clew to the
fracture can be vouchsafed. Let me also invite your attention to a
lesion by impact. Sir Charles Bell has drawn the figure of a man on a
stumbling horse ; the man is in the act of being thrown forward. The
position of the anterior limb of the horse and that of thearm of the man
are the same. In an instant afterward both limbs will come to the ground,
the horse's to enter into the second stage of the foot's normal cycle, the
man's to break. In placing his anterior extremity forward as though
it was well adapted to move on the ground (though it has long since
been adapted for an entirely different class of work), he applies it for
a purpose to which it is in reality unfitted, and disaster ensues.
I have been interested in studying the position of the hand in fract-
ure at the lower end of the forearm. The text-books teach that the
hand comes to the ground directly iu the middle, or on the thumb side.
I have concluded, when the body falls prone, that the hand comes down
on the little-finger side, as is normally the case in the lower animals
An examination of the specimeus.preserved in museums has convinced
me that this assumption is just as capable of explaining the deforma-
tion as is any other, and is sustained in addition by an examination of
its literature. A short time ago I stumbled and fell. I instinctively
threw the right hand forward to break the force of the fall. I found
when 1 examined the parts that my hand was bruised along the little-
finger side, and the clothing soiled on the corresponding part of the
forearm. In the explanation of a lesion, created as it is by an error of
impact, the line of reasoning essential to it is quite different from what
is met with in strain ; but the problem suggested is like it in one re.
gard, that it is profitable to the study of the manner by which the parts
of a limb adapted for strain are easily disadjusted when called upon to
perform the duties of impact, and also like it in another way that it
can be best explained by a knowledge of comparative anatomy.
The American Medical Association. — The committee appointed :it
the last meeting to consider the best means for promoting the prosper-
ity of the sections of the association will hold an adjourned meeting in
the Hotel Cadille, Detroit, Mich., on June 6th, at :; p, a. Members of
the committee are requested to notify the chain i of their intention
to be present at this meeting. The committee would esteem it a favor
if each member of the association would communicate in writing his oi-
lier views concerning the best measures for promoting the development
of the sections. Such communications may be sent to the chairman of
the committee, Dr. John S. Marshall, No. it Jackson Street, Chicago. ^
* Dr. Joseph Leidy. Proceedings of the Philadelphia Count;/ Medi-
cal Society, 1801; p. 73.
364
MISCELLANY.
[N. Y. Med. Jont.
Mortality in Cities in the United States. — The following table
represents the mortality in the cities named, as reported to Dr. Walter
Wyman, Surgeon-General of the Marine-Hospital Service, and pub-
lished in the Abstract of Sanitary Reports for March 18th :
New York, N. Y Mar. 12.
Philadelphia, Pa Alar. .">.
Brooklyn, N. Y Mar. 12.
St. Louis, Mo Mar. 12.
Boston, Mass Mar. 12.
San Francisco. Cal. . . Mar. 5.
Cincinnati, Ohio Mar. 11.
Cleveland, Ohio Mar. 12.
Pittsburgh, Pa Mar. 5.
Washington, D. C Mar. 12.
Detroit, Mich Mar. 8.
Newark. N. J Mar. 6.
Newark, N. J Mar. 12.
Minneapolis, Minn. . . Mar. [2.
Louisville, Ky Mar. 12.
Rochester, N. Y Mar. 12.
Kansas City, Mo Mar. 5.
Providence, R. I Mar. 12.
Denver, Col Mar. 5.
Denver, Col Mar. 12.
Toledo, Ohio Mar. 11.
Nashville, Tenn . . . . ,VI;n\ 12
Fall River, Mass Mar. 11.
Portland. Me Mar. 12.
Binghamton, N. Y. .. Mar. 12.
Mobile, Ala Mar. 5.
Mobile, Ala Mar. 12.
Galveston, Texas Mar. 4.
Auburn. N. Y Mar. 5.
San Diego, Cal Dec. 12.
San Diego. Cal Jan 10.
San Diego, Cal Mar. 5.
Pensacola, Fla Mar. 5.
■3 1
§■5
1,515
1,046,
806
451
44K
298
296
261
238
230,
205.
181.
181
164,
161
133
132,
132,
106,
L06.
81
76
74.
36
35
31
31
29
25,
16
16
16
11
DEATHS FROM-
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1
Parisian Surgery. — In one of a series of articles entitled Clinical
Notes in the Paris Hospitals now appearing in the British Medical
Journal, the writer, Mr. Ernest Hart, who is the editor of that journal,
says :
The leading surgeons and professors of the French hospitals have
the advantage, for the most part, of very complete arrangements for
teaching; the complete control of a highly skilled staff of internes, who
serve for three years, and when they are professors of the Faculty, of
chefs de cliniqme of thorough training and proved high accomplishment
(who serve for five years) ; their own operation theatre attached to
their wards, in which they perform a whole series of operations on their
clinical days, uninterrupted by the intervening operations of any other
surgeons. There is a staff of nurses and dressers trained to the meth-
ods and special views of the surgeons, so that whatever there is of in-
dividuality in the views and methods of the operator, and whatever is
special to him in his dressings and instruments, may always be found
thoroughly carried out. The surgical services, too, are generally larger
and more active than those in the London hospitals ; and the training
of the surgeons who have passed through a long course of competitive
examinations extending up to, and often beyond, the age of thirty, and
even into middle life, has accustomed them to the art of teaching in a
logical and systematic manner. As a rule, in an active surgical clinic,
half a dozen operations may always be seen performed in succession,
and each of these is illustrated by a short preliminary discourse, ex-
plaining the grounds for the diagnosis, the surgical and anatomical
relations, and the steps of the operation about to be performed; at
each stage of the operation, and while operating, the surgeon explains
hi- procedure, or any modification of it which he finds necessary to
adopt; and at the close of the operation he describes the result at-
tained, and comments on the course of events. The French hospital
surgeon or professor is trained to this end from his earliest career.
Unless he is capable of lucid, orderly, and thorough exposition on
almost any subject within the range of his art, he can never hope to
survive the numerous competitive trials of the kind which he has to
pass through at each successive grade of appointment, from that of in-
terne to chef de cliniquc, chirurgien du bureau central, agrege, etc. No
man who was not laborious, studious, conscious of ability, and capable
of the rapid improvisations and dissertations required at every stage,
would embark on a career which demands an average of at least ten to
fifteen years of continuous work and preparation, and even then only
the fittest survive. So that the surgeons, lecturers, and professors can
at least all of them operate, lecture, and teach with approved skill anil
trained powers of exposition and large resource in acquired knowledge
of the academic as well as the practical kind.
The surgical service of M. P6an, at St. Louis, is one of the most
active in Paris, and his operating days in the amphitheatre attract a
large number of students and of practitioners whose attendance is re-
warded by a fluent and instructive clinical commentary as well as brill-
iant operations which include methods of proceeding, many of them
invented and most of them modified by this able and eminent operator.
On the day on which I was present in the theatre of St. Louis in the
middle of the Christmas vacation there were fewer students than usual,
but the cases for operation were as usual numerous, and the whole pro-
ceedings were sufficiently characteristic of the special features of the
clinical and surgical teaching in the operating theatre to make me think
that a pretty full report of the day's work would be of interest as illus-
trative of a highly instructive method of operation and of demon-
stration.
To Contributors and Correspondents. — The attention of all who purpose
favoring us with communications is respectfully called to the follow-
ing :
Authors of articles intended for publication under the head of " original
contributions " are respectfully informed that, in accepting such arti-
cles, we alioays do so with the understanding that the following condi-
tions are to be observed: (1) when a manuscript is sent to this jour-
nal, a similar manuscript or any abstract thereof must not be or
have been sent to any other periodical, unless we are specially notified
of the fact at the time the article is sent to us ; (2) accepted articles
are subject to the customary rules of editorial revision, and will be
published as promptly as our other engagements will admit of — we
can not engage to publish an article in any specified issue ; (3) any
conditions which an author wishes complied with must be distinct/;
staled in a communication accompanying the manuscript, and no
new conditions can be considered after the manuscript has been pii
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Original Communications.
THE
DIAGNOSIS OF PANCREATIC DISEASE*
By JOHN S. THA CUTER, M. D.
The unsatisfactory position which the pancreas holds
in the minds of clinicians is indicated by the scant atten-
tion which the best modern works on clinical medicine give
to the consideration of its diseases. Fagge's book does not
discuss the subject at all. Striimpell gives thirty lines to
the symptoms and diagnosis of the various diseases of the
pancreas, and Flint gives fifty. Briscoe, in one of the most
recent English text-books on medicine, says that " very lit-
,i tie of clinical value is known about the diseases of the pan-
creas, and it would be a waste of time to discuss their diag-
nosis." Friedreich, in von Ziemssen, says that " the pan-
creas does not possess any function the suppression of which
would produce appreciable symptoms." This being the po-
sition of the best representatives of the profession even up
to quite recent times, while indicating a conspicuous need,
it would discourage us from any attempt to clear up our ig-
norance in this direction, were it not that several interest-
ing observations have recently been made bearing upon the
subject.
The pancreatic functions which are best understood are
the digestive functions, and indeed until very lately these
were the only ones which it had been even suspected of.
Of all the digestive fluids the pancreatic juice is the most
important, doing a greater work upon a greater variety of
food elements than any of the other fluids of the alimentary
canal. It would seem, then, that any disease of this organ,
interfering with the production of this juice, would prompt-
ly and conspicuously manifest itself, and we would expect
to find proteids, starches, and fats appearing undigested in
the faeces, and the patient's general nutrition distinctly in-
terfered with. But both clinical and experimental observa-
» tions on this point disappoint our a priori expectations. As
regards starch, while Abelmann's studies upon a dog whose
pancreas had been removed indicate a marked diminution
in the digestion and absorption of starch, yet there are
enough cases pointing otherwise to make Leo briefly dis-
miss the subject with the words that " the digestion of
. starch is in no way affected by the absence of pancreatic
juice."
As regards proteids, there have been some experiments
and some clinical observations showing that a pancreatic
lesion may lead to the presence of abundant meat fibers in
the fa'ces. But the experiments of Miiller and clinical ex-
perience seem to teach us that Leo is right in saying that
" the effect on the digestion of meat is not sufficiently marked
and constant to be of any value for the diagnosis of pancre-
atic disease." In the fats we have something to which most
clinicians have pinned their faith as about the only reliable
* Read before the hospital Graduated Club, at its fifty-fourth meet-
ing, November 19, 1891.
indication for the diagnosis of these diseases, and it can not
be denied that in several eases an abundance of fat has been
passed from the rectum, and certain experiments, notably
those of Abelmann, point in the same direction ; but the
basis of the belief in this diagnostic point has, on further
observation, become much weakened. As Leube states, " an
unusual abundance of fat in the faeces, which one would ex-
pect in all diseases of the pancreas, and especially in total
degeneration of the gland, is usually not found." Or, as
Leo puts it, " it has been shown that the view often here-
tofore expressed, that an absence of the pancreatic juice
from the alimentary canal produces an abundant presence
of fat in the fasces, is incorrect."
There have lately appeared the detailed reports of sev-
eral interesting experimental observations upon the absorp-
tion of fats from the alimentary canal, and the influence
upon this of the pancreatic juice and the bile, with quite
uniform testimony to the predominating influence of the
bile, leading us to an opinion that if there be simply an ab-
sence of the pancreatic juice from the intestines, while the
bile is normal, the absorption of fats will ordinarily be com-
plete.
The experiments of Miiller show that where the bile is
cut off from the intestines, while the absorption of starch
and proteids is very little or not at all affected, the absorp-
tion of fat falls from about ninety per cent, to between for-
ty-five and tweuty percent., and, on the other hand, that in
the absence of pancreatic juice the absorption of starch is
not affected, the digestion of proteids is a little less com-
plete, and no effect upon the absorption of fat could be es-
tablished.
Munk's experiments on a dog with biliary fistula show
a great diminution in the absorption of fats ; and, again,
the experiments of Dastre, while showing a slight diminu-
tion in the absorption of fat in the absence of pancreatic
juice, show a more marked effect in the same direction from
the absence of the bile. Moreover, in none of the cases of
pancreatic cyst collected by Treves did fatty dejecta occur,
and according to Grandmaison they are observed more often
in cancer, which is generally close to if not involving the
duodenum, than in other pancreatic disease. Taking these
facts into consideration, and also the fact that lesions of the
pancreas are often associated with obstruction of the biliary
duct, it seems possible that in many of the cases where fat-
ty dejecta have occurred, they may have been due to shut-
ting off of the bile rather than to the absence of pancreatic
juice.
Our practical clinical conclusion, then, as regards the
presence of proteids, starch, or fat in the faeces as a basis of
diagnosis, must be, that while they may occasionally occur
in cases of pancreatic trouble, and when occurring in abun-
dance would be one factor in the diagnosis, yet they usu-
ally do not occur, their absence does not by any means indi-.
cate a normal condition of the pancreas, and the presence
of fat would point more strongly to some trouble of' the-
liver or its ducts.
One point, however, associated with this, is perhaps on
its way toward establishment, and that concerns the dimin-
366
THAGHER: THE DIAGNOSIS OF PANCREATIC DISEASE.
[N. Y. Mkd. Jock,
ished ratio of the fatty acids to the neutral fats. Miiller
has shown, from three eases, that the ratio is in diseases of
the pancreas diminished from the normal eighty-four per
cent, to forty per cent., and Leo says that " the saponify-
ing power of the pancreatic juice is distinctly affected, which
gives ns the only means of positive proof that the pancreatic
juice is not doing its part in the intestinal digestion." This
point, however, loses largely from its practical value because
of the necessity of elaborate quantitative tests which could
not be undertaken except by an experienced chemist.
A further practical point has recently been suggested,
and possibly further observations will show it to he well
taken. Walker maintains that the presence of the pancre-
atic juice is necessary to the normal pigmentation of the
faeces, and that the absence of this juice, as well as the ab-
sence of the bile, may produce clay-colored stools.
This is based on two cases. In the first case the patient
had light-colored stools without jaundice, the liver on au-
topsy being normal and the ducts pervious. But there were
epigastric pain and diabetes, there were fatty fasces, and at
the autopsy the pancreas was found much enlarged, fatty,
and fibrous. In the second case the patient had had stone-
colored stools, without jaundice or other symptoms of liver
trouble, it and its ducts being normal at the autopsy ; but
there were greasy dejecta, also glycosuria, and at the autopsy
the duct of Wirsung was found involved in the cicatrix of
an ulcer.
The point suggested to Walker by these cases he also
supports by certain further considerations. In the first
place, the coloring matter of the bile is not the same as
that of the faeces, and is therefore altered chemically by
some agent, possibly by the pancreatic juice.
Again, as Claude Bernard observed some thirty-five
years ago, " the bile only colors matters a very light yellow,
while with the pancreatic juice the bile takes a decided
brown tint."
Again, meconium, which contains bile, does not, how-
ever, show the usual faecal color, and it is known that the
pancreatic juice does not flow until after birth.
And again, certain drugs which increase the faecal pig-
mentation and relieve symptoms of indigestion, are shown
by experiments not to increase the secretion of bile.
While these cases and arguments of Walker's can hardly
by themselves force us to accept the suggestion based upon
them as proved, it seems to be sufficiently worthy of con-
sideration to be borne in mind in suspected cases for fur-
ther demonstration or disapproval.
Before leaving this discussion of diagnostic aids based
on the digestive functions of this gland, let us notice this
further point which has been made by Pisenti.
The pancreatic juice effects the change of proteids into
peptones, and of these into leucine and tyrosine, from which,
by decomposition, are produced skatol, phenol, and espe-
cially indol, which latter is in turn the source of indican.
From this it would follow that pancreatic disease would lead
to the diminution of indican in the urine.
Pisenti's experiments show that ligation of the pan-
creatic duct reduces the indican of the urine to a quarter of
its normal quantity : but, as Leube states, " since human urine
in normal condition contains so scant an amount of indican,
its absence from the urine or its presence in traces is only
<>f diagnostic value in cases where, from the nature of the
attack, an increase of the indican in the urine was to be
confidently expected " ; or, as Leo puts it, "since tumors
of the stomach and intestines are generally accompanied by
a marked increase of indican, an epigastric tumor is proba-
bly pancreatic if the indican is not increased or is dimin-
ished."
Lipuria has been mentioned as a symptom of diseases
of the pancreas, but this is certainly so rare as not to merit
our attention.
Until quite recent times, experiments have revealed no
further functions of the pancreas than the digestive ones ;
but during the few years just past both experimental and
pathological observations have been rapidly accumulating
which now oblige us to admit at least the very plausible
showing in favor of a further and important office for this
gland.
It is true that even in the last century the coincidence
of diabetes with pancreatic affections was noted. But Bora
chardat was the first to propound a theory of the pancreatic
origin of diabetes. Lanceraux, later, supported this posi-
tion vigorously. But it was not until the experiments of
Mering and Minkowski, reported in 1889, showed that iota]
extirpation of the pancreas was followed by all the charac-
teristic symptoms of diabetes, that the idea of an essential
connection between this organ and this disease began to be
generally and seriously entertained.
Of twenty-one dogs upon which they operated, three
died within twenty-four hours without urinating; the other
eighteen all excreted sugar, and the condition after complete
removal of the pancreas was " not a simple temporary gly-
cosuria, but a genuine diabetes mellitus, resembling in all
respects the most severe forms of this disease in man, even
to extreme hunger and thirst, marked polyuria, emaciation,
and weakness."
Lepine also extirpated the pancreas from several dogs,
and found that in all those in which the autopsy showed
complete removal there was marked and increasing glyco-
suria.
Dominicis has done thirty-four extirpations with less
constant results, and yet, of these thirty-four animals,
twenty-one had glycosuria, and all showed progressive ema-
ciation, polyuria, polydipsia, and polyphagia, with various
affections of the skin.
Remond's experiments included total and partial extir-
pation and ligature of the excretory ducts, and in each set
he sometimes obtained and sometimes failed to obtain gly-
cosuria.
Hedon has operated on twenty-three animals. The first
ten died promptly, but improved technique resulted in the
survival of the other thirteen, and they all passed glucose
in their urine.
Arthaud and Butte also report similar results. They
say: "We have repeated the experiment of total removal
of the pancreas, and we have obtained results absolutely
identical with those reported by Minkowski and von Me-
ring and afterward by Lepine."
April 2, 1892.J
THACHER: THE DIAGNOSIS OF PANCREATIC DISEASE.
367
Renzi and Reale reported to the Tenth International
Congress that in their experiments total removal of the
pancreas was followed, in seventy-tive per cent, of the cases,
by glycosuria, and made the further interesting announce-
ment that diabetes could be experimentally produced by
removal of the duodenum or of the salivary glands.
It is of interest that incomplete extirpations have often
failed to produce glycosuria, a remnant of little more than
one tenth of the gland being enough in some cases to avoid
this result, recalling analogous experiences with myxcedema
after thyreoidectomy.
The experiments which we have just reviewed conflict,
it is true, with many former experiments on the pancreas,
but they were largely ligations of the ducts, and the at-
tempted extirpations were many, possibly most of them, in-
complete. If, for instance, we look over Martinotti's re-
ports of the operations from which he drew his decidedly
negative conclusions, we find that remnants of the organs
were revealed in three of the four cases, and that in the
fourth, where none was left, no examination of the urine is
reported, but there was marked emaciation.
Klebs and Munk failed to obtain diabetes by ligature or
exsection, and referred the diabetes observed by others
to lesions of the solar plexus. But Klebs has since ex-
pressed his adherence to the pancreatic explanation ;
and, moreover, Peiper's cases of solar-plexus extirpation
from fifteen animals, of which eleven survived, showed no
diabetes.
Experimental observations are then very emphatic in
support of the causative relation of pancreatic lesions to
diabetes.
ftor are post-mortem observations silent on this ques-
tion. Saundby's carefully detailed reports of the changes
in the various organs of fifteen cases of diabetes in man
which came to autopsy, show that the most constant and
marked was an atrophy of tlie pancreas, being present in
seven of the fifteen, and in all of the typical wasting cases.
In four others the gland was firm and fibroid, and in only
four did it appear normal.
Baumel professes to have found either gross or micro-
scopic lesions in all the cases of diabetes which he has in-
vestigated. And Lanceraux reports twenty consecutive
cases of the severe wasting variety, his " diabete maiyre"
which have come under his observation. Of these, fourteen
have died, and they have all shown abnormal conditions,
obstruction of the ducts, sclerosis, or steatosis. Frerichs
reports thirty cases, of which twelve showed an abnormal
atrophy. Senator says that one half show pancreatic le-
sions; and various others have recorded isolated cases illus-
trating the relation.
My own experience regarding this question has heen
this: During my connection with the Presbyterian and St.
Luke's Hospitals, five autopsies have been made, in those in-
stitutions upon well-marked cases of diabetes. To these I
will add a case from Dr. Draper's practice, in which 1 ex-
amined the organs, and a case in which the autopsy was
made by my associate, Dr. Tuttle. These include all the
CBSes clearly of this nature which have during this period
come to autopsy within the range of my direct investiga-
tion, and in all seven distinct pathological conditions of the
pancreas were found.
One was of about one third the normal size, with a flabby
atrophied appearance on gross examination. Another was
so atrophied that only minute traces of the glandular tissue
could be found. Another was of about two thirds the nor-
mal size, with apparently an increase in the interlobular
connective tissue. Another was of about half the normal
size, firm, and containing hardly any gland tissue except in
the head, the rest being only dense connective tissue. Mi-
croscopical examination showed an extreme increase in the
connective tissue at the expense of gland tissue, a good deal
of proliferative endarteritis, and in places large numbers of
infiltrated leucocytes. Another was a little larger than the
usual size of a pancreas, but, on microscopical examination,
showed a distinct, though not very abundant, increase of
connective tissue, considerable degeneration of the gland
cells, and a marked invasion of the gland by adipose tissue.
Another, while not appearing small on gross examination,
showed under the microscope extreme invasion by adipose
and much increase of connective tissue, while the last case
had dilated ducts which contained numerous calculi, the
tissues being cirrhotic and atrophied.
In two cases not included in this group the patients
were under observation for only six and twenty-four hours
— one in coma all of the time and the other a considerable
part of the time, so that no histories were obtained ; but
there was sugar in the urine, and yet the pancreas showed
in each case but very slight, perhaps I should say doubtful,
lesions.
On the other hand, I have examined the pancreas from
a large number of miscellaneous cases, and while slight
changes of the kinds related above are sometimes met with,
still it is rare to find even a trace of any pathological ab-
normity.
It is true, on the other hand, that very many cases of
pancreatic disease show no sugar in the urine. Of Fitz's
seventy cases of acute and suppurative pancreatitis and
pancreatic haemorrhage, in only one is susjar reported — a
very small proportion, even after allowing for the many
whose urine was probably not examined because of the
brevity of the attack or for other reasons.
Treves's collection of pancreatic cysts were accompanied
by glycosuria only " sometimes," and it seems to be in but
a small minority of cases of cancer of this organ that the
symptom is observed.
And yet, considering all the experimental and patho-
logical observations, we seem forced to respect the idea of a
causal relation between pancreatic disease and diabetes, and
to admit that for diagnostic purposes diabetes is of some
value, pointing to be sure rather to chronic pancreatitis,
lithiasis, cirrhosis, degeneration, and steatosis, than to tu-
mors or acute lesions.
Of the suggestions offered to explain how the glycosuria
follows from the absence of the pancreas, the most interest
ing, and the most reasonable in the scant light as yet
thrown on the subject, is that which supposes a normal
glycolytic ferment produced by the pancreas, thrown into
the circulation and necessary to the utilization of glucose.
368
ELIOT: TREATMENT OF
ACUTE OSTEOMYELITIS.
[N. Y. Med. Jodb.,
The blood, when no longer supplied with this, would
evidently find itself overloaded with sugar, which it could
no longer dispose of. The experiments of Lepine and
others bearing on this theory make very pleasant reading,
but the interesting nature of the recent observations already
described have led us far enough in the discussion of the
glycosuria symptom.
Pain in the epigastrium is generally present in acute le-
sions, often severe and of a colicky or neuralgic character.
It is sometimes spoken of as coeliac neuralgia. In the case
of cysts the pain is usually slight ; in cancers, not, as a rule,
prominent ; in cases of lithiasis or chronic inflammation it
is generally absent ; and is probably never caused by
steatosis or atrophy.
Jaundice is frequently produced by cancer of the pan-
creas, as would be expected from the intimate relation be-
tween the common bile duct and the head of the gland, and
often helps to locate an epigastric tumor. It is rarely pro-
duced by cysts, and not at all by the other pancreatic
lesions.
Ascites and enlargement of the spleen are frequently
caused by the pressure of a cancer upon the portal vein,
but not by a cyst or by other lesions.
It should be borne in mind that haemorrhages into the
intestine and stomach sometimes occur when the pancreas
is diseased. It has been recorded in some cases, and I have
happened to see two instances of hsematemesis due to cancer
of the bead of the pancreas. In each case the tumor had
invaded the wall of the duodenum, producing ulceration,
from which the hasmorrhages are supposed to have come.
Compression of the abdominal aorta, with or without
pulsation, is an occasional symptom of pancreatic tumor.
Compression of a ureter is rare.
The skin is said to be sometimes bronzed ; it is occasion-
ally dusky or yellow.
As regards further indigestion symptoms, there may be
loss of appetite, nausea, eructations of gas, a sense of full-
ness in the epigastrium, and diarrhoea or constipation.
Mental dullness and depression are common.
In acute lesions, in addition to the severe pains already
mentioned, there are apt to be vomiting and collapse, some-
times fever. A slowing of the pulse is sometimes noticed,
particularly in cases of haemorrhage, and in these, too, death
usually comes very quickly, often instantaneously.
Physical examination for a pancreatic cancer has failed
to find it in about half the cases, though the gland can
sometimes be felt even when normal. When found, it
is in the epigastrium, at the mid-line or a little to the
right of it, and is, as a rule, very slightly or not at all
movable.
A cyst occupies the same position, but is often large,
may fill the abdomen, and is generally immovable, round,
with distinct outline, tense and elastic, but fluctuation can
not always be made out. It usually enlarges rapidly, and
has been known to discharge itself into the intestine.
The cyst fluid is generally turbid, brownish, odorless, of
rather high specific gravity, alkaline or neutral, and con-
tains albumin, but no urea and no bile. It will generally,
but not always, emulsify fats and change starch into sugar
TREATMENT OF ACUTE OSTEOMYELITIS *
By ELLSWORTH ELIOT, Jk., M. D.,
ASSISTANT SURGEON IN THE VANDERBILT CLINIC ;
ASSISTANT DEMONSTRATOR OP ANATOMY
IN THE COLLEGE OP PHYSICIANS AND SURGEONS.
In the treatment of surgical affections, as in the treat-
ment of all medical troubles, one should always endeavor to
eliminate the cause of the disease.
When for any reason this can not be accomplished, our
treatment, conducted on purely symptomatic principles, be-
comes ineffectual. Nature may come to our assistance and
restore the patient to health, with full return of all the
patient's functions ; but, although this happy result is
moderately frequent in certain medical diseases, it must be
admitted by all that unskillful treatment in surgery too often
leads to a tardy convalescence, temporary, and at times
permanent, loss of function or serious deformity, with per-
haps the loss of a limb, and occasionally even loss of life
itself.
Of no disease is this more true than in acute osteomye-
litis, and in calling your attention to its treatment it will
not be inappropriate to consider briefly its cause and the
resulting pathological condition.
For years before bacteriology played its present impor-
tant r&le in pathological surgery, acute osteomyelitis was
considered an infectious disease simply from the resem-
blance of its symptoms to those of diseases whose infec-
tious character was undisputed. Bacteriological investiga-
tion has substantiated this fact, and to-day at least two
distinct forms of micrococci — namely, the Staphylococcus
aureus and Streptococcus albus — have been found, both
separately and together, in osteomyelitic exudations. These
have been cultivated in suitable media, and have, by inocu-
lation, reproduced in animals a pathological condition simi-
lar to that existing in the primary disease.
Undoubtedly these organisms gain access to bone
through the circulation. Why they should attack this
structure in preference to other organs is not clearly under-
stood. Various authors mention a " locus minoris resisten-
tice," indicating by this term that certain portions of the
body offer less resistance to the onslaught of germs than
others, every part of the body being equally subjected to
their attacks. Certainly, whenever the integrity of bone is
disturbed by traumatism, that particular portion is more
likely to become the seat of an osteomyelitic process than
any other part of the bone. Then, too, in children, who
are most frequently subject to this disease, the primary
foci are found near the epiphyseal line, and surely this
part of the bone, being constantly in an active state of de-
velopment, is less capable of resisting the attack of genus
than other more perfectly organized portions, for the blood-
vessels in the epiphyseal vicinity are imperfectly developed
and afford more abundant facilities for the lodgment and
collection of germs than do similar channels in perfectly
vascularized bone. When the inflammatory process is once
excited by the presence of these germs its onset is severe
and its course is rapid. This is readily accounted for by a
* Read before the Hospital Graduates' Club, December 17, 1891.
April 2, 1892.]
ELIOT: TREATMENT OF
ACUTE OSTEOMYELITIS.
369
consideration of the normal anatomical peculiarities of
bone, together with the virulent qualities of the micrococci.
Bone, to fulfill its function of support, must be practi-
cally unyielding. Consequently the walls of the cavities
that contain the blood-vessels are inexpansible. The exu-
dation resulting from the inflammatory process through the
walls of these blood-vessels collects between the bony, un-
yielding wall of the cavity and the yielding wall of the
blood-vessel. The force exerted by this exudation soon
overcomes the counter-resistance of the arterial pressure in
the nutrient vessel, the lumen of which gradually diminishes
in size, until finally the blood ceases to flow through it, and
that part of bone to which it imparts nutrition dies. This
process of disintegration is still further assisted by the
comparatively poor anastomotic circulation that exists in
bone. To be sure the vessels in the Haversian canals com-
municate freely, but this is more of a capillary net-work,
and is totally inadequate to supply any particular part of a
bone which has been deprived of nutrition by the inflam-
matory process.
It is not, therefore, surprising that acute osteomyelitis,
beginning near the epiphysis, should rapidly involve the
major portion of the shaft of a long bone, and, on the other
hand, it is very fortunate that the epiphyseal cartilage, ow-
ing no doubt to its lack of vascularity, should act as a bar-
rier, and so prevent the inflammatory process from involv-
ing by contiguity first the articular extremity, and subse-
quently the joint structures themselves ; and it is also very
fortunate that after the soft parts immediately overlying the
inflamed bone are involved, the capsular ligament of the
different joints attached to the bone within the epiphyseal
line should, in virtue of its strength, resist the disintegrat-
ing character of the inflammatory process, now at its height
in the soft tissues, and exclude it from the joint proper.
There is one joint in the body, and that a very impor-
tant one, which proves to be an exception to this general
rule. I refer, namely, to the hip ; and it is not difficult to
explain this exception if we consider the attachment of the
capsular ligament and its relationship to the epiphyseal line.
In front this ligament is attached to the spiral line running
around the inner aspect of the upper extremity above the
lesser trochanter, and behind it is attached along a line
at the junction of the outer third and inner two thirds
of the posterior surface of the neck, including in its at-
tachment, therefore, the head of the femur, the epiphyseal
line, the entire neck in front, and posteriorly the inner two
thirds of the neck. Hence any inflammatory process near
the epiphyseal line, in extending outward, must soon reach
the synovial membrane that lines the inner surface of the
capsular ligament and the bone itself within the above limit,
and necessarily involve the joint in a suppurative, infectious
process. The treatment of this, in itself a most serious con-
dition, demands special consideration, and will be discussed
subsequently.
But, although, as we see, the involvement of the joint
Dearest the focus of inflammation does not usually take
place by contiguity, yet in a certain number of cases this
same joint, or even others more remote, may become swol-
len, their synovial cavities filled with a serous or at times
even with a purulent fluid, and subsequently the whole joint
may become seriously involved in destructive inflammation.
This condition is readily explained by the fact that the
micrococci, having found a favorable soil for development,
are multiplying rapidly, and are being carried in constantly
increasing numbers by the circulation to the different parts
of the body. Whether joints, to which by this way they
gain access, become involved, depends upon the kind of
micrococcus. It can be incited artificially more frequently
with the streptococcus than with the staphylococcus, but
as an attack of osteomyelitis is usually due to both of these
germs acting together, the occurrence of joint inflammation
in this disease is not unusual.
If severe cases remain untreated, the occurrence of meta-
static abscesses in the different viscera, especially in the
kidney, may result from the lodgment of micrococci in these
organs.
With this understanding of the cause of osteomyelitis,
and of the serious consequences that may result, it is not
difficult to formulate a rational method of treatment which
may be applied to the great majority of cases.
In the first place, we should endeavor to prevent a pos-
sible attack by suitable prophylactic measures. In all ex-
anthemata and other infectious diseases, when convales-
cence is established the patient should not be allowed to
walk until a considerable interval has elapsed subsequent to
the fall of the patient's temperature to normal, and after-
ward, when walking, the patient should be careful not to
subject himself to any blows or contusions, either from
coming in contact with furniture or from possible falls,
from too sudden exertion, or from any cause whatsoever,
no matter of how trivial a character.
When, however, prophylactic measures are not success-
ful in preventing an attack of acute osteomyelitis, or when
a case presents itself, apparently spontaneously, without
known cause, the proper method of treatment may be a
subject of dispute. Some advocate the expectant plan of
treatment. Applications of poultices are advised, with ab-
solute rest in bed. Usually the administration of a brisk
cathartic follows, and then a general waiting-for-develop-
ment policy is pursued, which usually means waiting for
the soft parts to become involved in suppuration.
It must be said, however, that this general plan of treat-
ment is only employed by practitioners in that class of
cases where obscure symptoms make the diagnosis difficult,
and that, either when the diagnosis is easy or has been
made by skillful men, the radical method of treatment is
usually preferred. The expectant plan of treatment is the
oldest, and was very generally employed in pre-antiseptic
times when operations of all kinds were dangerous ; super-
seded by radical measures, it still shows its influence upon
the treatment of this disease, in that surgeons are inclined
to wait one, two, or three days before proceeding to opera-
tive interference. Delays are dangerous, and more espe-
cially in acute osteomyelitis, where every additional hour
means just so much more necrosis in the early stages and
greater liability to general septic infection in the later stages
of the disease. Consequently, now that antisepsis has re-
moved the danger of incisions, it would certainly be a ra-
370
ELIOT: TREATMENT OF
ACUTE OSTEOMYELITIS.
[N. Y. Meu. Joce.,
tional procedure to perform an exploratory operation at the
outset, in place of waiting for the symptoms to become of
such a marked character that the diagnosis no longer re-
mains doubtful.
If, after such a procedure, the diagnosis is confirmed,
further operative means should be resorted to to prevent
the death of the bone and the infection of the system. The
main indication for treatment may be expressed in one
word — namely, drainage, with, if possible, the removal of
the original focus of inflammation.
This is accomplished with either a trephine or a chisel,
by means of which, as soon as the periosteum has been
divided and reflected to one side, the medullary cavity, as
well as the cancellous spaces between it and the surface of
the bone, are thoroughly exposed by an opening at least an
inch long and a quarter to half an inch wide, according
to the normal dimensions of the bone affected. This open-
ing should be made in that part of the bone where the in-
flammatory process is most intense, for the reason that the
original focus is situated in this part, and it is desirable
that this focus should be removed with a Volkmann spoon,
or, at all events, that it should have a free exit, and so be
enabled to come away with the discharge as soon as the
process of ulceration has separated the dead from the
healthy bone beneath.
Great care should be taken that this opening is made
close to and on the shaft side of the epiphyseal line, but
not through it, in order that the natural growth of the
bone may not be disturbed, which, as is well known, de-
pends for its increase in length upon the epiphyseal carti-
lage.
One or more similar openings may be made at some dis-
tance from this, the essential one, in the inflammatory area,
but the intervening portions of bone need not be removed,
as such a procedure might lead to unnecessary weakening
of the bone without insuring any better result. The cavi-
ties thus exposed should be well irrigated with a strong
antiseptic solution, preferably the bichloride of mercury,
and packed loosely with iodoform gauze — the wounds being-
treated openly. After the application of a heavy Lister
dressing, the whole limb should be kept absolutely at rest
by immobilizing the joints both above and below the bone
involved.
By this means the exudation that has collected outside
the walls of the blood-vessels, in the Haversian canals,
readily flows into the antiseptic dressing, carrying with it a
large number of the micrococci. The blood-vessels, relieved
of an enormous pressure, once more are permeable. The
bone receives its usual nourishment, and thus practically a
" resolution " takes place, except in those portions of bone
which, having been deprived too long of their blood supply,
are dead and must separate gradually from the healthy bone
before granulations can be formed and the process of repair
be completed.
The integrity of the epiphyseal cartilage also is pre-
served by this radical treatment, and the growth of the limb
continues undisturbed when convalescence is established.
This is of paramount importance, for deformity would sure-
ly result if this epiphyseal layer of cartilage were destroyed
and the bone ceased to grow. The degree of deformity de-
pends upon the bone inflamed, and also upon which ex-
tremity of this bone is involved. In the humerus or femur
disintegration of the cartilage causes merely shortening of
the corresponding limb. Inasmuch as the growth of these
bones depends chiefly upon the epiphyseal cartilage in the
upper extremity of the humerus and the lower extremity of
the femur, the amount of shortening with destructive in-
flammations in this vicinity is very much greater than !d
case of involvement of the opposite ends of these same
bones.
In the bones of the forearm and leg the growth of the
corresponding limbs depends upon the development of the
cartilages in the upper extremities of the tibia and fibula,
but the lower ones in the radius and ulna. Consequently,
if any portion of these bones entering into formation of
elbow and ankle joints, respectively, are involved, the
growth of the limb is but slightly retarded; but if the op-
posite extremities to those above mentioned are involved
simultaneously, the growth of the limb is seriously curtailed.
If one extremity alone is involved, and this is the rule, the
unaffected bone continues to grow, and very marked lateral
deformities of wrist joint, especially, may render the hand
useless and demand surgical interference for its relief.
After the primary operation the subsequent treatment
of the wound is conducted on ordinary surgical principles.
If the disintegrating process has been so extensive as to
result in a fracture of the bone, the limb must be immo-
bilized until, after the subsidence of the disease, new bone
is formed and firm union takes place between the broken
fragments. With the destruction of a large portion of the
shaft of a long bone, immobilization must surely be en-
forced until sufficient new bone is formed to enable the part
to resume its normal function without danger of fracture.
Ordinarily an interval of from several weeks to as many
months must elapse before the bone in which the inflam-
matory process has occurred can resume its normal func-
tion.
In addition to the surgical treatment that we have just
described are several indications that demand medical
means for their relief. In the earliest stage of the disease
pain is not only a very prominent symptom, but also a very
disagreeable one, which requires the exhibition of an ano-
dyne, preferably morphine. The patient should naturally
be in bed, on a fluid diet, and some benefit may follow the
use of various antiphlogistic remedies.
After operative measures have relieved the condition of
tension in the bone, the subsequent discharge from the
wound is most profuse. Large dressings, with abundant
absorbent cotton, are usually well soaked at the end of
thirty-six to forty-eight hours. Such a drain upon the pa
tient's system, especially if it exists for any time, must
necessarily be followed by rapid progressive emaciation, and
demands some supportive treatment, preferably the admin-
istration of malt and sherry, in generous amounts, several
times daily. The dose can gradually be decreased as the
discharge becomes less abundant, and finally stopped alto-
gether when the patient fully regains his lost strength.
In no place in the body is the importance of early oper-
April 2, 1892.J
TAYLOR: MASSAGE AT RAPID OR VIBRATORY RATES.
371
ativc interference more clearly demonstrated than in the
treatment of acute osteomyelitis of the neck of the femur,
Dear the epiphyseal line. I have previously alluded to
the anatomical reasons which render the involvement of the
hip joint an absolute certainty, and it is only by an early
operation that this can be prevented.
In this class of cases we endeavor to remove the inflam-
matory focus before the destructive process incited by it
has reached the surface of the bone. If this can be accom-
plished, the periosteum may be preserved, while the inflam-
matory area is removed en masse, and, after new bone is
formed, the joint will resume its normal function of sup-
port, with, in all probability, a certain amount of stiffness,
the operation consisting practically in a subperiosteal resec-
tion of the head of the bone. If, however, the periosteum is
found in a necrotic condition and bathed in pus, the most
thorough removal of the dead bone, with subsequent drain-
age and irrigation, combined with rest, will alone save the
limb, and, after a tardy convalescence, the head of the femur,
if not actually dislocated, will be held in place by the com-
paratively weak support of strong bands of connective tis-
sue, the result of the process of repair.
Unfortunately, in neglected cases, when septic symp-
toms have developed, our treatment can only be supportive.
Large doses of stimulants, with antipyretics, are admin-
istered, and certain patients, especially those with a strong
constitution, may eventually recover. Such a fortunate ter-
mination is very exceptional, and, inasmuch as death does
occur from a general infection of the system, certainly that
plan of treatment should be followed that has for its pur-
pose the elimination of the micro-organisms that cause the
trouble, when these are localized and before they have an
opportunity, after great increase in number and under un-
due tension, of entering the general circulation and termi-
I nating the life of the patient.
MASSAGE AT RAPID OR VIBRATORY RATES.
By GEORGE H. TAYLOR, M. D.
The prevailing idea that massage is necessarily manual
in mode of application, and therefore limited to the motory
resources of a masseur, is an error that has served to re-
strict the study of the most beneficent phases of this medi-
cal recourse. The chronic invalid, even the very feeble, has
receptive capacity for rates of massage far beyond that of
the medium and comparatively neutral scope of manual
power. We have seen that rates of massage much slower
than the hand can supply corresponds to certain spontaneous
or auto-processes of the vital organism, and that these slow
rates therefore comply with fundamental therapeutic re-
quirements. But to secure the proper rate, and to ad just
its applications to parts of the body difficult of access, mech-
anism is necessary. This shows that therapeutic advan-
tages may be derived from sources which, without mechan-
ism, are incapable of being even tested. The remedial
capabilities of slow massage being thus rendered available
in therapeutics, naturally suggests the possibilities which
may lie hidden in untried higher rates of the same agent
waiting to be tested, studied, and exposed to professional
judgment and service.
Massage at rapid rates — those beyond the limits of the
hand to execute — likewise requires the intervention of mech-
anism for the purpose of multiplying the rate of the motor
processes. Mechanical adaptations are also required to ad-
just the applications to the different regions of the trunk
and extremities, to adapt the degree of the force to spe-
cial curative requirements, and to give instant control of
the action, especially as regards degree, to the person to
whom it is applied, for only by this provision can he
always derive agreeable and no other sensations from the
applications.
Quick massage is simply vibration of the fleshy mass
receiving it, without reference to its form, degree, or source.
The essential peculiarities of vibration are shortness of the
linear extent of the motion, and the consequent frequent
reversal of its direction. This causes very numerous end-
ings of the motion, which returns over the same line. Vi-
bration may be compared to the blows of an infinitesimal
hammer, under continuous and very rapid action. To show
the significance, physical and physiological, of this mode of
delivering energy is the purpose of the present article.
Apparatus suitable for communicating vibration, quick
massage, to the body and its parts admits of considerable
variety of form. The physical nature of flesh, being soft,
yielding, and elastic, permits vibratory waves to pervade its
mass. The action is propagated in flesh as it is in fluids,
and reaches all its innermost parts at the same rates and in
nearly equal degree. Such applications are by no means su-
perficial. Structural parts, cells, membranes, fluids, whether
interstitial or coursing in different directions in appropriate
channels, vital organs, and non-vital ingredients are pervaded
alike by this agency.
The vibrations thus mechanically transmitted to the
vital system are lost only in appearance, being, in fact,
changed without loss to other forms of energy, and subject
to identification by other tests than the direct senses. Both
the vitalized and the non vitalized ingredients encountered
by this agent present fields for its transformation. As the
motion of a meteor, on striking the atmosphere, becomes
not only retarded but changed to its equivalents, so does
the motion transmitted to tissues, on being retarded there-
in, become changed in several ways, according to the nature
of the ingredients obstructing its pathway.
The study of the effects of vibration or quick massage
becomes of interest from the following separate and distinct
considerations :
It is of scientific interest to determine just what equiva-
lent forms of energy arise in the vital organism under the
different forms and rates of vibratory action, and what con-
ditions, on the part of the organism, serve to promote, re-
strain, or modify its physical effects.
It is of physiological interest to determine whether the
different classes of vital functions may lie increased, trans-
posed, or diminished by means of directing motor energy
from outside sources to their respective vital organs. Also
to determine whether such transformed energy is identical
in form with that developed by the organism, and whether
372
TAYLOR: MASSAGE AT RAPID OR VIBRATORY RATES.
[N. Y. Med. Jouk.,
that arising from the two sources is capable of becoming
merged and physiologically undistinguishable.
And it is of high medical interest to determine the con-
sequences of the effects of vibration above suggested in
pathological states of the organism, the therapeutic values
derivable therefrom, and the conditions and cautions neces-
sary for rendering such therapeutic influences practical.
It hence appears that a wide and almost virgin field for
exploration is opened by the proposition to subject the vital
organism and its non-vital constituents, its diverse function-
ing activities, and its varied incorporated and spontaneous
chemical tendencies, to the influences flowing from trans-
mitted vibration.
The difficulties which this study has presented have
arisen chiefly from the fact that the inquirer is very apt to
seize upon some one effect or fact, and neglect others even
more worthy his attention. It shall be my endeavor to
place before the reader such facts as seem to establish prin-
ciples available for the physician. The nature of the case
does not permit of a strictly scientific order in the arrange-
ment of the subject; the topics embraced therein will
therefore be presented in the order of the presumed interest
of the inquirer.
Vibration as an Ancesthetic. — This agent is somewhat
known as a means for securing the suspension of pain, and
even for permanently removing chronic neuralgic affections
which have proved intractable to other remedies. Notwith-
standing the well-proved efficacy of this agent, its restrict-
ed use for this purpose is easily accounted for by the fact
that facilities for its proper administration are not usu-
ally at hand, and the necessary practical details are unfamil-
iar to the physician. Most physicians have seen references
to the efficacy of this agent in their reading, especially of
English medical periodicals of a dozen years ago. In these
days of prevalence of neuralgic disorders and of much
seeking of remedies adapted to ameliorate if not to obviate
pain, this effect of vibration is entitled to renewed consid-
eration, and a just estimate of its nature and value should
be acquired. Is this special remedial effect temporary or
permanent ? Is it to be classified with the so called seda-
tives, or with some heretofore imperfectly investigated class
of remedies ?
Different investigators have arrived at radically opposite
conclusions respecting the remedial effects of vibration in
painful nervous disorders. Some have accepted the easily
demonstrated fact as a fundamental principle ; others regard
suspension and even the radical cure of pain as secondary
and dependent on certain changes superinduced in the ordi-
nary physiological activities, which are neglected by the
sedative-seeking inquirers. These differences are doubtless
due to prepossession of opinions or their absence on the
part of the investigator. Experimenters are apt to find
what they are seeking, especially when the search is ob-
scure. Very much depends on the kind of instruments
employed, and their adaptation to determine the facts
sought.
A better understanding of this interesting subject may
be attained by bringing forward some of its historic as well
as' its scientific particulars. Medical literature is indebted
to Dr. J. Mortimer Granville, of London, England, for set-
ting forth his experience and conclusions in a hook pub-
lished in 1884, entitled Nerve Vibration and Excitation, or
Stimulating/ Percussion for Functional Nervous Disorders.
The applications are described as light, rapid blows of a
percuteur — a small hammer with an ivory point, which,
under the reciprocating motion imparted to it, transmitted
vibratory action to the skin and fiesh underneath. The
operator's hand was evidently the source of power in the
earlier experiments, but irregularities of rate and decree,
and the very limited time it was possible to sustain the ac-
tion, rendered the effects uncertain, and so clockwork
mechanism, operated by a spring, was substituted. The
apparatus while in action was moved about upon and near
the painful region, and therefore communicated rapid waves
of vibration to the flesh underneath. There is no statement
of the vibratory rate. The action was frequently inter-
rupted by necessity for rewinding the machine, and irregu-
lar from the varying force of the spring. A small electro-
motor was, in a few instances, substituted for the spring,
but no hint of its superiority appears, or that the conclu-
sions previously made were in any way modified by this
motor recourse.
The purpose in view in these vibratory applications was
avowedly the single one of arresting pain. There was ab-
sence of expectation of other effects, and such others as
necessarily accompanied the suppression of pain were
quietly ignored. A long array of cases of neuralgic and
other painful chronic affections, successfully treated by
vibration, are given in support of the claim for the thera-
peutic power and efficacy of this agent.
Dr. Granville engaged the attention of several physi-
cians of eminence, among them Sir Hugh Campbell, who
repeated the experiments, apparently without attempting
any variations, and added confirmation to Dr. Granville's
views. At about the same time similar experiments were
conducted by M. Boudet and M. Vigoureux, of Paris, lead-
ing to the same conclusion ; not, however, without a vigor-
ous dispute as to priority of discovery of what was regarded
as a remedial principle. Readers of the medical literature
current a dozen or more years ago will doubtless retain
some memory of these discussions. Most remarkable is the
unanimity with which these inquirers excluded all considera-
tion of other effects of the agent whose powers they ex-
amined, except the single one of suspending pain. They
did not even intimate that sensations of an agreeable kind
are also suspended by the same agent.
The above statements respecting the control of pain in
chronic affections by proper applications of vibration (or
quick massage) are fully supported by my personal experi-
ence in employing this agent for the class of invalids men-
tioned. This experience, it is due to say, has unquestion-
ably been more extended and varied than those which have
above been referred to. This statement will, 1 hope, be
sufficient justification for presenting facts additional to
those with which the medical profession is most familiar,
and which lead to far different as well as broader conclu-
sions respecting the nature and effects of the agent under
discussion.
April 2, 1892.]
TAYLOR: MASSAGE AT RAPID OR VIBRATORY RATES.
373
Dr. Granville and his associates adopted a theory re-
specting the nature and effect of vibration which is best ex-
plained in words quoted from his book, written for this
purpose. He says : " All nerve action is vibratile . . . the
neuralgic state consists essentially in an abnormal set or
series of vibrations into which the nerve has been thrown,
perhaps by cold, or a mechanical or chemical irritant. This
state may be changed by mechanical vibrations, propagated
to the nerve sheath and its contents." Again, " we deal
with the nerve and not with its surroundings " — an evi-
dent mechanical impossibility. " No force is communi-
cated by the hammer of the percuteur." What, then, is
communicated ? " The sole effect of vibration is to excite
the centers and call out their potential energy, converting it
into kinetic force. It can act only through the nerves."
" Vibration, artificially supplied, introduces discord into the
rhythm of the morbid vibrations of the painful state, and
a change that brings relief," etc. Dr. Granville's subse-
quent difficulties in securing the desired relief of pain by
this means ought to have shaken his faith in the theory, for
he says : " Great care and tact are necessary in treating
pain by vibration." " By continuing the process too long,
painful vibrations may be set up " ; hence directions are
given to approach the painful region slowly, first sub-
jecting non-painful, contiguous parts to the process — de-
tails of cases being given in which the non-success of pre-
vious treatment was changed to success by adopting this
change of method.
If these investigators had reflected that it is physically
impossible to vibrate nerve tissue separately from its sur-
roundings ; that the other tissues and the fluids included in
a fleshy mass exceed, according to trustworthy authorities,
by a hundredfold that of the nerve filaments it includes ;
and, further, that the fluid and solid, organized and unor-
ganized, vitalized and non-vitalized, contents of the mass in-
clude ingredients strongly predisposed to chemical changes
— that, in fact, such changes, either normal in consonance
of physiological purposes or in opposition to those purposes,
are inevitable — these factors would undoubtedly have in-
fluenced their conclusions.
Historical accuracy, the curiosity of the reader, and
possibly justice, unite in requiring that certain dates be here
recorded. In a correspondence, claiming priority over Dr.
Boudet and the French claimants of the " discovery " of the
pain-relieving power of vibration, Dr. Granville says : " As
a matter of fact, nerve vibration by percussion with instru-
ments furnished by myself was tried at the National Hos-
pital, in Queen Square, London, in January and February,
1878, these trials having been led up to by previous ex-
periments by less satisfactory methods."
My personal investigations of the destiny of vibration
in the vital organism, and the physiological and therapeutic
effects flowing from this agency, assumed practical forms in
1863-'64, and very soon led to diversifying the mechanism
whereby the effects may be varied and duly tested. The
conclusions drawn from my experience were embodied in my
article in the November, IH(5<), number of the New York
Medical Journal, entitled Inquiries relat ing to the '1 herapeu-
tic Effects and Uses of Vibratory Motion. The succeeding
March number of the same journal contained a second
article, a sequel to the above, entitled On the Use of Force
as Vibratory Motion in the Treatment of Diseases of the
Nerves. My book, bearing a title nearly identical with that
of Dr. Granville's book, was published in 1870.
The foregoing account of transatlantic experiments deter-
mining the anaesthetic effects of vibration proves the detri-
mental influence of preconceived theory in the recognition
and appreciation of facts. The experimenters, in discover-
ing what they sought, neglected to observe facts of even
greater importance. No evidence is shown that nerve ener-
gy is vibratory in its development or transmission ; or that,
if vibratory, such form of action bears any relation to
that of any mechanism. No allusion is made to ultimate
nutritive- sources of nervous energy; to its possible dete-
rioration from nutritive faults ; to the consequences of
imperfect rfenutrition, for nutritive waste is even more
liable to defects which react on the sensorial powers than
nutritive supply ; of suffering caused by maldistribution,
as well as from faulty development of nervous powers ; of
impressions of the consciousness from general and local ex-
cess, as well as from insufficiency of nervous energy — all of
which are topics inseparable from that of pain, its modifi-
cations, suspension, and remedies.
My purpose in devising means for subjecting the organ-
ism and its parts to vibration was less that of subduing
pain than that of reaching the nutritive sources of pain by
an adequate remedy. It seemed to me that the disagree-
able and the painful impressions of the consciousness which
invalids experience may be legitimate, denoting either faults
of nutrition in the parts to which the undesirable sensation
is referred, or obstacles in the line of sensory conduction. It
is also notable that pain is intimately connected with appre-
ciable defects of the other forms of energy which the vital
organism coincidently develops, all of which depend on
nutritive processes as their sources. True remedies there-
fore must extend to the fundamental seat of energy, to the
tissues wherein its distinctive forms are assumed. It fol-
lows that to correct morbid impressions in the seat of the
consciousness, it is essential to rectify the nutritive source
whence they spring, which, as we all know, may or may
not be in nervous tissues.
Now, nutritive acts necessarily include two considera-
tions, both of which are equally involved in the consumma-
tion of the nutritive purpose, whatever the function or
the tissue concerned in the nutrition may be as a whole.
Nutrition implies the supply of ingredients to, and the re-
moval of the same from, the local point at which energy is
evolved or other purpose complied with. Nutrition is far
from consisting of accumulation of substances, vital or
otherwise; it implies an equal amount of outflow or ^nu-
trition. The first is largely associated with motor physics ;
for the latter, cAmtco-physics are indispensable. The sup-
ply and convoy of ingredients to the vital arena are of no
account, while the changes due their elemental constitution
are unprovided for. In fact, the controlling phase of nutri-
tive purpose is the (/enutritive, chemico-physical excluding
process. Now, since the energy for conducting these in-
indispensable factors of nutrition is in health developed
374
TAYLOR: MASSAGE AT RAPID OR VIBRATORY HATES.
[N. Y. Med. Jook.,
within tlu' organism, and since defects of health are mani-
fested in these factors, the suggestion of re-enforcing them
by direct supply of energy from exterior sources when their
insufficiency becomes apparent arose very naturally.
This suggestion is strengthened by direct experiment
which any one commanding sufficient manual dexterity may
repeat and verify. By widely separating the fingers of the
right hand so that when a smart blow is given the stroke
of each ringer falls distinctly separate, the rate of the im-
pact or percussion is quadrupled, and vibratory waves are
made to pervade any fleshy part subjected to the process
and may be felt at its opposite side. In a proper case for
vibratory treatment not only is pain abated, but the accom-
panying soreness and swelling also. On account, however,
of the impossibility of sustaining the required rate of mo-
tion, the recourse described is impracticable.
Two direct effects of vibration serve to explain the salu-
tary consequences of its application to the vital organism.
One of these is the contribution it affords in aid of the de-
fective motor physics of the physiological system ; the other
is the ready and abundant contribution it brings in support
of the cAenwco-physics of the organism whenever this de-
partment of physiology is faulty — a department whose de-
fects are the chief concern of the average therapeutist.
How the mechanical or motorv purpose is served by
vibration is so obvious, even to the superficial inquirer, that
but little explanation is required. The motor energy com-
municated from the exterior travels as such in the fleshy
parts. But flesh is pervaded by conduits streaming with
fluids (blood) in directions predestined by the mechanism
of organization. The local aspect of chronic disease is
marked by areas of detention of these fluids, by local me-
chanical obstructions, and by defective operation of the
causes to which the outflow of these fluids is due. Now,
vibration affords a succession of impulses direct to the con-
tents of the vessels, urging them forward in the several di-
rections required, thus becoming an effective auxiliary to
pre-existing causes of the circulation. The same cause also
restores the natural contractile powers of the circulatory
vessels, and these causes unite in impelling forward what-
ever mechanical obstacles these motory defects may have
superinduced, or w hich previously existed.
The consequences of outflow of the contents of ob-
structed vessels are immediately apparent in surrounding
parts. Fluids of whatever quality, normal interstitial juices
and those loaded with morbid materials, return directly to
the venous vessels to become resubjected to the corrective
chemistry of the organism as a whole.
Important as these effects may be considered thera-
peutically, they are in reality the least of those superin-
duced by vibration.
These experiments and observations were begun in
lHG-J-u'^, and soon led to others through amplified means
and diversified methods. The physiological inquirer is not
content with generalizations; he insists on specific tests for
the facts he seeks. lie submits each tissue, secretion, func-
tion, or other object of investigation to separate and to con-
joint experiment, and thus assures himself of the circum-
stances which influence the behavior of each part and of1
each to all. The mechanical scope of the human hand was
evidently too restricted, and incapable of bringing further
facts to light ; its narrow field has been occupied and un-
derstood for ages, and is comprised largely of motor phys-
ics. What other important relations of therapeutic sig-
nificance might be opened by a survey for which mechan-
ism is required remained to be developed.
The Mechanical Apparatus. — A proper investigation of
the higher rates of motor energy or vibration requires ap-
paratus capable of complying with the following particu-
lars :
It should transmit vibration at variable but known rates
to any selected part of trunk and limbs.
It should impart this action in diversified forms.
It should be capable of limiting the action and its effects
to designated parts while other parts are omitted.
It should be capable of confining its action to distinct
classes of functioning tissues.
It should be operated by adequate and untiring sources-
of mechanical power.
In pursuance of these purposes above outlined, I con-
structed (1864-'65) the several pieces of apparatus shown
below. The first (Fig. 1) imparted rapid alternating mo-
FlG. 1.
tion to two percuteurs in close proximity, which act upon
any part exposed to them by means of necessary mechanism
through an opening in the couch upon which the patient
rests. The position of the patient is shifted at will, or as
may be agreeable, and the degree of the impulse is controlled
by the patient.
The percuteurs are set in action by a very short crank,
rapidly revolved by a multiplying wheel, operated by a light
motor or by hand or foot power.
The most effective rate for this and other forms of
mechanism for similar purposes was found to be in the vi-
cinity of a thousand waves or strokes a minute. Dimi-
nution or entire suspension of pain was a pretty constant
effect, provided the conditions before stated were complied
with. The term then thought to afford a satisfactory ex-
planation of this effect was revulsion, which referred to its
mechanical rather than its physiological scope. Experi-
ence, however, brought to light other reasons for consider-
ing this term a proper one.
Fig. 2 represents a form of apparatus made at this time
in which the effect of impact or percussion upon the nerve
centers through surface impressions is wholly eliminated.
Even a much larger amount of motor euergy may be trans-
mitted than by the apparatus shown at Fig. 1, but entirely
without percussion and the effects arising therefrom in either
April 2, 18'J2.]
TAYLOR: MASSAGE AT RAPID OR VIBRATORY RATES.
875
the reflex or the sensory nerves of the part. The nerves of
the skin, and for a distance regulated at option beneath it,
Fig. 2.
are neither impinged upon nor traversed in the application
of this process. The apparatus imparts very short, perpen-
dicular motory excursions to the fleshy mass com-
pressed against a very soft elastic pad. The mechani-
cal conditions are such that the pad (/rasps the flesh,
which moves as a whole, while interaction of distinct
anatomical parts is mainly prevented. The superfi-
cial nerves therefore wholly escape mechanical dis-
turbance, and they convey no impressions to the
nerve centers. Nervous irritability becomes sus-
pended while the muscles, or at least their deeper
portions, are subjected to passive motions in the
direction of the axes of their fibers. In short, mus- -">
cle action, and consequently muscle nutritive changes,
are in this way incited in opposition to nerve incita-
tion and its consequences. This effect is nearly the
reverse of that caused by No. 1. For distinction,
this consequence of this application may be called func-
tional revulsion. The evidence of this effect is shown by
diminished or sus-
pended pain and in-
clination to sleep, ef-
fects which increase
day by day as the
treatment is pursued.
This process may
be extended to the
arms and legs as well
as to all parts of (he
trunk, according to the
requirements of the
case, it being only ne-
cessary to turn the
bocly and to adjust
the height of the ac-
tion to the part which is to receive it.
A similar process can be applied to the arms, legs, and
even the trunk, by including either of these parts between
Fig. 3.
two pads to which reciprocating action is given. Fig. :i
shows the application to the arms of this form of vibration,
the effects of which are intensified by pressure. The press-
ure is given by means of a lever under the hand of the pa-
tient and under instant control. Relaxation of pressure di-
minishes or suspends the action. It is perfectly safe to
leave the control to the option of the recipient, the feelings
in this case being a safe guide. The double pads do not
increase the rate, but insure contact of molecular constitu-
ents, and thus secure the transformation of motor to other
forms of energy. In this case also the superficial endings
of nerves are neither traversed nor impinged upon, as in Fig.
1, but other functional processes are incited, to be subse-
quently explained.
Vibration is transmitted to parts of the organism by still
another method, which may be called oscillating, and is readi-
ly understood by reference to Fig. 4. A foot is snugly held
by an appropriate device at the end of a shaft, which, by
suitable mechanism, is made to oscillate on its axis. The
bone of the leg, being practically a continuation of the shaft,
participates in the same action to which it in turn subjects
the flesh and the fluids of the limb. A similar device (Fig.
5) applies to the hand and arm.
Fig. 4
Fig. 5.
In this use and form of vibration (the same rate as be-
fore stated being preserved) both percussion and compres-
sion are eliminated. It follows that the effects of vibration
are secured in such a manner that nervous impressions are
entirely absent, and all nerve functions — either afferent, ef-
ferent, or central — are in abeyance.
The principal effects inure to the morphological ele-
ments, and especially to the chemical phase of all the con-
stituents of the parts. Motor energy encounters various
orders of resistance, compelling it to assume other and dif-
ferent forms.
The above are samples of many tonus of apparatus de-
vised by me at the period above referred to for transmit-
ting motor energy in vibratory form to parts of the vital
organism, and which enabled me not only to determine ap-
proximately what forms were assumed l>y it under different
circumstances, but also what physical, physiological, and
therapeutic effects were superinduced, as well as (he posi-
tive and relative value of these effects in differing patho-
logical states.
The Cheinico-phi/xics of Vibration. — The foregoing de-
376
TAYLOR: MASSAGE AT RAPID OR VIBRATORY RATES.
[N. Y. Med. Jour.,
script ion of apparatus affords a necessary preparation for
understanding what is clearly the most important effect of
the transmission of motor energy to the vital tissues,
whether considered in its physical, physiological, or thera-
peutic aspect. For the attending conditions are such that
the motor energy of the vibration is largely transformed to
chemical activity, and results in elemental changes and
transpositions of matter in conformity with physiological
purposes.
These effects also accord with the purposes of therapeu-
tics, especially in chronic cases. Cures are largely sought
through remedies which have been proved by experience to
re-enforce the chemical phase of physiological activity, or
which naturally tend to increase this form of action. This
ultimate principle appears whenever the operation of reme-
dies in the cases referred to is fairly analyzed, and is sus-
tained by experience, however empirical.
Pathology, whether its manifestation be general or local,
is easily understood to have its source in some form or de-
gree of incompleteness of the chemical phase of physiology.
For it is only through this cause that injurious ingredients,
tending to retrogression and to impair the vital structures
and processes, can be retained by the vital organism to exert
their destructive influence. And the correctness of this as-
sumption is proved whenever the chemical phase of physio-
logical activity is properly and judiciously promoted.
Primarily, vibration consists of very short motory
excursions between two endings or turning points. The
motory force is resisted by whatever it meets or collides
with at these endings ; at these points the motor energy is
imparted to whatever objects or ingredients may be present
to receive it. Each distinct wave-ending is therefore com-
parable to the blow of a light hammer ; and vibratory ap-
plications become the continuance of such infinitesimal
blows, having the shortest possible intervening time. The
energy expended at each impact is taken up by the atomic
elements of the ingredients thus forced into intimate rela-
tions.
While blows of a hammer develop heat and rend co-
hesion, those of the percuteur and the other vibratory
methods described are expended under radically different
circumstances. The collision between ingredients of com
plex chemical constitution and of- extreme instability is pro-
duced. The component atoms of these ingredients are very
unlike in their nature, and are therefore receptive of the
suddenly imposed energy in different degrees. The inevi-
table consequence is a destruction of the weak chemical
equilibrium, and a new distribution of chemical affinities
resulting in new compounds less unstable in chemical char-
acter. In short, the effect of vibration in vital structures is
largely chemical, arising from the transformation of motor
to chemical physics, and the reduction of unstable, there-
fore incomplete and injurious products, whatever their
source in the organism, to physiologically completed and
therefore normal and innocuous products which find imme-
diate egress.
The school lecture-room affords abundant and apt illus-
trations of the principle above stated; as when phosphorus
is made to ignite when the motion of a rapidly revolving
wheel, to whose periphery it is attached, is suddenly
stopped; and when gun-cotton, nitroglycerin, and many
similar bodies are exploded by sudden arrest of motion or
concussion, although, perhaps, capable of burning on being
ignited in the ordinary way.
These are apt illustrations, derived from inorganic
chemistry, of what occurs in the vital organism under simi-
lar conditions — namely, that forceful contact is even more
provocative of chemical change than any other circumstance ;
that the development of chemical energy is simultaneous
with the disappearance of motor energy ; that unstable
compounds subjected to chemical change from this cause
are inevitably reduced -to more stable forms ; that vital
energy arises coincidently with the passage of an unstable
body from a state of more chemical energy to one of less ;
that unstable ingredients, in becoming stable, are rendered
indifferent, consequently innocuous ; that the vital endow-
ment of matter in affording protection against the influence
of chemico-physics is equivalent, for the time, to chemical
stability ; and that vibration or concussion of elements se-
cures the extreme degrees of chemical products contem-
plated in the physiological purposes.
Turning now to the vital organism, we find in it a most
admirable field for the physical processes and for insuring-
the physical consequences above indicated. Its components
are exceedingly heterogeneous, and the differing classes of
ingredients are largely diffused. The vitalized components
are, for the instant, under protection of vitality. The non-
vitalized are in various orderly stages of resolution. Every-
where are residual or waiting ingredients, and everywhere
imperfectly and improperly employed materials, in which
chemical reduction is due and in which chemical change is
inevitable. Whether such change be in the progressive
physiological order, or become disorderly and deteriorative,
is determined by the extent and the degree of the chemico-
physics whose influence is brought to bear on the impend-
ing act. All components of the vital organism occupy
stages of a career ; all are passing forward to the next
stage ; and all are predestined to the chemical change
which signalizes the evolution of either heat or other form
of energy. Pathology is necessarily associated with imper-
fect fulfillment of the chemical change wherein energy is
liberated for the advantage of the individual.
O.ryyen, its Uses by the Vital System, and what deter-
mines its Consumption. — Of the oxygen introduced by the
respiratory process from the unlimited and ever-ready sup-
ply afforded by the atmosphere in which we dwell, just so
much is taken in health as is required by the chemico-
physics of the organism. Food of all kinds has definite
composition ; the completed products of its chemical change
which pass from the vital system are also definite in com-
position, but increased by the exact amount of oxygen taken
from the air of respiration.
The purposes of oxygen in the vital system thus become
clear, and the consequences of its defective use by the vital
system are intelligible, although the pathological states
which the physician is called upon to correct are often re-
ferred to some intermediate circumstance which has little
to do with the use or non-use by the vital system of oxy-
April 2, 18SI2.J
TAYLOR:
MASSAGE AT RAPID OR VIBRATORY RATES.
377
gen. Why the system takes up less of this ingredient than
is required to dispose of its waste and superfluous ingredi-
ents is seldom inquired. The pathology which arises from
faults of use being attributed to secondary causes, other than
direct remedies are apt to be chosen for its correction.
There has. indeed, been a vast amount of experiment-
ing based on the therapeutic need and artificial supply of
oxygen, thus palpably connecting its defects with pathology.
Among these devices is that of increasing its proportion in
the air respired; that of condensing by pressure the air for
respiration ; that of liberating oxygen from chemicals in
the air respired and in the digestive organs ; that of in-
creasing the air space in the chest by developing its mus-
cles, etc. These methods only promise increase of supply
to, not use by, the system of this element — things very differ-
ent in practice. These devices all prove disappointing, not
only because the supply thus afforded is necessarily tem-
porary while the need is continuous, but more emphatically
because none of these devices are capable of supplying the
thing wanting — that degree of chemico-physical action
which insures the appropriation by the unstable residuals
of the system of the oxygen which, though present, remains
unappropriated.
Oxygen is appropriated at all points where heat or other
form of energy is disengaged, because, under these circum-
stances, the systemic ingredients are passing into higher
and usually into emergent forms of oxidation. It is clear
that both motory physics and chemico-physics are required
to secure the effect desired ; the one to transport ingredients
to the several points of use ; the other to effect the forceful
contact whereby motory is transformed to chemical energy
by its transfer to the elementary constituents of the chang-
ing materials.
These effects arise spontaneously in health, and, though
appearing to be causeless, are, in fact, intimately associated
with the involuntary and the voluntary motory functions.
The first have also the reciprocating form, and in the arterial
department, which conveys oxygen on its being demanded,
approaches the vibratory rate, while the voluntary motions
seem to incite and perfect the involuntary.
The therapeutic uses of vibration consist, therefore, in
securing such higher degrees of perfection in the faulty ac-
tivities of the organism as shall remove the consequences
of previous defective mechanico-physics and chemico-phys-
ics. The effects of applications of vibration extend pri-
marily to the oxidizable ingredients, whatever be the name
of the affection of which such ingredients are a funda-
mental factor. For reasons stated, those ingredients of the
blood, interstitial fluids, and solids which possess the highest
instability are the first to become destroyed on forcible
contact with the oxygen, always in readiness for this physio-
logical purpose, and always effective when the conditions
prescribed in the organic mechanism are complied with,
whether these l>e classed as hygienic or remedial.
The substantial reason now appears why vibration allays
pain and proves a trustworthy remedy in chronic neuralgias
and other painful affections. This agent, by promoting
physiological oxidation, removes the essential cause of pain,
so far as this depends on impressions received by the nerv-
ous system from morbid environment. The pain is not the
disease,- local or general ; it is the evidence of the presence
of unstable ingredients, embarrassing nutrition, compromis-
ing the development of energy in other forms, defeating
organic purposes, and affording timely warning of a severer
fate. Pain is the disagreeable consciousness superinduced
by these and similar physical circumstances. It is these,
rather than the notification of their existence, which should
be removed.
The vital system necessarily at all times contains inter-
mediate products in various stages of progress toward the
final goal of the physiologically perfected stage of oxida-
tion, which stage is represented mainly by carbonic dioxide,
water, urea, and salines. Faulty conditions diminish the
degree attained by the oxidizing process; and the interme-
diate products, well known to chemical investigators, neces-
sarily increase, and thereupon assume abnormal and morbid
phases and strange chemical forms. The discharge from
the system of the above-named perfected products is di-
minished, but their equivalents are retained in some noxious
form, awaiting bettered conditions, which shall render them
inoffensive.
If we may consider chronic neuralgia and other painful
affections as resulting from the impressions the nerves and
consciousness receive from the presence of adventitious in-
gredients inimical to vitality, the morbid condition may be
understood by the term auto- poisoning, and bears an analo-
gy to the poisoning arising from accumulation of oxidizable
ingredients accidentally or willfully ingested. The effects of
alcohol, opium, ether, and the alkaloids and sedatives in
general will answer for illustration. Experience proves that
the most trustworthy remedial recourse in these cases is to
promote and to intensify physiological oxidation by main-
taining the respiratory process by every means available
till the poison, if the dose be not too large, is neutralized
by oxidation. The effect of vibration proves that the same
principle is practically available for removing the cause of
chronic neuralgic pains, and the rapidity and certainty of
this effect indicates that oxidation, the cessation of pain,
and the production of heat are synchronous in the part sub-
jected to the process.
Other Physical Effects of Vibration and their Physio-
logical Consequences ; Heat. — It is clearly provable bv many
conclusive tests that heat-production is very much increased
by vibratory applications. The glow of warmth produced
in the skin, soon reaching the previously habituallv cold ex-
tremities, affords satisfactory evidence of this effect. The
temperature of the body, however, never rises above the
normal standard, since the regulative powers, having their
seat in the nervous system, are in effective operation. The
increased heat becomes equally diffused ; in part because the
circulation is also diffused, but in greater part because the
process of heat development is no longer limited to the
central parts, but is restored in normal degree to peripheral
parts.
The rapid restoration of heat by vibration arises from
two causes. One is the direct transformation of the motor
energy to heat by friction of anatomical components of the
organism — the fibers and membranes, down to the minutest
378
TAYLOR: MASSAGE AT RAPID OR VIBRATORY RATES.
[N. Y. Med. Joub.,
morphological ingredients, being- compelled, by the motory
waves, to glide with pressure upon each other — as when a
piece of rubber is repeatedly stretched, or even rubbed, it
becomes heated without chemical change. The other cause
of heat arises from chemical arts arising from the increased
consumption of oxygen.
The sources of heat are the muscle cells, whose rate of
heat development is greatly quickened by vibration, even
though the motor function be suspended, and also the non-
vital fluids which pervade all tissues. These contain un-
stable and highly oxidizable ingredients, which only wait a
due impact or collision of elements to be rendered stable,
and necessarily yield heat in the act.
The evidences of therapeutic oxidation are patent to the
least scientific observer. These are of two kinds. One is
the palpable increase of completed products of oxidation,
whose emergence is due to the process. The urine becomes
increased, assumes its natural odor and color, and ceases to
yield a precipitate on cooling. This change is due to
diminution of extractives, another word for the various
products of defective oxidation. The quantity of watery
vapor transpired and exhaled is likewise sensibly increased,
as we know must happen, since water is part of the product
of the resolution of the same ingredients that also afford
the urea and carbon dioxide which is disengaged.
The other class of evidences consists of positive appeals
to the senses. These are indications through the feelings
and the muscular powers of returning health, the most sig-
nificant of which is subsidence of pain and increase of
volitional manifestations of energy, mental and physical-
The mutuality of these relations appeal s to imply that pain
is at the expense of the energy-evolving functions — that
such energy requires guidance, not abatement or destruc-
tion ; in short, that the central idea of remedying pain,
legitimately, should be that of affording it more useful, and
therefore agreeable, scope, through other than nervous chan-
nels of expenditure.
The principle of transferring manifestations of energy
from one to another functioning seat, which I have above
shown to be practicable, is invested with deep scientific and
physiological interest, since it appears to open the way for
radical change of therapeutic purposes. The desire to sus-
pend the consciousness of disagreeable impressions, instead
ot abolishing their source, has greatly increased the number
of drugs whose principal claim of merit is the possession of
this power, which experience proves to be liable to enor-
mous abuses. The practicability of changing painful to
agreeable manifestations of nervous power by rectifying the
nutritive source whence such powers emanate naturally
supersedes, to the extent the method is practiced, the de-
mand for drugs whose chief value lies in preventing painful
impressions from reaching the powers of the consciousness.
\ ibration, aside from the mechanical and chemical
physics it introduces, is, however, entirely capable of sus-
pend/in;/ pain and the sensory powers of any local portion of
the body. This effect appears to arise from the fact that
when a part is subjected to vibration, its sensory nerves,
each and all, thereby receive exactly the same impression.
No differences exist and none are perceptible. The dis-
criminating power of the consciousness is therefore abol-
ished, because the effect of impressions is abolished, and
with it feeling, both agreeable and disagreeable, including
local pain. The fact stated is easily proved to the most in-
credulous, who is at liberty to adopt other reasons than
those assigned. The well-attested effects of wdiat is called
hypnotism, in respect to pain, may be susceptible of similar
explanation. The vibratory subject does not, however, need
to have a special susceptibility. It is probable that this
incidental effect of vibration arrested and held the atten-
tion of the transatlantic investigators referred to in another
part of this article.
We may now briefly review some of the physiological
and therapeutic effects superinduced by quick or vibratory
massage :
1. Vibration may be so applied as to impress the sen-
sory nerves principally. This is when the impingement is
on the skin. By this means the nutrition of sensory nerv-
ous tissues, conductors and centers, is increased, and there-
fore their product of sensory nervous energy. This effect
is easily carried to a morbid degree, to the detriment of
other functioning parts.
Vibration may also be so applied as practically to omit
the nervous sensory tissues. In this case the motory phys-
ics, hut more especially the chemico-physics, of the vital
organism are increased, while the excess of nerve nutrition
and the irregular, obstinate, excessive, and morbid mani-
festations of nervous power are thereby diminished and
permanently remedied. This effect of vibration has ex-
tensive application in nervous affections and the chronic
diseases which are the usual accompaniments of nervous
diseases.
2. The remedial effects of vibration are by no means
restricted to functional diseases. Its chief sphere is in the
motory and chemico-physics of the organism. The curative
powers of this agent, through reduction by oxygen of in-
jurious ingredients which spontaneously arise from faults
of what may be called motory hygiene, require personal
investigation by the inquirer, to be understood or entitled
to belief.
Vibration is not exercise, and, since the will is not en-
gaged, causes no fatigue. The rate of vibratory motion is
incompatible with muscular nutrition, which requires a slow-
er rate.
3. Vibration may be regarded as specific in all chronic
inflammations of whatever part of the organism, and what-
ever may be the morbid product developed therefrom.
The several effects of vibration which are conjoined in
producing this remedial consequence may be noted. One
is thorough diffusion of the circulation — increasing the
amount of blood at will in any desired region of the body,
and correspondingly diminishing it in other regions, espe-
cially in that suffering from inflammation. The caliber of
the capillaries is increased and contracted, in compliance
with the disposition of their contents. Another is the urgiug
forward, from the affected region, the obstructive contents
of capillary vessels, including both morbid chemical and
other materials, thereby allowing interstitial, effused ma-
terials to return to the circulation, and so to remove the
April 2, 1892.]
1TTTLE: (1 OXOREHCEA OF THE RECTUM.
379
swelling. A third effect is the submission of these morbid
ingredients to the chemico-physics of the organism, while
this function is exalted to high efficiency by the addition
from motor energy. Intimately connected with these is the
modification of pulse-rate. The rate is never quickened, and
in all cases of abnormally high pulse the rate is diminished
— in pulmonary affections to the extent of fifteen or twenty
beats a minute, and often this effect becomes permanent.
GONORRHOEA OF TOE RECTUM.
A REPORT OF THREE CASES.
By JAMES P. TOTTLE, M. D.,
LECTURER ON RECTAL DISEASES IN THE NEW YORK POLYCLINIC.
Since the famous experiments of Bonniere, showing the
comparative immunity of mucous membranes covered with
cylindrical epithelium from blennorrhagic infection, the
existence of gonorrhoea of the rectum has been seriously
questioned by many observers. The discovery, by Neisser,
of the Bacillus gonococcus has, however, put to rest all con-
tention upon this point. It is not my intention here to dis-
cuss the subject of gonorrhoea of the rectum, but simply to
report three cases of the disease. They were all observed
in my clinic for diseases of the rectum and anus at the New
York Polyclinic, and were seen by several members of the
classes during the past two years.
Case I. — M. R. appeared at the clinic on April 10, 1891.
He complained of pain and burning about his rectum, frequent
desire to go to stool, and inability to sleep, on account of the
intolerable itching at the anus. The stools, he said, were some-
times solid, but usually composed of thick mucus. He confessed
to the practice of sodomy, but thought that had nothing to do
with the case. The anus and the contiguous surfaces of the
buttocks were red and swollen. The anus was not funnel-
shaped, and the mucous folds were not obliterated. The parts
were bathed with a muco-pnrulent discharge, and there were
several little cracks in the muco-cutaneous border, resembling
fissures. The rectum was hot and tender to the touch and cov-
ered with a slimy-feeling secretion. Through the speculum it
appeared red, inflamed, and bathed with a thick, yellowish pus.
There were no ulcerations observed, and no haemorrhoids what-
ever. Microscopic examination of the pus, after straining,
showed Neisser's gonococcus in abundance.
The method of collecting the pus for these examinations be-
ing of importance, it may be described here. The anus is wiped
off as gently and thoroughly as possible with absorbent cotton,
and then washed with a solution of salicylic and boric acids —
Thiersch's solution. An O'Neil's speculum is then introduced
closed, and the sliding bar on the upper side is withdrawn, the
patient lying on his left side. The specimen is then taken from
the surface of the rectum, and not from the discharge which
flows down into the speculum, iest by any chance some of the
secretion from the anus should have been carried up on the end
of the speculum. Several specimens are then examined, to cor-
roborate one another, and to avoid, as far as possible, the error
of mistaking disease of the rectum for that of the anus. The
solutions used for staining in these cases were gentian violet and
ammoniated carmin, and the results were practically the same
with both.
The treatment in this case was by injections of bichloride of
mercury (1 to 20,000) and the separation of the inflamed but-
tocks by a pledget of lint dusted with a powder of oxide of
zinc and starch, equal parts.
The patient made a good recovery after four weeks' treat-
ment.
Case II. — F. S., aged twenty-three, presented himself at the
clinic on November 10, 1891, complaining of pain, itching,
burning, and occasional haemorrhages in the rectum. He has too
frequent stools, and has noticed of late a small lump on the edge
of the anus. He confesses to habitual sodomy, and has had a
discharge from the rectum for several weeks. There are two
small condylomata about half an inch from and posterior to the
muco cutaneous border of the anus. The anus is infundibuli-
form, the sphincters are relaxed, and the mucous folds are ob-
literated. The rectum is hot and tender to the touch ; through
the speculum it appears red, swollen, and rather excoriated than
ulcerated in patches of considerable area. The pus was not
very thick, rather of a creamy yellow, and not very profuse.
The patient said it had decreased of late. The pus cells con-
tained gonococci.
The condylomata were removed with the scissors and their
bases cauterized with nitric acid. The rectum was then irri"
gated, by means of my rectal irrigator, with a saturated solution
of boric acid. The advantages of this irrigator are its cleanli-
ness and the facility with which a constant stream of fresh so-
lution can be passed through the rectum without wetting the
couch, while at the same time it distends the folds of mucous
membrane so as to cleanse and medicate them.
This patient made a good recovery in ten days.
Case III. — D. K., aged twenty-one, a domestic, came to the
clinic on February 12, 1892. She complained of severe pain in
the rectum, with itching and burning. She denies paederasty,
but confesses to illicit intercourse. She has no venereal disease
of the vulva or vagina. The anus is much inflamed, red, and
swollen. The funnel shape is not marked. There are four shal-
low ulcers around its border, and a profuse, thick, greenish pus
exudes from the parts. She says that she noticed the discharge
before the ulcers. The rectum is hot and tender to the touch
and more or less filled with the greenish pus, which follows the
finger as it is withdrawn. The pus cells contain gonococci in
abundance.
The ulcers were washed with the boric-acid solution and
touched with a ten-per-cent. solution of nitrate of silver. After
irrigating the rectum with the boric-acid solution the ulcers were
dressed with pledgets of lint dusted with a powder of equal parts
of oxide of zinc and calomel.
The discharge had ceased and the ulcers were granulating
satisfactorily when, at the end of two weeks, she disappeared.
These cases are not unique, but they are interesting on
account of the few which have been reported as verified by
the examination for gonococci.
36 West Forty-fifth Street.
SOME OBSERVATIONS UPON THE RIVIERA.
By FREDERICK PETERSON, M. D.
In the issue of the Journal for June 1:5, 1891, 1 pub-
lished some notes upon Southern Health Resorts in tin-
United States, the result of travels and investigations made
during the late winter months of last year. Saving just
spent some two months along the Riviera, which is the chief
winter sanatorium of Europe, I have thought some words
upon this subject might not prove uninteresting to such of
380
PETERSON: SOME OBSERVATIONS UPON THE RIVIERA.
[N. Y. Med. Jouh.,
your readers as have not visited this favored locality, and
who are not in a position like myself to draw contrasts be-
tween these foreign health resorts and our own.
The Riviera, as is well known, is the region upon the
Mediterranean coast extending from Toulon in France to
Leghorn in Italy. It is sometimes divided into the West-
ern and Eastern Riviera, the former, the more important,
comprising the district between Toulon and San Remo; the
latter, that between San Remo and Leghorn. The chief in-
valid stations are, in their order from west to east, Hyeres
with Costebelle, St. Raphael, Cannes, Nice, Mentone
(French), San Remo (Italian). All of these places are upon
the tideless Midland Sea and nearly at sea-level. Back of
them are lofty mountains, some of them snow-capped, the
Maritime Alps, which give the coast a rugged and magnifi-
cent aspect. Immediately behind Eyeres arc the Maures
Mountains of moderate height, separating this place from
the Alps to the northeast. The great Rhone valley, begin-
ning in Switzerland, sweeps southward through France to
the sea immediately west of Marseilles, and therefore west
of the Riviera. We now have some of the elements that
go to make up the climate of the Littoral. The ordinary
moisture of the atmosphere at sea-level is abstracted by the
mountains, so that its relative humidity is small. The pre-
vailing winds must either come from the mountains or the
sea or be a hybrid from both. A purely south wind, which
is not common, would come from the Sahara across the long
stretch of warm water, and would be quite warm and dry.
It is the sirocco. A purely north wind must sweep directly
down over snowy mountains and cold valleys. It is cold
and piercing and is called the mistral. When a great depth
of atmosphere is not included, it does not come over the
mountains, but, sweeping down the great valley of the
Rhone, breaks over to the Riviera from the northwest or
west with almost equal intensity and rigor. A direct mis-
tral is not frequent. It blows perhaps twelve days in the
season. But it would seem to be very common as an indi-
rect assailant. It is seldom that winds of some kind do not
blow, for here are some figures of M. Teysseire's for a year
in Nice : 88 days more or less strong winds, 257 days mild
winds, 21 days of absolute calm. To judge by my own ex-
perience in the early months of the winter season, all of the
winds have that penetrating, " nipping and eager " charac-
ter which leads one to the shelter of a wall or hedge if he
intends to sit still. In walking they are not unpleasant. I
had no experience of warm southerly winds. Rainfalls and
cloudiness are comparatively rare. For instance, taking the
average in twenty years, the following figures are given for
Nice (which are applicable to the other stations also) dur-
ing the six months' winter season : Clear days, 102 ; cloudy
days, 41 ; rainy days, 36.
Dr. Cormack, of Hyeres, called my attention to the fact
that rain there in at least one third of the cases falls at night,
and this I corroborated during my stay. The porous soil
rapidly absorbs it, and the next day is clear, sunny, and dry
under foot as usual.
As to temperature, perhaps more can be understood
|>ia« t i« allv by examination of the flora than by reference to
the dry statistics. Although the Riviera lies in about lati-
tude 43° to 44°, corresponding to that of Saratoga and Tort-
land, yet here the oranges are ripening through the winter,
and the gardens are all abloom with roses, violets, jonquils,
mimosa, jasmine, and other flowers. F>om the olive forests
the crops are gathered in December. The roads and streets
are lined with the eucalyptus and palm. The Japanese med-
lars, the yuccas, the agaves, the aloes, the cacti, and the
cork oak flourish luxuriantly. The climate is therefore
semi-tropical, and yet you may stand in the midst of this
vegetation and shiver with cold. The sun is hot, sometimes
unendurable. But in the shade a chili strikes you to the
marrow. As soon as the sun sets, on with the overcoat !
Filtering an unsunned room is like a visit to the catacombs.
But climate is never quite enough for invalids. More
important still are the creature comforts. Thanks, not to
French or Italian enterprise, but to English and American
requirements, these places are all supplied with good water,
good sewer systems, and hotels and villas providing every
comfort. The plumbing is mostly of London installation.
All rooms may be well heated with good wood tires, the fire-
places and fuel being quite adequate, which is not true of
many other continental regions. Of course, in the old parts
of these towns, with their rambling, narrow, gloomy, foul-
smelling streets, the proverbial uncleanliness of the Italian
and French people prevails, the pavements serving the two
purposes of sidewalk and common sewer. Providence pro-
tects them from disease and the rain acts as scavenger.
Strangers, however, reside far from the older portions of
the cities, and only go there when the love of the picturesque
gets the better of their sanatory judgment. The old towns
must be unhealthful in summer. There are marshes about
Hyeres and St. Raphael which are said to be malarial in
summer. Every town has its parks or botanical and zoo-
logical gardens, its open-air concerts, its libraries and read-
ing rooms, its casinos for concerts, theatricals, balls, and the
like, magnificent macadamized roads in every direction for
drives, beautiful wood and mountain paths for walks, and
baths of some sort, it being naturally considered a part of
the duty of a health resort to provide more than the climate
to make a place attractive and draw money into the pockets
of its inhabitants. The mind must have its amusements or
occupations while the body is recovering its health.
Much has been written concerning differences of cli-
mate between the towns of the Riviera, and very fine dis-
tinctions have been drawn which really have no existence.
Thev are all much alike. They have the same semi-tropi-
cal flora, the same sea before them, the same mountains
behind them. When the mistral blows they feel it about
alike, for in each town certain hillsides protect at one time
and not at another. They are all equally warm, equally
dry, equally sunny, equally tonic, equally stimulating.
From what has been written above, it may be under-
stood that the Riviera has a delightful winter climate for
all healthy people and for some sick people. But it is a
climate not to be recommended without due care and many
precautions to delicate invalids. Quite recently Dr.
Thomas Linn, an American physician, practicing in Nice,
has printed in a little book some excellent rules to be ob-
served by Riviera patients, some of which I can not for-
April 2, 1892.]
PETERSON': SOME OBSERVATION'S UPON THE RIVIERA.
381
bear to repeat here, since they have their application also
to some of our own American climates. They are as
follows ;
" Do not travel South too quickly.
" Do not put off coming South until too late in the year.
" Do not hurry away from the South too soon in the spring.
'•The regimen must be changed in the South.
" See that the sanitary arrangements are good in the house.
"Insist on having a room facing the south.
" All invalids should go indoors before the sun sets and
not go out before it rises.
" When going from the sun into the shade, put on additional
covering.
" It is necessary to carry a sun umbrella.
"It is advisable to wear smoked eye-glasses in the bright
sunshine.
"One 3hould not overdress or walk too fast.
" On entering the house, do not remove outer wraps at
once."
The Riviera climate, being the driest in Europe, is a
good place for rheumatism and rheumatic neuralgias and
; for bronchitis and consumption in its early stages. Being
stimulating, it is a good place for apathetic forms of men-
tal trouble, like mild melancholia, and for certain forms of
neurasthenia, but insomnia is always a contra-indication.
Hyeres is the best station on the Riviera for several rea-
sons. It has mountain walks and paths through forests of
cork oak in greater number than any of the other places
can boast. The town is so small that one is practically in
the country, whereas in a place like Nice (with nearly
8G,000 inhabitants) it is difficult to get out of the city. If
one does not sleep well in Hyeres, he can go to Costebelle,
which is several hundred feet higher and only a mile
away. Hyeres is three miles from the sea and has, per-
haps, more days of absolute calm than the other littoral
towns. Hyeres is the nearest winter station to Marseilles,
and hence is the most accessible from London or Paris,
: while one may make one's escape from the Riviera at this
point in very short order by rail or boat should the climate
prove to be hurtful in any degree. In a few hours one
may be sailing from Marseilles to Malaga, Oran, Tangier,
the Canary Islands, Algiers, or Egypt in search of more
suitable winter climes.
Now, when we seek in America some homologous cli-
i mate we meet with difficulties. We have certainly no-
where just the same juxtaposition of lofty mountain and
> warm sea. We may discover a similar flora in parts of
Florida and in southern California; the dryness in Aiken,
Thomasville, and Colorado ; the equable temperature and
cloudless skies in many places ; but the exact combination
of isotherms and isobars is not to be found.
1 I do not think any good climatologist would say so,
but I have heard Colorado Springs, Asheville, and Aiken
each spoken of as the " Hyeres of America." For im-
part, I have no doubt that in Colorado and New Mexico we
have climates which, if not comparable to that of the Ri-
viera, are not so because they are so much better. As for
Asheville, it is not exactly a winter resort, though an ex-
cellent health station for the nine months of the year pre-
ceding January 1st. We have yet to learn authoritatively
whether it is a particularly dry climate. The Riviera re-
sorts are mostly about at sea level and littoral, Asheville
being several hundred miles inland at an elevation of 2,400
feet. The contrast of the semi-tropical flora of the Riviera
with the seasonally varying northern flora of Asheville is
still more pronounced. Aiken has neither mountain nor
sea, but depends for its dryness upon its miles of piny
sand-hills. Its flora, too, is northern.
The climate of southern California is, perhaps, the nearest
akin to that of the Riviera. It is akin to it, but is better.
It has not the night and day temperature variations of the
Littoral. It is quite as sunny and clear. It is, perhaps,
warmer. It may not be so dry. The flora is quite the same.
The mountain panorama is not so beautiful, and the villas
and villages are not so picturesque. It is not so danger-
ous and treacherous, for it has no mistral to pounce upon
and make easy prey of unsuspecting victims. It does not
stimulate you to walk fast or pour the poison of its subtle
chills through your pores when you stop to rest a moment.
In California, in New Mexico, in Aiken, and in Thomas-
ville we have far better climates than can be found in the
south of France, and it seems to me a grievous wrong that
American invalids should be sent, as they seem to be in
considerable numbers, so far from home when better clima-
tological remedies lie so near at hand.
The Riviera certainly has been, and is still, the great
resort for consumptives from all parts of Europe, and is
full of Russians, Germans, Swedes, British, and the like ;
but Teneriffe, Algiers, and Egypt are beginning to deflect
from it large portions of that annual tide of phthisical
hibernants. So, too, many go to the higher Alpine sta-
tions for that " cold " treatment that has come into vogue
of late years and which, it seems to me, we Americans
misapply when we try to substitute Minnesota and the
Adirondacks for the rare, cold atmosphere of high altitudes
in southern countries like Switzerland. It is not yet
fashionable in Europe to send consumptives to Norway or
Siberia for the winter.
When one sees how much is done for the entertain-
ment of visitors and invalids in these European resorts, one
can not but regret that lack of local enterprise in America
which blinds the tax-payers and voters to their own ad-
vantages. How much might they not do to increase the
value of their town property to attract visitors, to stimulate
the trade of the community, if they would but see the indi-
ces before their eyes !
Suppose that Asheville should pave all her streets,
should macadamize her country roads for several miles
from town, should construct paths along her picturesque
mountains, should lay out a public park with swimming
baths by the French Broad, should establish a botanical
and zoological garden, should line her avenues with rare
trees, should build a casino with restaurant, parlors, read-
ing-rooms, library, solarium, concert-ball, theatre — but the
imagination halts at the metamorphosis. She might make
herself the most beautiful, the most charming, the most
attractive (and the best-paying) health resort in the
United States. She could defy bad winters and make her-
self happy and enjoyable all the year round.
382
LEADING ARTICLES. -MINOR PARAGRAPHS.
[N. Y. Meij. Jour.,
the
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by Edited by
D. Appi.eton & Co. Frank P. Foster, M. D.
NEW YORK, SATURDAY, APRIL 2, 1892.
THE TREATMENT OF ENDOMETRITIS.
At ji recent meeting of the Philadelphia County Medical
Society a paper was read in which the author advocated the
use of intra-uterine injections for the cure of chronic endomet-
ritis. In the discussion that followed, Dr. Charles P. Noble
made some remarks that seem to us most judicious.
A mere discharge from the uterus, he said, did not indicate
endometritis. We were indebted to Dr. Emmet and others for
disproving the idea that every uterine discharge indicated endo-
metritis. This might come from various constitutional derange-
ments, such as a feeble heart, general debility, phthisis, constipa-
tion, or a sluggish portal circulation, and if these were remedied
the discharge would disappear. This class of cases must be
eliminated strictly when discussing endometritis. Some even
went so far as to deny that there was such a disease as endo-
metritis. The speaker had not studied the endometrium micro-
scopically, but clinically he believed that there was such a
thing as endometritis. Another important point in the study of
endometritis from the therapeutic standpoint was whether the
disease was or was not complicated. Treatment that was bene-
ficial in uncomplicated endometritis might be and was danger-
ous where complications existed. Endometritis was often the
forerunner of salpingitis, which was the forerunner of perito-
nitis. Patients with chronic peritonitis generally had endomet-
ritis. It was apparent that the treatment of such cases should
be essentially different from the treatment of uncomplicated
endometritis. Where the endometritis was uncomplicated,
treatment directed to the uterus was moderately safe, although
even here one might produce complications from intra-uterine
applications, and especially from intra-uterine injections. The
experience of our predecessors had proved this, and had shown
that most cases of endometritis could be cured without treating
the endometrium directly. When the cervix was dilated
wieldy, as after curetting, the danger of intra-uterine injections
was probably slight; but without such dilatation they were
distinctly dangerous — how much so any old book on gynaecology
would prove.
THE BROOKLYN METHODIST EPISCOPAL HOSPITAL.
Tins institution — better known as the Seney Hospital, from
the name of its founder, Mr. George I. Seney — has been open
for patients but little more than four years. The Fourth An-
nual Report, for the year ending October 81, 1891, shows clear-
ly that in this short time it has done a noteworthy amount of
good work, not only in its primary sphere of relieving the sick,
but also in contributing to the advancement of the medical art,
in training young physicians and surgeons, and in fitting young
women to act as efficient nurses.
The Report is an octavo of nearly a hundred and fifty pa^es,
and the greater portion of it is taken up with statistical accounts
of the work done in the medical and surgical divisions, inter-
woven with brief but unusually well prepared outlines of the
clinical histories of interesting cases. This is a feature that we
should be glad to see in the annual reports of more of our large
hospitals. The fundamental object of hospitals, of course, is to
shelter the sick and injured and to afford them the best attain-
able treatment of their ailments, but it is not only legitimate,
but positively desirable, for them to devote a considerable part
of their resources, even if they are not ample, to publications of
this sort, for they serve far better than mere tables of figures to
spread among the medical profession and, through its members,
among the community a realizing sense of what the institutions
are really accomplishing and of the degree in which they are
respectively worthy of additional benefactions. Moreover, by
such a course the members of the medical staff are encouraged
to strive harder than ever for continuous improvement in their
work, and men of the best attainments are led to seek the office
of physician or surgeon.
The plan of teaching given the pupil nurses is outlined in
the Report, and we must say of it that it seems excellent.
MINOR PARAGRAPHS.
THE EFFECT OF LEAD POISONING UPON THE PERISTALTIC
ACTION OF THE INTESTINES.
Professor Bokai, of Budapest, during a series of experi-
mental studies regarding the pathology of the peristaltic action
of the intestines, produced lead poisoning in a number of rabbits
by the administration of from one to five cubic centimetres of
sugar of lead for from five to forty-six days, and the Deutsche
Medizinal-Zeitung furnishes us with a brief resume of the re-
sults. The positive results were that he found the intestines
deficient in blood, the mucous membrane dry, and the lar^e in-
testine filled with numerous dry balls of faeces which could with
difficulty be moved onward. The intestines were highly hyper-
aesthetic and hyperalgesia and the peripheral motor intestinal
nerves were in excellent nutritive condition. The negative re-
sults were that the reaction of the intestinal muscles showed no
change, the nervous system about the intestines showed no
special condition of irritation, intestinal movements were not
inhibited by section of the vagi, and there appeared no special
condition of irritation of the central nervous system. These
results lead Bokai to conclude that the obstipation of lead poi-
soning is due to the dryness of the mucous membrane and of the
faeces rather than to paresis or spasm of the intestine or irrita-
tion of the splanchnic nerve. The diarrhoea which sometimes
occurs is due to the irritation produced by the scybala. He is
also inclined to consider attacks of lead colic to be usually of a
reflex nature, for he has found that they occur pretty frequently
after errors of diet, mechanical irritation, or the administration
of laxatives. The spasm of the abdominal muscles during an
attack of colic also seems to be of reflex origin. The tension,
hardness, and slowness of the pulse he ascribes to the irritation
of the vaso-motor nervous system by the chronic lead poisoning,
and its elasticity during an attack of colic to a reflex contraction
of the blood-vessels.
April 2, 1892.]
MINOR PARA GRAPES.— ITEMS.
383
THE EXAMINATION OF THE EYES SEPARATELY FOR
COLOBr-BLINDNESS.
Mr. Sneli, calls attention in the British Medical Journal to
the importance of testing each eye separately for color-Mind-
less. He details a case which came under his observation in
which there was green color-blindness of the left eye alone, and
a second in which there was red blindness in the right eye and
incomplete green blindness in the left. With both eyes open
both patients correctly sorted Holmgren's wools, and would
probably have passed an ordinary examination for color-blind-
ness. The importance of sufficient examination of every person
who may occupy a position where good color vision is requisite
can not be t"0 firmly insisted on, and every means should be
employed to make such examination perfect. Such a condition
is probably rare, for Fontenay, in the Archives of Ophthalmolo-
gy, in 1881, states that he examined two hundred and seventeen
persons, and found the two eyes in each case always alike. But
this is insufficient to prove that such cases as those here men-
tioned exist, in which the exclusion of the use of one eye, even
for a brief period, might be attended with the possibility of dis-
astrous results.
THE NON-MEDICAL USES OF POISONOUS DRUGS.
The Pharmaceutical Record states that enormous quantities
of strychnine are used in the Western States for non-medical
purposes. The county commissioners of Spokane, Washington,
recently made a purchase of 1,500 ounces without entering into
competition. The favored drug house gets the contract at a
high figure, while the rest of the drug trade is left with huge
stocks of the drug — enough to last many generations, according
to ordinary demands. The mystery seems to be that there
should be a public demand on the part of a county of not more
than 25,000 population for so large an amount of poison, when
a single ounce of it will last most drug stores many months, if
not years. The non-medical sale of poisons in the West is
very great, and it is believed that most of the strychnine pro-
duced, for example, is consumed in the work of destroying
animal life. To kill game and destructive animals, such as
wolves, foxes, squirrels, rabbits, etc., the farmer and the hunter
find the poisonous drugs useful, whether they are in pursuit of
bounty money or the animals1 pelts.
ETHER AS A STIMULANT.
The Lancet is the authority for the statement that in a cer-
tain English temperance hospital ether is allowed as a stimu-
lant, instead of alcohol. Referring to the ether drinking vice
in Ireland, it is truly said that it is ''affectation to regard the
use of such an agent as morally or physically better than the
use of approved forms of alcohol."
THE PHYSICIANS' MUTUAL AID ASSOCIATION.
It is announced that the membership of the New York
Physicians1 Mutual Aid Association now amounts :<> a thousand,
and that when it reaches eleven hundred the association will be
able to pay $1,000 on each death. This sum is the limit fixed
by the by laws, and it ought to be readied soon.
THE FLINT CLUB.
Baltimore lias an organization of physicians bearing the
title of the Flint Club, named after the late Dr. Austin Flint.
The membership numbers over thirty of the most social and
clever of the rising generation of doctors. The meetings are
held monthly for the purpose of increasing the members' gas-
tronomic knowledge and of forgetting for the time being every-
thing of a medical nature. Feasting and a flow of wit rule the
hour one night out of every thirty for the members of this in-
genious coterie.
ITEMS, ETC.
Infectious Diseases in New York. — We are indebted to the Sanitary
Bureau of the Health Department for the following statement of cases
and deaths reported during the two weeks ending March 29, 1892 :
DISEASES.
Week ending Mar. 23.
Week ending Mar. 20.
Cases.
Deaths.
Cases.
Deaths.
2
6
0
0
9
6
13
5
215
28
206
22
Cerebro-spinal meningitis. . . .
4
4
4
3
282
23
423
16
Diphtheria
109
37
124
34
4
1
3
0
Erysipelas
2
()
0
0
10
0
0
2
0
0
Mumps
2
0
0
0
The Association of the Alumni of the New York Hospital. — At the
meeting for organization, to which we referred last week, the following
officers were elected: President, Dr. Thomas M. Markoe; vice-president,
Dr. William Oilman Thompson ; secretary, Dr. Edwin T. Doubleday ;
treasurer, Dr. Henry A. Griffin ; executive committee, Dr. Frank P.
Foster, Dr. George R. Lockwood, and Dr. C. R. Garrison ; committee on
entertainment, Dr. John L. Adams, Dr. Paul Kimball, and Dr. Percy
Bolton ; committee on admissions, Dr. C. S. Cole, Dr. W. F. Martin, and
Dr. George H. Cobb. Meetings are to he held on the second Friday of
February, April, October, and December.
To Deodorize Iodoform. — The following combination is allowed by
the Addendum of the Nctlierlaml Pharmacopoeia to deodorize iodoform:
Carbolic acid, one part; oil of peppermint, two parts; iodoform, one
hundred and ninety-seven parts.
Meetings of State Medical Societies for the Month of April. — Florida
Medical Association, Key West, 5th ; Medical Society of the State of
Tennessee, Knoxville, 12th; Medical Society of the State of California,
San Francisco, 19th ; Medical Association of Montana, Butte, 20th ; Mis-
sissippi State Medical Association, Natchez, 20th ; Medical and Chirur-
gieal Faculty of Maryland, Baltimore, 26th ; Texas State Medical Asso-
ciation, Tyler, 26th; Louisiana State Medical Society, New Orleans,
27th ; South Carolina Medical Association, Georgetown, 28th.
The Brooklyn Dermatological and Genito-urinary Society has been
organized with Dr. Samuel Sherwell as president, Dr. A. E. Smylie as
vice-president, and Dr. George D. Holsten as secretary and treasurer.
The meetings, which are private, are held on the first Friday of each
month, except July, August, and September.
Changes of Address. — Dr. Burdette P. Craig, to No. 258 Montgom-
ery Street, Jersey City ; Dr. J. M. Hays, to No. 826 Fourteenth Street,
N. W., Washington; Dr. M. J. Roberts, to No. 122 West Seventy-first
Street.
The Doctor's Retort. — The Evening Post quotes the following from
the Lrwixton Journal: One of the brightest physicians of Portland and
one of the ablest theologians of Rath were in the physiological room at
Bowdoin Medical School, not long ago, examining, in company with
others, microscopic slides, showing certain peculiar glands of the intes-
tines. The physician at once launched out into a brilliant discussion of
the glands and their relation to various diseases. The theologian g ew
tired after a time, and finally said : " You doctors know so much about
the uncertainties of this world that I should think you would not want
to live." " You theologians," came the (puck reply, " tell us so much
about the certainties of the next that we don't want to die."
384
ITEMS.— LETTERS TO THE EDITOR.— PRO CEEDINOS OF SOCIETIES. [N. Y. Med. Jour.,
The New York Otological Society has recently been organized. The
meetings are held upon the third Tuesday of November, January, March,
and May. The work of organization was completed at a meeting held
on March 22d, at the house of Dr. Gotham Bacon, at which time the
following officers were elected: President, Dr. Albert II. Buck; vice-
president, Dr. Emil Greening; secretary, Dr. E. B. Dench. The first
regular meeting will be held on Tuesday, May 17th, at 8 p. m.
Army Intelligence. — Official List of Changes in the Stations and
Duties of Officers serving >'« 'he Medical Department, United State*
Army, from March 13 to March 26, 1892:
Town, Francis L., Lieutenant-Colonel and Surgeon, while on duty at
Headquarters, Department of California, in charge of the office of
the Medical Director, will, in addition to said duty, examine recruits
at the rendezvous in San Francisco, Cal.
De Witt, Theodore F., First Lieutenant and Assistant Surgeon, is
granted leave of absence to include May 16, 1892, at which date his
resignation has been accepted by the President to take effect.
Johnson, R. W., Captain and Assistant Surgeon. The leave of absence
granted for seven days is hereby extended fourteen days.
Munday, Benjamin, Captain and Assistant Surgeon, is granted leave of
absence for one month, with permission to apply for an extension of
one month.
Promotions.
Baii.y, Joseph C, Lieutenant-Colonel and Assistant Medical Purveyor,
to lie Surgeon, with the rank of Colonel, March 9, 1892, vice
Norris, retired from active service.
Woi.verton, William D., Major and Surgeon, to be Assistant Medical
Purveyor, with the rank of Lieutenant-Colonel, March 9, 1892, vice
Bailv, promoted.
Skinner, John 0., Captain and Assistant Surgeon, to be Surgeon, with
the rank of Major, March 9, 1892, vice Wolverton, promoted.
Appointments.
Winter, Francis A., of Alabama, to be Assistant Surgeon, with the
rank of First Lieutenant, March 9, 1892, vice De Iianne, retired from
active service.
Purviance, William E., of Illinois, to be Assistant Surgeon, with the
rank of First Lieutenant, March 9, 1892, vice Stcinmetz, retired
from active service.
Naval Intelligence. — Official L'ist of Changes in the Medical Corps
of the United States Navy for the week ending March 26, 1892 :
HoEtiLiNG, A. A., Medical Inspector. Ordered as President Naval
Medical Examining Board.
Neilson, J. L., Surgeon. Ordered as member and Recorder of Naval
Medical Examining Board.
Walton, T. C, Medical Inspector. Granted six months' extension of
leave, with permission to remain abroad.
Bagg, Charles Perry, of Los Angeles, California, commissioned an
Assistant Surgeon in the Navy.
Society Meetings for the Coming "Week :
Monday, April Jfth : New York Academy of Sciences (Section in Biolo-
gy) ; German Medical Society of the City of New York ; Morrisania
Medical Society (private) ; Brooklyn Anatomical and Surgical Soci-
ety (private) ; Utica Medical Library Association ; Corning, N. Y.,
Academy of Medicine ; Boston Society for Medical Observation ;
St. Albans, Vt., Medical Association (annual) ; Providence, R. I.,
Medical Association ; Hartford, Conn., Medical Society ; Chicago
Medical Society (annual).
TUESDAY, April 5th : Florida Medical Association (first day — Key West) ;
New York Obstetrical Society (private) ; New York Neurological So-
ciety ; Elmira, X. Y., Academy of Medicine; Buffalo Medical and
Surgical Association (private); Ogdensburgh, N. Y., Medical Asso-
ciation; Medical Societies of the Counties of Broome (quarterly) and
Niagara (quarterly — Lockport), X. Y. ; Hudson, N. J., County Medi-
cal Society (Jersey City) ; Essex, N. J. (annual — Newark) and Union,
X. J. (annual — Elizabeth), County Medical Societies; Androscoggin,
Me., County Medical Association (Lewiston); Chittenden, Vt., County
Medical Society ; Baltimore Academy of Medicine.
Wednesday, April 6th : Florida Medical Association (second-day) ; So-
ciety of the Alumni of Bellevue Hospital ; Harlem Medical Associa-
tion of the City of New York ; Medical Microscopical Society of
Brooklyn ; Medical Society of the County of Richmond (Stapleton),
N. Y. ; Bridgeport, Conn., Medical Association; Penobscot, Me.,
County Medical Society (Bangor); Philadelphia County Medical So-
ciety.
Thursday, April 7th: New York Academy of Medicine; Brooklyn Sur-
gical Society ; Society of Physicians of the Village of Canandaigua,
N.Y. ; Boston Medico-psychological Association; Obstetrical Society
of Philadelphia ; United States Naval Medical Society (Washington) ;
Washington, Vt., County Medical Society.
Friday, April 8th : New York Academy of Medicine (Section in Neu-
rology) ; Yorkville Medical Association (private) ; German Medical
Society of Brooklyn ; Medical Society of the Town of Saugerties, N. Y.
Saturday, April 9th : Obstetrical Society of Boston (private).
Answers to Correspondents :
No. 377. — An examination has to be passed. For particulars you
had better write to the Board of Regents of the University of the State
of New York, Albany.
No 378. — The organs removed were undoubtedly subject to the hus-
band's disposition.
gutters to tbe (£bitor.
AN IMPOSTOR.
56 East Twenty-fifth Street, New York, March 25, 1892.
To the Editor of the New York Medical Journal:
Sir: Some months ago a person calling himself Dr. Good-
man, and pretending to have been my schoolmate, friend, and
benefactor, succeeded in extracting various sums of money from
a number of professional men in several Western cities. His
method was to sell a gas-burner of his invention, but never to
deliver it. Dr. F. M. Bauer, of 225 East Eighty-sixth Street,
has informed me, in a letter dated yesterday, that a Dr. Good-
man tried the same game on him. I beg to notify the members
of the profession to be on their guard against this person, whom
I do not know, and who apparently is a common swindler!
Have him arrested. Arpad G. Gerster, M. D.
|3rocccbincjs of Societies.
NEW YORK ACADEMY OF MEDICINE.
Meeting of March 3, 1892.
The President, Dr. Alfred L. Loomis, in the Chair.
Cases of Appendicitis illustrating Different Forms of
the Disease, with Remarks. — Dr. Charles McBurney read a
paper with this title. He urged the importance of opening the
peritoneal cavity in cases in which this condition existed, differs!
ing in this respect with Treves, who was in favor of avoiding
such a procedure. There were cases, however, in which it was
preferable to avoid the danger of a peritoneal incision if it was
at all probable that the abscess would approach the surface,
especially in very fat persons, in the very old, and in the very
young. Cases were narrated illustrating the various complica-
tions that might accompany the disease. The author did not
believe that the temperature was a safe guide in determining
the severity of the disease. Thus it was not infrequently the
April 2, 1892.J "
PROCEEDINGS OF SOCIETIES.
385
case that the temperature would fall from 101° to 08° F., and a
recurrence of bad symptoms would indicate that an opera
tion was required. An incision having been made, it was not
always possible to see the diseased structures: the tinkers would
often discover the lesion when the eyes did not. If the adhe-
sions were very firm, they should be cut; those which were less
firm could be torn. A gangrenous condition of the tissues de-
veloped early in some cases, and this fact emphasized the neces-
sity of early operations. In other words, a diagno is having
been made early in the history of the disease, an operation must
be done early to insure success. Of fifty cases in which the
operation had been one of election, only one had resulted fatally.
Some writers had asserted the reliability of examination through
the rectum. This method was not approved of by the author.
It was not desirable to wait until perforation through the rectum
was imminent. Recurrent or relapsing appendicitis in patients
who had not been operated upon were of frequent occurrence,
one attack being frequently followed by others, and each being
more dangerous than the previous one, besides involving loss of
time, etc. Moreover, the recurrences might take place at a time
when surgical relief was not available. Operations in recurrent
attacks were likely to be much more difficult, and therefore
more dangerous, than under the primary conditions of the dis-
ease. It was not deemed advisable to operate while the patient
was suffering from shock, as in cases in which perforation had
occurred. It was well to wait until the patient had rallied, and
then perform the operation as quickly as possible The author
believed that the operation had established itself as a reliable
and justifiable procedure, and that it had been so established
more quickly than was usual with operations of equal magni-
tude.
Dr. Francis Delafield defined the province of the physi-
cian in the condition under discussion as that of making the
diagnosis and saying what should be done, while the surgeon
was to act upon the physician's recommendation. The respon-
sibility of the one differed from that of the other, and he be-
lieved that there might be an honest difference of opinion be-
tween the two attendants. He thought it probable that in some
of the cases that had been narrated permanent recovery would
have occurred if an operation had not been performed, but in
these doubtful cases he admitted that it was very difficult to
decide as to the proper course to pursue. It must also be ad-
mitted that after an operation the abdominal wall was weak-
ened on account of the presence of cicatricial tissue. If gan-
grene of the appendix was present, a fatal issue was inevitable,
unless an operation was performed. In such cases general sep-
sis occurred very quickly, the phenomena resembling those of
malignant diphtheria. In recurrent appendicitis the diagnosis
j was very difficult, and the question as to the propriety of oper-
ating could not be easily decided. He believed that many cases
in which the diagnosis was that of recurrent appendicitis were
not appendicitis at all. If there was perforation, an immediate
i operation was imperative, but in some cases he believed that
the area of perforation was quickly shut in by adhesions.
Dr. Lewis A. Stimson referred in a complimentary manner
to the services of the author of the yjaper in increasing our
i knowledge of the subject of appendicitis, and congratulated
him on the excellent results that had attended his efforts. He
thought there should be no question as to the propriety of oper-
i ating in cases of appendicitis, in view of the serious character
of the condition. There was still misunderstanding as to the
scope of the remedy which was proposed. The risks of the oper-
ation had been alluded to ; the risks of the disease should also be
seriously appreciated. The patients that died without operation
were not reported. Again, the merits of the operation were
too often judged by cases in whic h it had been delayed until
general peritonitis occurred. In cases in which a cure was sup-
pose I to be effected by medical treatment there was usually
only a temporary cessation of the condition. The only way to
be sure of the existing condition was to make an incision and
find out l>Y examination.
Dr. A Jacobi was not sure that a diagnosis in doubtful
cases should always be made by means of the cutting operation.
It was possible to make a diagnosis by other means. The ana-
tomical lesions causing the symptoms of appendicitis might be
various and might not always require an operation. There
were at least three conditions which presented similar symp-
toms— namely, perityphlitis, paratyphlitis, and appendicitis. If
all the customary symptoms were present with the exception of
swelling, an operation would be indicated. If swelling was
present at the outset of the disease, he would be inclined to
wait before advising an operation. In paratyphlitis the abscess
w as entirely outside the peritonaeum, and the appendix was not
involved. He had seen many cases of that character in which
recovery had occurred without an operation. The disease would
also differ with the age of the patient. In infants and children
the appendix was very large, and appendicitis was of common
occurrence. In the aged the appendix was small, and hence
with them appendicitis was relatively infrequent. Sonnenburg,
of Berlin, had advised operating very early in the history of
the disease, the tissues being divided only as far as the peri-
tonaeum, and a secondary operation being performed if the con-
dition required it. For doubtful cases it seemed to the speaker
that such a course was advisable.
Dr. F. P. Kinniodtt had seen thirteen cases of the disease
in the past twelve months, and some of them he had studied
from their very inception. Of these cases, resolution had taken
place in three without an operation, and in nine cases opera-
tions had been performed. In nine of the cases there had been
recurrent attacks, and he had reached the conclusion that in
catarrhal appendicitis recurrences were frequent and probable.
For such cases medical treatment was unavailing. If perfora-
tion occurred, there was usually severe pain with vomiting.
There might be a remission of the bad symptoms for twenty-
four hours, followed by recurrence The treatment of such
cases with laxatives was deemed unavailing and unwise; opium
might be given for the relief of the pain.
Dr. Robert Abbe believed that appendicitis began as a
catarrhal inflammation, and that gangrene was not the first
manifestation, though it might occur very quickly in the history
of the disease. lie believed that the condition was identical in
children and in adults. It had been stated by some writers that
suppuration did not occur in the recurrent conditions, but clini-
cal investigation did not sustain such a statement. He believed
that suppuration and a fatal issue might occur in such cases.
The gravest responsibility rested with the physician, who fre-
quently delayed in calling the surgeon to his assistance until the
disease was too far advanced to be curable. A period of qui-
escence might begin on the second day of the disease, when the
inflammatory mass had been shut in by plastic lymph. Subse-
quently this harrier was broken down and the severe symptoms
recurred, possibly with a fatal result. In some ot the cases in
which the speaker had operated he had found it advantageous
to make counter-openings in the loins, thus obtaining thorough
drainage. He concurred in the statement that purgation was
not to be recommended in this disease.
Dr. A. G. Gerster thought it was now admitted by phy-
sicians that early operations in appendicitis were or might be
necessary. Be concurred in the statement that those cases in
which swelling was prominent in the early history ot the disease
were not necessarily the ones to be operated upon. He saw no
reason why a diagnosis Hhould not be made by means of an ex-
386
PROCEEDINGS
OF SOCIETIES.
IN. Y. Mki>. Jouu.,
ploratory incision, just as it was made in other diseased condi-
tions. Like the author of the paper, he ohjected to operating
while the patient was ,in shock; it was better to wait until
the symptoms had improved. It was true that hernia was a
possible sequel to an operation, but such an accident could usu-
ally be obviated if special care was exercised. The operation
should not be performed by one who was without skill or ex-
perience in this line of work. The incision might be made in
the median line, and if this did not enable one to reach the ab-
scess, a second incision might be made in the loin.
Dr. W. II. Draper thought that the physician should have
the responsibility and direction of cases of appendicitis, the
surgeon being subject to his guidance. He appreciated the
statement that it was often very difficult to diagnosticate ap-
pendicitis, and there were several conditions which might be
confounded with it. Among such conditions might be men-
tioned salpingitis, oophoritis, and stricture of one or another
portion of the intestine. He admitted the value of exploratory
incisions for this disease, and believed that patients who re-
covered without an operation were very likely to be subject to
recurrence.
The President believed that patients might recover from
this disease without an operation and be free from recurrence.
This had been shown by post-mortem statistics. Clinically, one
should recognize mild cases and severe cases, and much was to
be learned in this particular from the aspect of the patient. He
believed that the first attack of the disease was usually mild;
subsequent ones might be more severe. With the first appear-
ance of sepsis or shock the assistance of the surgeon should be
sought. In genera], he would say that if improvement were not
apparent within forty-eight hours from the inception of the dis-
ease, consultation with a surgeon should be sought. Medical
treatment was not usually efficient in secondary attacks. As
long as induration in the diseased area was present there was a
condition of danger. If there was doubt as to the existing con-
dition of affairs an exploratory incision was indicated.
Dr. McBuexet admitted the possibility of hernia as a sequel
to an operation for appendicitis, but he thought that improved
methods of operating would overcome this objection. As to
the method of operating at two different periods, it was neither
new nor would it be generally useful. It had been practiced
years ago by the late Dr. Sands, and there were, many cases in
which the abscess was too deeply seated to be influenced by an
incision which extended only to the peritonaeum.
SECTION IN ORTnOP.EDIC SURGERY.
Meeting of February 19, 1892.
Dr. Henry Ling Taylor in the Chair.
Rotary Lateral Curvature of the Spine after Empyema
and Poliomyelitis. — Dr. W. li. Townsend presented a girl,
fourteen years of age, with rotary lateral curvature of the spine.
At the age of three years, and after whooping-cough, she had had
an empyema on the left side, which had opened spontaneously.
The sinuses had continued to discharge for five year?, and the
three cicatrices — one to the left of the nipple and two slightly
below and to the right — showed the points where the openings
had occurred. When she was five years old, it had been no-
ticed one morning that there was a complete loss of power in
the left upper extremity. The mother said there had never been
any curvature of the spine before the attack of paralysis, al-
though the child had always slept on the left side, and the
curvature had been steadily increasing since then. The circum-
ference of the chest at the nipples was twenty-four inches, the
right side measuring fifteen, and the left nine inches. There
was a very marked lateral rotary doviation of the spiual column
to the right, extending from the seventh cervical to the tenth
dorsal, with compensating curves above and below. There was
no torticollis. The breathing space was good, considering the
amount of the deformity. The heart was not displaced. There
was complete loss of reaction to faradism in the left supraspinatus
and infraspinatus and in the deltoid, and a reversal of the formu-
la with the galvanic current. There was no amesthesia, but
marked atrophy of the shoulder and upper left arm. There was
a partial loss of reaction in the pectoral, but the biceps, triceps,
and forearm muscles reacted well. The interesting feature was
the relation of the rotary curvature to the empyema and the
poliomyelitis. The speaker's opinion was that the empyema
had probably caused a slight curvature, and that the paralysis
had helped to increase it, but that there was no connection be-
tween the empyema and the paralysis ; in' other words, the pa-
ralysis was not produced by the scoliosis, but was separate and
distinct and due to a poliomyelitis. He had presented the case
chiefly because it was of interest in connection with the first
paper announced for the evening.
Dr. Royal Whitman also presented a little girl as an illus-
tration of a pure rotary lateral curvature caused by anterior
poliomyelitis.
Dr. H. W. Berg said that he had had an opportunity of see-
ing this patient, and had obtained a somewhat different history.
According to this version, the patient was still in bed with the
empyema when the family first noticed that she was lying more
upon the left side. The occurrence of the paralysis had been
sudden, and the attending physician had allowed her to get out
of bed, and at this time the extreme lateral curvature had first
been noticed. If this curvature was the result of the poliomye-
litis, it would not have been so extreme at this early stage, for
it took time for muscles to contract and cause deformity. In
this case the paralyzed muscles were on the left side of the
body and the primary curve toward the right, while in cases of
lateral curvature due to paralysis the healthy muscles must
necessarily be on the concave side of the deformity. The only
way in which poliomyelitis could possibly produce a curvature
on the concave side of the deformity would be in the third
stage of this disease — i. e., in the third or fourth year after the
paralysis, when the muscles began to contract into firm fibrous
cords.
Dr. Royal Whitman thought that, if the long supporting
muscles were paralyzed, it might be as the previous speaker
had said ; but in these cases where only the muscles supplying
the shoulder were paralyzed, one would expect the curvature to
be toward the opposite side.
Dr. Berg replied that the intrinsic muscles were not alone
paralyzed in this case. Lateral curvature must follow contrac-
tion of the intrinsic muscles of the spine, and not of the long
muscles.
Dr. R. H. Sayre had seen a number of cases of lateral curva-
ture dependent upon poliomyelitis with paralyses of the external
muscles on the concave side, and hence, he thought, the state-
ment that the convexity was always on the side of the paralyzed
muscles could not be accepted without qualification. He had
been surprised that German writers took it for granted that
empyema curves were not rotary.
Dr. S. Ketch was not prepared to indorse the view that the
curvature was mainly due to the empyema; on the contrary, he
thought the patient had that form of curvatnre usually found as
a result of anterior poliomyelitis. Undoubtedly the empyema
tended to exaggerate this curvature.
Dr. N. M. Shaffer said that, so far as he knew, the first re-
ported case of lateral curvature due to poliomyelitis had been
published in his book in 1876 or 1878. That case had been ex-
amined by Dr. Seguin, Dr. Draper, and himself, and they had
April 2, 1892.]
PROCEEDINGS
OF SOCIETIES.
387
found the paralysis on the hollow side. On general principles,
he believed that Dr. Berg was correct in his statement. In 1881
he hail called attention to the fact that a rotary element existed
in empyematous curves. It was exceptional for him to find a
lateral curvature of the spine, due to empyema, which was not
associated with a greater or less degree of rotation. The error
probably arose from the fact that Dr. W. J. Little, of London,
who had first described it, had made this mistake, and other
writers had perpetuated the error.
Dr. Mary Putnam Jacobi called attention to the monograph
by Enlenberg on lateral curvature of the spine, in which he
stated very categorically that in ordinary typical cases of lateral
curvature the muscles on the concave side were necessarily the
stronger, and explained on this principle the mechanism of the
production of lateral curvature. His idea was that it was due
to a disturbance in the balance of the muscles of the two sides,
whether extrinsic or intrinsic.
Dr. A. 13. Jt'DSON said that in his earlier studies of lateral
curvature he had adopted, without due verification, the state-
ment of foreign observers that rotation was absent from the
curvature caused by pleural disease. At present he believed
. that it did not occur, but in a very modified and unimportant
degree. The collapse of the chest wall would weaken the action
of some of the muscular and fibrous structures which caused
rotation by holding the spinous processes nearer the median
line than the bodies of the vertebras. For this reason we might
well expect the rotation to be less marked. In the case shown
there was little difference in the diagonal diameters, which was
the chief feature of rotation, and was caused, in an ordinary
case, by the prominence, posteriorly, of the right back of the
chest, and the complementary prominence, anteriorly, of the
left front of the chest. Here we had prominence before and
behind on the right side, and depression before and behind on
the left side, with but little difference in the diagonal diameters,
a condition very unlike the effect of rotation. Still there might
be, and probably was, some rotation in the vertebral column of
this patient, although its effect on the deformity was not easily
recognizable.
Dr. Townsend said that, owing to the fact that in this case
one was compelled to rely wholly upon the varying statements
of the parents of the child, who were not very close observers,
it would be well to be cautious in drawing conclusions from a
study of this case alone. He did not agree with Dr. Berg as to
the relation of the paralyzed muscles to the concave side.
Voluntary Subluxation of the Knee produced by Mus-
cular Action.— Dr. R. H. Satre showed a child of fourteen
months presenting this condition. The mother had first noticed
this condition when the child was eight months old. When he
was excited, the right knee was pushed in and out with a dis-
tinct click. The child had been born after a normal labor, and
there was no history of injury. The speaker proposed to apply
a splint, in order to retain the knee in position.
An Appliance for the Prevention of Deformity in Hip
Disease. — Dr. Whitman presented a case illustrating this ap-
pliance. He believed that the long traction brace was the mosi
useful appliance in these cases, for it assured as a perineal
crutch a protection which could not be removed by the patient.
This was the principal objection to any brace which depended
on axillary crutches for its usefulness. Simple fixation of the
joint, allowing the patient to walk about on the affected limb,
as practiced by Thomas and others, did not afford this protec-
tion, which he considered the most important element in the
treatment of any joint affection. On the other hand, with the
simple long traction brace, gradual and increasing flexion of the
leg was a very common and troublesome complication. This
was the weak point of the brace, and the one most constant lv
attacked by its opponents. He had therefore attempted to com-
bine the merits of two braces as follows: The limb having been
brought into perfect position, a slender steel bar, attached above
to an encircling thoracic band and terminating just above the
knee in a thigh band, was closely applied along the posterior
aspect of the joint, after the manner of Thomas. The long
traction brace was then applied as usual. Thus flexion was pre-
vented and additional fixation assured, combined with effective
protection, By dividing the function of the two braces, the
posterior or miniature Thomas brace could be made very light
and comfortable; it, however, was not to be used as a lever to
correct deformity. This should first be overcome by traction in
bed or otherwise. He believed this division of labor to he more
practicable than the addition of perineal bands and traction to
the ordinary Thomas brace, as suggested by Lovett and De Pass.
Dr. Judson commended the use of one apparatus, the hip
splint, to protect the joint, and another, the antero-posterior
lever, if apparatus was necessary for this purpose, to oppose
flexion. In general, it was better not to attempt too many
things with one and the same apparatus. He thought the antero-
posterior lever, for combating flexion and maintaining fixation,
was the essential element of the Thomas splint.
Dr. Shaffer said that where supplementary apparatus was
employed to limit the motion of the dorso-lumbar spine and the
motion on the acetabulum, unnecessary traumatism was in-
flicted upon the acetabulum. He had studied this subject quite
closely, and, in his opinion, this motion of the dorso-lumbar
spine was one of the greatest aids in the treatment of this con-
dition. It was better to treat flexion by recumbency and rest
until the flexion was overcome, than to apply an apparatus
which antagonized the very strong action of the flexor muscles.
Dr. Whitman said he recognized the force of what Dr.
Shaffer had said about the flexibility of the lumbar spine, but
he was inclined to think that the motion of the diseased joint
which the simple traction brace permitted, and the deformity
which it did not prevent, were more important considerations
than the theoretical objection which Dr. Shaffer had presented.
This fixation apparatus was applied before there was any flex-
ion, and in the case presented there was no spasm of any of the
muscles.
Does Scoliosis ever give rise to Pressure Myelitis? —
Dr. H. W. Berg read a paper with this title.
Dr. R. H. Sayre thought there was no doubt that the differ-
ences in mammary development observed in cases of rotary
lateral curvature were the result of trophic change, but the
cause of this disturbance was still uncertain. In advanced
cases he had been inclined to attribute this disturbance to
pressure on the nerves at their exit from the bony canal.
Pathological specimens showed not only a narrowing of the
bony canal, but also large exostoses at the points where the
vertebra} joined ; it was quite possible that these might project
inward as well as outward. The case described in the paper
had at one time been under his care, and he had considered it
as closely resembling disseminated sclerosis, although it was not
typical of any diseased condition with which he was familiar.
Dr. Spitzka had held the same position The case had been
diagnosticated as lateral sclerosis by one neurologist, and as
hysteria by another eminent neurologist, who had employed
hypnotism upon the patient, though unsuccessfully. She had
been referred to the speaker with the idea that there was some
pressure on the cord at about the tenth dorsal vertebra, which
might possibly be relieved by a surgical operation. He had
been unable, however, to detect any mass pressing upon the
cord, and, from the effects of momentary suspension, he did not
think this method of treatment would prove beneficial. He did
not associate the cord lesion with the lateral curvature. The
388
BOOK NOTICES.
[N. Y. Med. Joob.,
tropliic changes were probably due to disturbance of nutrition
external to the cord.
Dr. Shaffek considered that the author's case of lateral
curvature differed only in degree from almost every case of this
condition. It was rare to find lateral curvature without an ex-
aggerated tendon reflex, a non-deforming club-foot, or various
trophic changes, and the latter occurred in incipient cases, be-
fore there could be any pressure on the cord. Girls suffering
from lateral curvature were usually peculiarly nervous, and
oftentimes seemed to assume the responsibilities of their entire
family. This was the direct result of the central nervous lesion —
one which pertained more to the psychical condition than to the
spinal-cord condition. Our clinical studies drove us by analogy
to look in the motor tract of the brain for the cause of the con-
dition.
Dr. Ketch looked upOn the trophic changes as an element in
the astiology of lateral curvature, rather than the result of this
condition. It was probable that, at a very early period in life,
there was a disturbance of the nervous system, most probably
of the brain, which produced the lateral curvature. Hoys hav-
ing lateral curvature showed atrophy of the limbs, but the gen-
eral nervousness was not so marked. For example, he had at
present under observation a robust boy, fifteen years old, with
lateral curvature, who was supernaturally strong and supernatu-
rally slow and apathetic. He thought it highly improbable that
pressure myelitis ever occurred in these cases.
Dr. L. W. Hubbard could not understand how the paraple-
gia of Pott's disease could be said to be due to cord pressure
from change of position, as clinically it seemed to bear no rela-
tion to the amount of curvature or the situation of the lesion,
and it was present when there was no curvature, and, moreover,
recovery took place without any change in the curve of the spine.
He saw nothing in the case reported analogous to the myelitis
of Pott's disease.
Dr. Judson would eliminate muscular contraction as a factor
in the causation of lateral curvature, believing that rotation and
the curvatures, primary and secondary, were only the mechani-
cal result of muscular failure to sustain the weight of the trunk.
He would welcome with extreme pleasure any advance in our
exact knowledge of the aetiology of lateral curvature.
Dr. V. P. Gibnet had never seen pressure myelitis iu an un-
complicated case of rotary lateral curvature.
The Chairman agreed with Dr. Hubbard that the analogy of
the case under discussion to the myelitis of Pott's disease was
not very strong, as, according to the view advanced by Dr.
Hoffa at the last meeting of the American Orthopaedic Associa-
tion, and generally accepted by those present, the paraplegia
was due to the pressure of inflammatory products. Personally,
he had never seen a case of lateral curvature complicated by
paraplegia or symptoms of lateral sclerosis. Last autumn lie
had had a case of very moderate curvature, with a very peculiar
ataxic gait, but a careful examination had excluded organic dis-
ease of the spinal cord, and it had been decided to be a case of
functional nervous disturbance, possibly produced by masturba-
tion. It seemed strange that such a mild case as the one de-
scribed in the paper should produce such marked nervous symp-
toms, while the much more severe cases so often seen had no
analogous symptoms. He looked upon the cord lesion as merely
a coincidence.
Dr. Hero thought the diagnosis of disseminated sclerosis
very improbable, and this diagnosis had probably been made
because a primary sclerosis of the cord was such a rare condition
that whenever a neurologist saw a spastic paralysis in an adult
and could find no cerebral symptoms, or symptoms of pressure
upon the cord, he made a diagnosis of disseminated sclerosis.
Dr. S. W eir Mitchell had given it as his opinion that the case
was one of primary lateral sclerosis. There was no doubt as to
the sclerosis and the lateral curvature; the only doubt was as to
the connection between the lateral curvature and the sclerosis.
Pott's paraplegia was caused by a variety of conditions, but he
believed that in nearly seventy-five per cent, of the cases the
paraplegia was due to pressure resulting from flexion of the cord
at the angle of the curve. He had no doubt that hundreds of
cases had been seen where the lateral curvature had been con-
sidered the result of paralysis, where it was really the cause.
Femoral Abduction, Adduction, and Flexion.— Dr. Hud-
son presented a convenient method of observing the degrees of
motion in cured and convalescing cases of hip disease. The sub-
ject was illustrated by boards on which dolls were fixed, the
center of motion at the hip in each case being surrounded by a
graduated arc. with the degrees numbered from zero, in the
natural posture of supine recumbency, with a slight lordosis, up
to the widest limit of normal motion. In practice the retrion of
motion was first to be found, and then the extent to which it
might be pushed, without disturbing the natural and symmetri-
cal position of the lumbar vertebra? and the iliac spines, was to
be noted on the goniometer. The degrees of motion in flexion
and laterally might thus be readily recorded. The presence of
considerable motion warranted a serious effort to reduce what-
ever deformity might exist. He cited two cases in which the
patients, being considered cured, relief had been sought for the
deformity. Enough motion had been found to encourage hope,
and good results had been recorded in a few months in each
case after the application of a hip splint, and, later, a -imple
ischiadic crutch, and the return of the patient by instruction and
drill to the natural rhythm of walking. The improvement had
been readily measured in degrees, from time to time, and the
deformity had been almost completely reduced.
A New Method of making Plaster Casts of the Thorax
in Cases of Rotary Lateral Curvature.— Dr. Mary Pi t n am
Jacobi exhibited a series of models which she had prepared by
an original method. It had been suggested to her by observa-
tions made with the cyrtometer upon the condition of the thorax
after empyema. An outline of the thorax at the desired level
was first taken with a cyrtometer (which was an instrument
consisting of two soft strips of lead united by a hinge), which
was placed over the vertebral column, and the lead strips closely
applied to the chest walls. The lead was next placed upon a
slab of marble, where it served as a sort of shallow frame, into
which the plaster-of-Paris cream was poured and allowed to set.
This gave practically a thin plaster cast, representing a section
of the thorax. She called attention to the ease with which the
diagonal diameter could be obtained, and also to the way in
which these casts brought out small degrees of curvature.
^ooli Boticcs.
A Treat m- on the Ligation of the Great Arteries in Continuity.
With Observations on the Nature, Progress, and Treatment
of Aneurysm. By Charles A. Ballance, M. B., M. S. Lond.,
F. R. C. S., Assistant Surgeon to St. Thomas's Hospital, etc.,
and Walter Edmunds, M. A., M. C. Cantab., Resident Medi-
cal Officer. St. Thomas's Home. Illustrated by Ten Plates
and Two Hundred and Thirty-two Figures. London and
New York: Macmillan & Co., 1891. Pp. xxviii to 568.
[Price, $10.]
It is rare that the medical reader is offered a volume so ele-
gantly prepared as this is; but a slight widening of the page
April 2, 1892.]
BOOK NOTICES.
389
margins, and another quality of paper, and this work, with its
delightfully distinct typography, its numerous and excellent
illustrations and plates, would be the peer of any edition de luxe.
It is a pleasure to commend the enterprise of the publishers in
these particulars, and the character of the work done by the
authors justifies such a presentation of their topic. For seven
years Mr. Ballance and Mr. Edmunds have been engaged in the
researches on which this volume is founded, and they conclude
that in ligation in continuity, in experimental work as well as in
human surgery, "the method of rupture leads, with certain ar-
teries, almost inevitably to the dread sequel of haemorrhage and
death ; and, further, that the rise of Listerian surgery has not
abolished the danger." This last statement will probably be a
Surprise to some surgeons and will be questioned by others.
And yet the various statistics published during the past decade
seem to substantiate the statement, and Billroth is quoted as
stating that the statistics of haemorrhage after ligation in con-
tinuity probably understate the case.
As a preliminary study of the subject the authors investi-
gated the physiological occlusion of arteries occurring in the cir-
culatory changes at birth and the pathological occlusion that
happens in certain diseases. In the former instance they show
that Nature does not think it necessary, when occluding the
ductus arteriosus, to rupture the inner coats of that vessel, and
that it is not divided in order to reduce the longitudinal tension ;
and yet it is rare that failure to occlude occurs, and haemorrhage
is unknown. So, in pathology, a vessel may be obliterated with-
out either of those supposed necessary features being called into
play.
It is demonstrated that the plasma cells of the arterial wall,
and not the leucocytes of the blood, form the scar tissue that
occludes the artery, and the authors' experiments corroborate
Ziegler's to the effect that the connective-tissue corpuscles are
the sole active agents in the formation of cicatricial tissue, the
Jeucocyte possessing no fibroblastic power. They found that
one of the first results of ligation was a multiplication of the
endothelial cells to twice or three times their usual depth; soon
the connective-tissue corpuscles in the middle coat became
active and subdivided, and the daughter cells of these corpuscles
passed through the openings in the membrane of Henle and
entered the clot that had formed in the artery. The red
corpuscles at the periphery of the clot first lost their sharp-
ness of outline, breaking down into granular masses and
becoming oval or fusiform, while those at the* center of the
clot retained their appearance and shape for a considerable
time. Fibrin nodes were formed, about which the invad-
ing plasma cells formed islets from which elongated cells
were thrown out, uniting with similar processes from other
islets. About the fourth week capillaries appeared in the
clot, and ultimately the artery became converted into a mere
cord of fibrous tissue. This result refutes Bruns's statement
that clotting does not take place unless the coats of the artery
are ruptured.
They quote from Pare, Monro, Heister, Platner, Bell, John
Hunter, and Scarpa to show that these fathers in surgery did
not advocate rupture of the internal walls. And to Abernethy
they attribute the renaissance of the operation of Celsus, and to
Jones the prevalent idea of the necessity of rupturing the inter-
nal walls in ligation in continuity.
Their experiments show that the ligature selected should bo
round, smooth, strong, inelastic, pliable, and not easily absorbed.
Even chromated catgut ligatures were easily penetrated by the
leucocytes and plasma-cells, the intestinal villi facilitating their
entrance into and consequent softening of tho ligature. But in
kangaroo tendon its homogeneity permitted its absorption from
the surface only. Next to kangaroo tendon, ox peritonaeum,
boiled floss silk, and silkworm gut proved to be most suitable
for ligatures.
In tying the ligature they consider that the reef, granny, or
surgical knot may be converted into a slip knot, and they advise
a stay knot formed by two or more ligatures tied separately, as
in the first half of a reef knot, and then completed by all the
ends on each side being tied as in completing a reef knot. The
force to be employed in tying the ligature is about the same
whatever material is used, and averages about a pound of trac-
tion to occlude the vessel without rupture.
In seventy-one experiments on sheep, asses, and horses of
ligature of arteries under strict antiseptic precautions they found
that the vessels could be permanently occluded without rupture
of their coats, and that secondary haemorrhage did not occur if
a suitable ligature was tied in a suitable knot with appropriate
force.
The concluding chapter, on the conduct of the operation and
the fate of the patient, is one that will prove of interest to all
surgeons.
Surgical Anatomy for Students. By A. Marmaduke Sheild,
M. B. (Cantab.), F. R. 0. S., Senior Assistant Surgeon, Aural
Surgeon, and Teacher of Operative Surgery, Charing Cross
Hospital. New York : D. Appleton & Co., 1891.
This little volume is based upon a series of demonstrations
that the author has delivered to his students, and, as it is to be
used with the living body, it will be found particularly service-
able to students for the purpose of demonstration. The various
chapters treat of the different surgical regions of the body, and
the practical considerations in each include allusions to the
more frequent operations and injuries. It is a compact and
satisfactory manual.
BOUKS, ETC., RECEIVED.
The Principles and Practice of Medicine. Designed for the Use of
Practitioners and Students of Medicine. By William Osier, M. D., Fel-
low of the Royal College of Physicians of London ; Professor of Medi-
cine in the .Tohns Hopkins University and Physician-in-chief to the
Johns Hopkins Hospital, Baltimore. New York : D. Appleton & Co.,
1892. Pp. xvi to 1079. [Price, $5.50.J
A System of Practical Therapeutics. Edited by Hobart Amory
Hare, M. D., Professor of Therapeutics and Materia Medica in the Jef-
ferson Medical College of Philadelphia. Assisted by Walter Chrystie,
M. D., formerly Instructor in Physical Diagnosis in the University of
Pennsylvania. Vol. II. Fevers — Diseases of the Respiratory System,
Circulatory System, and Haematopoietic System — Diseases of the Digest-
ive System. With Illustrations. Philadelphia : Lea Brothers & Co.,
1892. Pp. 6-17 to 1158.
A Practical Manual of Diseases of the Skin. By George H. Rohe,
M. D., Professor of Materia Medica, Therapeutics, and Hygiene, and
formerly Professor of Dermatology in the College of Physicians and
Surgeons, Baltimore. Assisted by J. Williams Lord, A. B., M. D., Lect-
urer on Dermatology and Bandaging in the College of Physicians and
Surgeons, Baltimore. Philadelphia and London : The F. A. Davis Co.,
1892. Pp. viii to 303. [No. 13 in the Physicians' and Students Ready
Reference Series.]
The Mediterranean Shores of America. Southern California : its
Climatic, Physical, and Meteorological Conditions. By P. C. Remondi-
no, M. D., Member of the American Medical Association, etc. Fully
illustrated. Philadelphia and London: The F. A. Davis Co., 1892.
Pp. xiv to 160.
Abdominal Surgery. By J. Greig Smith, M. A., F. R. S. E., Surgeon
to the Bristol Royal Infirmary ; Lecturer on Surgery, Bristol Medical
School, etc. Fourth Edition. Philadelphia: P. Blakiston, Son, & Co.,
1891. Pp. xviii to 800.
Lectures on Pathology delivered at the London Hospital by the late
Henry Gawen Sutton, M. B., F. R. C. P., Physician and Lecturer on Pa-
390
BOOK NOTICES.
[N. Y. Med. Jocr.,
thology at the London Hospital, etc. Edited by Maurice Eden Paul,
M. D., and revised by Samuel Wilks, M. D., LL. D., F. R. 8. Philadel-
phia: P. Blakiston, Son, & Co.. 1891. Pp. xviii to 503.
Practical and Analytical Chemistry. A Complete Course in Chemi-
cal Analysis. By Henry Trimble, Ph. M., Professor of Analytical
Chemistry in the Philadelphia College of Pharmacy. Fourth Edition.
With Illustrations. Philadelphia : P. Hlakiston, Son,& Co., 1892. Pp.
xiii-17 to 119.
The Book of Prescriptions, containing upward of 3,000 Prescrip-
tions collected from the Practice of the most Eminent Physicians and
Surgeons, English and Foreign ; comprising also a Compendious His-
tory of the Materia Medica, Lists of the Doses of all Official or Estab-
lished Preparations, and an Index of Diseases and Remedies Bv Henry
Beasley. Seventh Edition. Philadelphia : P. Blakiston. Son, & Co.,
1892. Pp. xx to 599.
A Manual of Diseases of the Nervous System. By W. R. Cowers,
M. D., F. R. C. P., F. R. S., Consulting Physician to University College
Hospital, etc. Second Edition, revised and enlarged. Volume 1. Dis-
eases of the Nerves and Spinal Cord. With One Hundred and Eighty
Illustrations, including Three Hundred and Seventy Figures. Philadel-
phia: P. Blakiston, Son, & Co., 1892. Pp. xvi to 616.
A Manual of Autopsies. Designed for the Use of Hospitals for the
Insane and other Public Institutions. By I. W. Blackburn, M. D., Pa-
thologist to the Government Hospital for the Insane, Washington, D. C.
Illustrated. Philadelphia: P. Blakiston, Son, & Co., 1892. Pp. x-17
to 84.
The Pathology and Prevention of Influenza. By Julius Althaus,
M. D., M. R. C. P. Lond., Senior Physician to the Hospital for Epilepsy
and Paralysis, Regent's Park. New York : G. P. Putnam's Sons, 1892.
Pp. 7 to 64.
Epidemic Influenza: Notes on its Origin and Method of Spread.
By Richard Sisley, M. D., Member of the Royal College of Physicians of
London. London: Longmans, Green, & Co., 1891. Pp. xi to 150.
Traite elinique et therapeutique de l'hysterie d'apres l'enseignement
de la Salpetriere. Par le Docteur Gilles de la Tourette, ancien chef
de elinique des maladies du systeme nerveux a la Salpetriere. Preface
de M. le Dr. J. M. Charcot, Professeur de elinique des maladies du sys-
teme nerveux, raembre de l'institut. Hysteric normale ou interparoxy-
stique. Avee 46 figures dans le texte. Paris: E. Plon Nourrit et cie.,
1891. Pp. xv to 582.
Lehrbuch der Hebammenkunst. Von Dr. Bernhard Sigmund
Schultze, Geheimhofrath off. ord. Prof, der Geburtshulfe, etc. Zehnte
Aufiage. Mit 98 Holschnitten. Leipzig: Wilhelm Engelmann, 1891.
Pp. xxiii to 380.
Official Transactions of the National Association of Railway Sur-
geons, 1891.
Transactions of the New Hampshire Medical Society at the Centen-
nial Anniversary, held at Concord, June 15, 16, and 17, 1891.
A Study of the Sputum in Pulmonary Consumption. By E. L.
Shurly, M. D., Detroit, Mich. [Reprinted from the Climatologlft.]
Inaugural Address to the Physiology Class in Anderson's College.
Session 1891-'92. By D. Campbell Black, M. D. Glasgow: Hugh
Hopkins.
Obstetric Problems : Being an Inquiry into the Nature of the Forces
determining Head Presentations, Internal Rotation, and also the De-
velopment of the Amnion. By D. T. Smith, M. D., Louisville, Ky.
With Illustrations. Louisville: John P. Morton & Co., lS'.rj.
Observation and Experiment in Phthisis. A Reply to Professor
Tyndall. By Thomas J. Mays, M. I)., Philadelphia. [Reprinted from
the Climatologist.]
A Study of the Processes which result in the Arrest or Cure of
Phthisis. By Henry P. Loomis, M. I)., New York. [Reprinted from
the Medical Ilceord.]
On the Collection of Samples of Water for Bacteriological Analysis.
By Wyatt Johnston, M. Yk, Montreal. [Reprinted from the Canadian
Jtecord of Science.]
Nomenclature of Diseases to be followed by Physicians in the In-
dian Service in making Reports to Indian Office. Washington: Gov-
ernment Printing Oflice, 1892.
A Quarter of a Century's Retrospect of Laryngology. By Lennox
Browne, F. R. C. S. Ed. [Reprinted from the Journal of Laryngology,
Rhinology, and Otology. \
A Statistical Review of the Proportion and Cause of Blindness in
Thirty-two Thousand Eyes consecutively treated in the Jefferson Col-
lege Hospital. By Howard F. Hansell, M. D., and James H. Bell, M. I).,
Philadelphia. [Reprinted from the A rehire* of ( )phth<dmoloijy.]
The Therapeutic Aspect of some Ovarian Disorders. By Edward
W. Jenks, Iff. D., LL. D., Detroit, Mich. [Reprinted from the Tranx-
actions of the American (1 ynaioloyical Society.]
The Bicycle in the Treatment of Nervous Diseases. By Graeme M.
Hammond, M. D., New York. [Reprinted from the Journal of Nervoilk
and Mental Disease.]
Seventh Annual Report of the New York Post-graduate Hospital
(and the Babies' Wards) for the Year ending September 15, 1891.
Third Annual Report of the Babies' Hospital of the City of New
York.
Annual Report of the Board of Managers of the Maryland Hospital
for the Insane, November, 1891.
Fourteenth Annual Report of the Presbyterian Eye, Ear, and Throat
Charity Hospital, Baltimore.
Additional Report of the Commissioners of Capital Punishment of
the State of New York. Transmitted to the Legislature January 19,
1892.
Transactions of the American Association of Obstetricians and
Gynaecologists. Vol. IV. For the Year 1891. Philadelphia: W.J.
Dornan, 1892.
Some Points in the Diagnosis and Nature of Certain Functional and
Organic Nervous Diseases. By J. T. Eskiidge, M. D., Denver, Colorado.
[Reprinted f rom the Alienist and Neurologist. \
Subacute Recurrent Multiple Neuritis. By J. T. Eskridge, M. D.,
Denver, Colorado. [Reprinted from the Journal of Nervous awl Mental
Disease.]
The Indications for Colotomy. By Charles B. Kelsey, M. D., New
York. [Reprinted from the Therapeutic Gazette.]
Transactions of the American Surgical Association. Volume the
Ninth. Edited by J. Ewing Mears, M. D. Philadelphia: William J.
Dornan, 1891.
Transactions of the American Otological Society. Twenty-fourth
Annual Meeting. Arlington House, Washington, D. O, September 22,
1891. Vol. V. Part I.
A Text-book of Nursing, for the Use of Training Schools, Families,
and Private Students. Compiled by Clara S. Weeks-Shaw. Second
Edition, revised and enlarged, with Illustrations. New York : D. Ap-
pleton & Co., 1892. Pp. 8-11 to 391. [Price, $1.75.]
The Pocket Pharmacy, with Therapeutic Index. A Resume of the
Clinical Applications of Remedies adapted to the Pocket-case, for the
Treatment of Emergencies and Acute Diseases. By John Aulde, M. D.,
Member of the American Medical Association, of the Medical Society
of the State of Pennsylvania, etc. New York : D. Appleton & Co.,
1892. Pp. 16-17 to 204. [Price, $2.]
The Year-book of Treatment for 1892. A Critical Review for
Practitioners of Medicine and Surgery. Philadelphia : Lea Brothers &
Co., 1892. Pp. vii to 486.
The Miitter Lectures on Surgical Pathology. Delivered before the
College of Physicians of Philadelphia, 1890-'91. By Roswell Park,
A. M., M. D., Professor of Surgery, Medical Department, University of
Buffalo. [Reprinted from the Annals of Surgery.]
Traiteraent des maladies de la peau. avec un abrege de la symp-
tomatologie, du diagnostic et de l'etiologie des dermatoses. Par le Dr.
L. Brocq, Medecin des hopitaux de Paris. La partie pharmacologique a
ete revue par M. L. Portes, Pharmacieu en chef de l'Hopital Saint-
Louis de Paris. Deuxieme edition, corrigee et augmentee. Paris :
Octave Doin, 1892. Pp. ix-894. [Prix, 15 francs.]
Traite de medecine. Public sous la direction de MM. Charcot, Pro-
fesseur de elinique des maladies nerveuses a la Faculte de medecine de
Paris; Bouchard, Professeur de pathologie generate a la Faculte de
medecine de Paris, et Brissaud, Professeur agrege a la Faculte de
medecine de Paris. Par MM. Babinski, Ballet, Brault, Chantemesse,
Charrin, Chauffard, Gilbert, Guinon, Legendre, Marfan, Marie, Mathieu,
Netter, Oettinger, Andre Petit, Richardiere, Roger, Ruault, Thibierge,
April 2, 1892.
NEW INVENTIONS.— MISCELLANY.
391
Thoinot, Fernand Widal. Tome XI. Par MM. L.-H. Thoiaot, Louis
Guinon, (J. Thibierge, A. Gilbert, Richardiere. A vet figures dans le
texte. Paris: G. Masson, 1892. Pp. 678.
A Human Embryo Twenty-six Days Old. By F. Mall. [Reprinted
from the Journal of Morphology.]
Ueber Hypertrichosis auf pigmentirter Haut. Von Dr. Max
Joseph, in Berlin. [Sonderabdruck aus Berliner klin. Wochen-
tehrift.]
Abdominal and Uterine Tolerance in Pregnant Women, as
shown by the Low Rate of Mortality under Severe Lacerated
and other Wounds, the Result of Diieet Violence. By Robert
P. Harris, A. M., M. D., Philadelphia.
The Lumbar, the Sacral, and the Coccygeal Nerves in the Domestic
Cat. By T. B Stowell, A. M., Ph. D., Principal of the State Normal
and Training School at Potsdam, X. V. [Reprinted from the Journal
of Comparative Neurology.]
Acute (Edema of the Larynx, with the Report of a Case resulting
from Pyamia. By .1. ii. Bryan, M. D., of Washington, D. C. [Re-
printed from the Medical News.]
Rupture of the Sac of an Extra-uterine Pregnancy through the Fim-
briated Extremity without tearing the Falloppian Tube. Operation,
Recovery. By Hunter Robb, M. D., Baltimore, Md. [Reprinted from
the New York Journal of Gynecology and Obstetrics.]
Clinical Report of Six Surgical Cases. By George W. Cale, M. D.,
St. Louis, Mo.
Subglottic Neoplasms. By Jonathan Wright, M. D., Brooklyn.
[Reprinted from the Journal of the American Medical Association.]
A Case of Primary Lupus of the Pharynx. By Jonathan Wright,
M. D., Brooklyn. [Reprinted from the Medical Nam.]
Another Method for Palpation of the Kidney. By Robert T. Morris,
M. D., New York. [Reprinted from the Transactions of the American
Association of Obstetricians and Gynaecologists.]
The Prevention of Secondary Peritoneal Adhesions by Means of an
Aristol Film. By Robert T. Morris, M. D., New York. [Reprinted
from the Transactions of the American Association of Obstetricians and
G-yneecolog ists. ]
Contributions to the Physiology and Pathology of the Nervous Sys-
tem. From the Private Laboratory of Dr. Isaac Ott, Easton, Pa. [Re-
printed from the Journal of Nervous and Mental Disease.]
The Morphological Importance of the Membranous or other Thin
Portions of the Parietes of the Encephalic Cavities. By Burt G.
Wilder, M. D. [Reprinted from the Journal of Comparative Neu-
rology.]
The Application of Sacral Resection to Gynaecological Work. By
E. E. Montgomery, M. I)., Philadelphia. [Reprinted from the Trans-
actions of the American Association of Obstetricians and, G ynaicologists.]
Scorbutus in Infants ; American Cases. By William P. Northrup,
M. D. [Reprinted from the Archives of Pediatrics.]
Twenty-first Annual Report of the Managers of the Buffalo State
Hospital, for the Year 1891.
membrane is reached. The openings for the outflow of liquid are at
b, behind the bulb <•, so the liquid can not enter the bladder.
The instrument is introduced until the "tender spot" is passed, and
we generally find one; then the tube of an ordinary fountain syringe is
attached, and by raising or lowering this the pressure is easily governed.
I use about a quart at each sitting, and repeat about twice a week,
usually two or three sittings sufficing. I use a weak solution, warm,
antiseptic, and astringent, and I know of none better than a weak dilu-
tion of listerine.
This instrument can lie used as a recurrent catheter also.
fteto Indentions, etc.
A URETHRAL IRRIGATOR.
By Lester Keller, M. D.,
BEURY, W. VA.
Having met with a number of cases of gonorrhoea that have resisted
all my efforts, a slight discharge continuing after all my resources were
exhausted, I have had made by George Tiemann & Co., of New York,
a urethral irrigator that has so far proved satisfactory.
It is made of sterling silver, not readily corroded and easily kept
bright. It is made in two lengths — one for the curved and one for the
Straight portion of the urethra.
A tube, a, is corrugated to permit the liquid to liovv back, and, by oc-
casionally rotating the tube very slightly, every portion of the mucous
IE t s c c 1 1 ;i n n .
Mortality in Cities in the United States. — The following table
represents the mortality in the cities named, as reported to Dr. Walter
Wyman, Surgeon-General of the Marine-Hospital Service, and pub-
lished in the Abstract of Sanitary Reports for March 25th :
New York, N. Y...
Philadelphia, Pa...
Brooklyn, N. Y
St. Loiiis, Mo
Boston, Mass
Baltimore, Md
San Francisco, Cal .
Pittsburgh, Pa
Washington, D. C
Detroit, Mich
Milwaukee, Wis
Milwaukee, Wis
Newark, N. J
Minneapolis, Minn. . .
Louisville, Ky
Rochester, N. Y
Providence, R. I
Fall River, Mass ,
Portland, Me j Mar.
Binghamton, N. Y.
Mobile, Ala Mar.
Galveston, Texas.
Auburn, N. Y
Auburn. N. Y
San Diego, Cal
PensacoTa, Fla
Week ending —
Population, U. S.
Census of 1890.
Total deaths from
all causes.
DEATHS FROM —
Phthisis pul- {
monalis.
>*
p.
S
CO
3
EH*
(2
CO
6
.= -3
— ii
.e 8
3
4
1
Mar. 10.
Mar. 12.
Mar. 19.
Mar. 19.
Mar. 19.
Mar. 19.
Mar. 12.
Mar. 18.
Mar. 19.
Mar. 12.
Mar. 5.
Mar. 19.
Mar. 12.
Mar. 19.
Mar. 19.
Mar. 19.
Mar. 19.
Mar. 19.
Mar. 19.
Mar. 18.
Mar. 12.
Mar. 19.
Mar. 19.
Mar. 18.
Mar. 19.
Mar. 19.
Mar. 19.
Mar. 11.
Mar. 12.
Mar. 19.
Mar. 12.
Mar. 12.
1,515,301
1,046,964
sin;.* 13
451,770
1 IS,477
434.439
298,997
296,908
261,353
238,617
230,392
205,876
2"4,468
204,468
181.830
164,738
161.129
133,896
132,110
81,434
81,388
81,388
70,10*
74,398
36,425
35.005
31,076
29.084
25,858
25,858
16,159
11,750
885
515
364
185
223
189
143
119
109
113
130
85
77
81
115
47
60
43
47
19
45
41
38
30
14
13
23
"ii
8
3
1
132
59
38
2
13
7
3
2
25
16
9
1
5
9
1
1
3
5
4
4
8
1
28
30
27
"l
7
15
6
4
9
2
t
5
15
7
1
0
24
1
6
26
26
27
10
9
8
15
"5'
5
9
2
1
i
1
2
1
1
1
2
1
4
3
1
4
1
2
1
1
2
4
1
13
1
2
6
2
5
4
4
3
1
1
2
4
1
1
1
1
1
1
1
■■
The World's Fair and the Water Supply of Chicago. — The British
Medical Journal for March 12th contains the following editorial article:
On the eve of the great World's Fair of 1893, any danger threat-
ening the pul die health of Chicago has a direct personal interest to
many thousands upon this side of the Atlantic, and something like
consternation will be caused by the now evident fact that enteric fever
is highly and dangerously prevalent in that city, owing to the use of
water polluted by sewage. In January last a paper on the Statistics of
Typhoid Fever in Chicago was read before the American Statistical As-
sociation by Professor W. T. Sedgwick, of the Massachusetts Institute
of Technology, and Mr. Allen Hazen, chemist to the Massachusetts State
Board of Health. The authors stated that enteric, or typhoid, fever
had for some years past been intermittently prevalent in Chicago, and
that in 1891) there was a sudden increase in the number of deaths at-
tributed to this cause.
♦
392
MISCELLANY.
[N. Y. Med. Joub.
During 1800 the enteric deaths numbered 1,008; in 1891, 1,997; cor-
responding to the death-rates of 0'9 and T6 respectively. It was pointed
out that the general death-rate of Chicago was by no means high, and
that the excessive mortality from enteric fever was in ominous accord-
ance witli what was known of the danger of pollution of the water
supply by sewage. The city stands, as everybody knows, on the shore
of Lake Michigan, and takes its water supply from that source. It
seems that the sewage of some 180,000 persons passes directly into the
lake ; and that further pollution is brought about by means of the
Chicago River, which communicates with the Mississippi as well as Lake
Michigan, and delivers its polluted waters in either direction, according
to circumstances. The water intake is at different points in the lake
which do not seem to be sufficiently far removed from the sources of
pollution to afford any satisfactory assurance of safety. A proposal to
construct a water tunnel four miles in length has not yet been carried
out.
The statements made as to the prevalence of fever were at first met
with flat contradiction. According to the health commissioner for
Chicago the assertions were ridiculous; there was not, and had not
been, any epidemic ; it was simply a scare intended to frighten people
from coming to the World's Fair. His view was supported by the pub-
lished statements of several medical practitioners. There was very
little fever, and that little was due to atmospheric conditions, to close
alleys, to faulty drainage, to decaying refuse kept in cellars, to catch-
ing cold, to " grip," to everything, in short, except water. The water
was all right, except after rain, and then it should be filtered. It was
stated by the health commissioner that analysis showed the water to be
pure. Nevertheless, Pr. Ranch was instructed to investigate the facts
on behalf of a higher authority — the Illinois State Board of Health —
and his report will be awaited with eager interest. Meanwhile, the offi-
cial denials from the Chicago authorities appear to have ceased, but not
the epidemic. It seems now to be admitted that there has, in truth,
been alarming prevalence of enteric fever, as stated by Messrs. Sedg-
wick and Hazen, and that in January, 1892, there were no fewer than
311 deaths.
Unless the facts have been grossly misstated in the papers which
have reached us, the action of the Chicago authorities is open to two
explanations only — either they were culpably ignorant of local facts
and records of the gravest importance to the public health, or else they
disputed them knowing them to be substantially correct. It is difficult
to say which hypothesis is the less creditable or the more calculated to
destroy all confidence in their future statements or efforts.
On the evidence before us, we may point out that the prima facie
case for water infection is a convincing one. The sewage of a vast city,
a city in which enteric fever abounds, is poured into an inland sea.
The drinking-water of that city is taken from points which are admit-
tedly in unsafe proximity to the sewage outlets ; moreover, it is open to
question how far safety could be secured by merely increasing the dis-
tance. Enteric fever of a mild type has been for two years epidemic
among the population supplied with this water. The alleged mildness
of tvpe only increases the terrible significance of the high mortality,
and is a familiar phenomenon in water epidemics in this country. Un-
der such conditions chemical analysis of the water can never prove
safety, but may confirm the suspicion of danger, and it is announced
that a recent official analysis was followed by an emphatic recommen-
dation from the analyst that the water should always be boiled before
use.
It is said that vigorous efforts are now being made to remove the
intake to a point four miles from Chicago, far beyond any probable
range of sewage pollution, and that the river-bome part of the sewage
is to be prevented from entering the lake. The success of the World's
Fair is likely to depend in no small degree upon the sanitary history of
Chicago during the next few months. We may therefore assume that
no endeavor will now be spared to discover and remove the causes of
the epidemic, and to provide a supply of water which shall be free from
danger of pollution by sewage. Dr. Rauch's high reputation is a suffi-
cient guarantee that his part of the investigation will be thorough and
complete; but, even if he should fail to find proof of the theory that
the epidemic has been water-borne, the danger of the present mode of
sewage disposal and water supply is manifest
The evidence that the lake water is at present the source through
which the typhoid fever prevalent in Chicago is conveyed convinces
physicians generally, and the heavy typhoid mortality of January em-
phasizes the danger. There is a great demand for "pure" drinking-
water derived from sources other than Lake Michigan, but it adds a
new element to the danger of the situation that evidence is forthcom-
ing in the local papers that in the localities from which " the peddlers
of pure water" are observed to draw their supplies its purity is more
than doubtful. What is sold as distilled water is declared to be " lake
water" or its equivalent. A good deal of this is described as " sent out
in tin cans or iron tanks," obviously dangerous methods of even attempt-
ing to carry pure water. It illustrates the extremities to which Chicago
is reduced that there is much discussion as to the propriety of licensing
retailers of " pure water " in order to have facilities of inspection. It
is obvious that the drinking-water supply of Chicago is in a state expos-
ing visitors as well as residents to great danger, anil that those who
visit Chicago for the "World's Fair" will do well to bear this danger
in mind, and to be very sure that they do not drink " lake water," or
any of the doubtful substitutes which are, it is alleged, being palmed
off upon consumers who have taken the alarm, but are yet too easily
satisfied with anything that is sealed in a bottle and calls itself pure.
To Contributors and Correspondents. — The attention of all wlio purpose
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THE NEW YORK MEDICAL JOURNAL, April 9, 1892.
Vighml Communications.
THE TROUBLESOME SYMPTOMS CAUSED BY
ENLARGEMENTS OF THE EPIGLOTTIS,
AND THE ADVISABILITY OF REDUCING
THE SIZE OF THIS CARTILAGE BY OPERATIVE MEASURES.*
By CLARENCE C. RICE, M. D.,
PROFESSOR OF DISEASES OF THE NOSE AND THROAT IN THE NEW YORK
POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL,
This subject is not a large one, nor is it one to which
any great amount of attention has been paid by this asso-
ciation. Enlargements of the lingual tonsil and contact be-
tween such lymphatic hypertrophies and the epiglottis have
been thoroughly studied and elaborated in recent writings.
The condition of the epiglottis in tuberculosis, in syphi-
lis, and in lupus has received due consideration, and since
the lesions of these diseases are frequently limited in a char-
acteristic manner to the epiglottis, the epiglottis has proba-
bly been examined as carefully as any other portion of the
respiratory tract. Great progress was made in the treat-
ment of catarrhal affections of the top of the larynx when it
was recognized that contact between the base of the tongue
and the epiglottic cartilage occasioned such symptoms as
tickling in the throat, a feeling of fullness in the lower phar-
ynx, a disposition to swallow, and eventually paroxysms of
coughing. It was found also that contact between the
tongue and epiglottis was a sufficient irritant to cause a
chronic catarrhal laryngitis.
In a paper entitled Unusual Causes of Coughing, f read
before the Medical Society of the State of New York in
February, 1886, at a time when I believe this subject had
not been brought before this association, I noted that in the
frequent condition of contact between the tongue and epi-
glottis, sometimes it was enlargement of the lingual tonsil
which was the primary source of the difficulty, and some-
times it was some abnormity of the epiglottis which was at
fault.
It was found that an enlargement of the lingual tonsil
which overhung and rested upon the epiglottis caused at
first a temporary congestion, and very soon a permanent
congestion and enlargement of the epiglottis. I believed
then, and my opinion has not been changed, that the con-
tact of the epiglottis, either with the tongue in front or w ith
the lateral walls of the pharynx, was the most frequent cause
of those peculiar epiglottides which are the subject of tliis
paper — epiglottides which are sometimes enlarged vertically,
sometimes laterally, which are always congested, and which
are prone to attacks of subacute inflammation.
To say that such epiglottides are simply an exhibition of
a chronic catarrhal process which has affected the entire
larynx does not satisfactorily explain the condition, for we
have all noted that the enlargement and congestion of the
kind of epiglottis here described are much more marked
than are the evidences of a catarrhal inflammation within
* Read before the American Laryngological Association at its thir
teenth annual congress.
f Med. Record, May 1, 1886.
the larynx proper. This epiglottis is frequently found en-
larged when the remainder of the larynx is practically nor-
mal. And, again, whereas the appearances of congestion
and swelling in the larynx will disappear when properly
treated, the chronically enlarged and congested epiglottis
either is not benefited at all by treatment, or, if improved,
it quickly returns to its condition of congestion.
The fact that the epiglottis becomes congested and en-
larged when the larynx remains in a healthy state, and also
that these epiglottides are constantly fluctuating from a slight
to a large degree of congestion, and even changing in the
degree of thickening and lateral enlargement, the larynx as
a whole remaining in a quiescent condition — these facts
point strongly to the conclusion that the cause of the an-
noyance to the epiglottis is very limited in its action and is
applied directly to the epiglottis, and is not one of the
sources of general catarrhal inflammation which are to be
found without the body.
In addition to the enlarged lingual tonsil which is the
most frequent cause of enlargement and congestion of the
epiglottis, there are a number of other factors to be men-
tioned as causative in the production of such enlargement.
It is quite proper here to lay some stress upon predisposing
causes and to say that the congenital formation of the epi-
glottis as regards size, shape, curvature, length, and breadth,
determine largely whether it will be exposed to contact with
neighboring parts or to external irritants. It is unnecessary
to describe the normal epiglottis ; we know that its direction
is vertically upward and that its free extremity is curved
forward toward the base of the tongue. It is undoubtedly
true, as Merkel * demonstrated by experiment, that the length
of the ejfiglottis in man stands in a fixed relation to th e an
tero-posterior diameter of the larynx, so that when the epi-
glottis covers the larynx during deglutition its margin es-
capes the posterior wall of the pharynx by the distance of
a quarter of an inch. An epiglottis which is compressed
laterally (see Fig. 1) can hardly be rubbed against by those
lateral bands of
lymphatic tissue
which form a con-
nection between
the faucial and
the lingual tonsil,
though its com-
pressed corners
may rest against
the posterior wall
of the pharynx,
while a broad epi-
glottis — that is,
one of long diameter from side to side — is very apt to
come in contact with the sides of the pharynx if there is
any lymphatic enlargement (see Fig. 2).
. Some epiglottides have such a sharp anterior curvature at
their superior margin that they can hardly escape friciont
with the base of the tongue (see Fig. 3). We see the op-
* Merkel. Die Fitnctionen des menschJivhin Sc/thuid laid Kehlkopfes,
Leipzig, 1805.
Fig. 1.
394
RICE: ENLARGEMENTS OF THE EPIGLOTTIS.
[N. Y. Med. Jouk.,
Fio. -2.
posite position of the epiglottis occasionally in health, when
the laryngeal mirror shows it to be fallen over backward,
covering the aper-
ture into the glot-
tis and resting
against the poste-
rior wall of the
pharynx. This is
the pendulous epi-
glottis (see Fig. 4),
and Camalt-Jones*
says : " It is not
a normal one, and
its position is gene-
rally on account of
some throat trouble." In an interesting monograph writ-
ten by Sir George Duncan Gibb,f in which he gives the re-
sults of his study of the effect of the pendulous epiglottis
upon the voice and upon the general health, he states that
eleven per cent, of
four thousand six
hundred people ex-
amined were found to
have this variety of
epiglottis, and that
every one of two hun-
dred and eighty na-
tives of India, China,
and Africa had a
pendulous epiglottis.
FjG. 3. He thinks this is
due to the relaxation
induced by living in a hot climate. He emphasizes the evil
effect of the pendulous epiglottis upon voice and health in
that it causes a slight dyspnoea. I have quoted from this
article only because it is an unusual one.
The large pendulous epiglottis is seen most frequently
in disease, and the
faulty position is due
largely to the in-
creased weight of the
margin of the carti-
lage. In tuberculosis
laryngis, for exam-
ple, where the edge
of the epiglottis
is thickened many
Fk. 4 times, it is not un-
common to find the
cartilage King far backward. The epiglottis will assume
a more erect position as fast as the inflammatory weight
is removed. This fact was shown to be true in a case of
fibroma of tlie epiglottis ; as the growth increased in size the
cartilage was carried backward and downward, but it re-
turned to its normal position when the growth was removed.
We see, too, epiglottides which are not symmetrical, one
side of which extends nearer the lateral wall of the pharynx
* Jones. Tram, of the Internal. Med. Congress, p. 112.
•f- Tranx. of the Anthropological Society, vol. iii.
Fig
than does the other side. More commonly we find a pro-
longation of the cartilage at either one of the superior cor-
ners (see Fig. o). Occasionally there is a spur extending
from a point midway in the superior margin of the epiglot-
tis. I have always thought that these elongations of the
epiglottis were due but slightly to congenital causes, but,
commencing perhaps in this way, were irritated by contact
with neighboring parts,
and so the elongation
became much more
prominent than it
otherwise would.
I do not know
whether Dr. Donald-
son * was referring to
the inflammatory epi-
glottis in his article on
the Functions of the
Epiglottis in Deglu-
tition when he says:
" The epiglottis is frequently out of proportion to the
size of the rima glottidis. The free edges of this various-
shaped cartilage are of such different contour that they can
not fit the margin of the glottis accurately."
The epiglottis normally and pathologically presents not
more than five or six radically different shapes, but each of
these lias numerous shades of variation in form. Browne f
says the epiglottis may be looked upon as the distinctive
feature of the larynx, for no part is so variable in shape and
size. Audubert, \ in Moure's clinic, made careful record of
the different-shaped epiglottides, and published his results
in twenty-eight plates.
Epiglottides of such curvatures, shapes, and sizes as noted
in the illustration are strongly predisposed to congestive
enlargements, on account of the injury they invite from con-
tact with parts in the neighborhood. Undoubtedly there
are other factors present which make it difficult, if not im-
possible, to diminish the congestion or to reduce the epi-
glottis in size.
An unusually high position of the epiglottis in the
pharynx particularly exposes it during deglutition, and im-
purities in the respiratory current are more harmful to it
than to an epiglottis of normal size placed lower down.
These enlarged epiglottides always seem to be especially con-
gested and irritable in people wrho use tobacco and alcohol
freely. The degree of the congestion of the epiglottis seems
to bear a very intimate relation with the condition of the
middle pharynx. The color of the mucous membrane is apt to
be of the same shade in botli these locations. Disturbances
in digestion, gastric disorders, are apt to fire up the chron-
ically enlarged epiglottis. In fact, the epiglottis when in
this condition seems to be more nearly related to inflamma-
tory exacerbations of the pharynx than to those of the
larynx. It is possible that the enlarged epiglottis owes
something of its size to either venous or arterial congestion
caused by pulmonary, cardiac, or hepatic disease. In two
* Donaldson. Trans, of the Am. Latyng. Assoc., vol. viii, p. 53.
f Browne. Diseases of the Throat, p. 63.
\ Aucluliort. Annul, ile la Po/i/rli niijiu Je llurihauT, January, 1888.
April 9, 1892.-J
BICE: ENLARGEMENTS OF THE EPIGLOTTIS.
395
of my most marked cases, both occurring in men about
Hftv-five years of age, one suffered with emphysema and
chronic bronchitis, and the other had a weak, fatty heart.
The variety of epiglottis which I have tried to describe
is not commonly seen. I am not speaking of epiglottides
which have become moderately congested and slightly en-
larged by the pressure of the lingual tonsil, but of marked
hypertrophies of the epiglottis. I should say that I had
seen ten or twelve cases, and three fourths of them in men.
We should expect this preponderance in men, because of
their having a larger degree of catarrhal inflammation of
mucous membrane than women, and also because of the use
of tobacco and stimulants.
Enough has been said as to the manner in which the
epiglottis becomes at first congested and eventually per-
manently enlarged. As to the pathology, a single sentence
will describe the condition: It is a pure hyperchondrosis
effected by an abnormally large blood supply. The mucous
covering becomes somewhat thickened, the superficial
blood-vessels are increased in number and size, there is
seldom any oedema, the enlarged epiglottis is hard and
cartilaginous throughout its entire extent. No matter
how much enlarged the epiglottis is, it always presents the
appearance of the normal cartilage as regards texture so
well described by Collier,* who says that " on looking at
the epiglottis from behind it is seen to be covered by a
thin mucous membrane continued from the inner aspect of
one arytajno-epiglottic fold to the other. Through the mu-
cous membrane the well-defined and sharply cut edges of
the epiglottis can be seen."
There are certain peculiar symptoms which are occa-
sioned by an hypertrophid epiglottis, but it will hardly be
necessary to depend upon any characteristic symptom, as
the diagnosis of this condition will readily be made the
first time a laryngeal mirror is introduced into the mouth.
The constant tickling and feeling of fullness in the larynx,
the hard, unsatisfactory paroxysms of coughing, which may
be followed by glottic spasm or by vomiting, and the partial
loss of voice which remains for a time — these point to
laryngeal irritation and reflex phenomena. The symptom
of " empty swallowing," spoken of by Gleitsmann f in cases
of enlarged lingual tonsil, is common also where an enlarged
epiglottis is present. These patients frequently give the
history of having swallowed foreign bodies, and they have
a strong belief that the uncomfortable feeling in the throat
is due to their lodgment in the pharynx. These out-
breaks of coughing occur upon the slightest provocation,
when the patient is talking, singing, laughing, or eating,
when he lies down or when he rises, and when he first
goes out of doors. Paroxysms of coughing are not so
easily produced in any other disturbance of the larynx or
of the lungs. The long-continued mechanical violence
caused by the cough usually gives rise to a very irritable
mucous membrane throughout the upper respiratory tract,
and in this condition the smallest external irritant is suffi-
* Collier. Lancet, 1889, i, p. 882.
f Gleitsmann. Hypertrophy of the Tonsil of the Tongue. Medical
Record, December 17, 1887.
cient to cause an explosion. It is not an encouraging task
to control the unpleasant symptoms caused by an enlarged
epiglottis in any patient, but it is especially difficult to do
so in singers and in public speakers. Patients of this class
are particularly unfortunate if their epiglottides are perma-
nently enlarged, for not only will the use of the voice pro-
duce tickling, but the patient is so afraid of coughing that
he holds the throat stiffly by muscular power, and this gives
rise to a bad quality of tone. Fatigue of the voice is
another symptom produced by an-enlarged epiglottis.
Reflex cough caused by a very sensitive nasal mucous
membrane, by accumulations in the auditory canal, by
elongated uvulae, by enlarged lingual tonsils, and by bron-
chial and pulmonary disease, should be distinguished from
the cough due to an hypertrophied epiglottis.
It is only within the last year that I have treated these
cases of large catarrhal epiglottides with any degree of satis-
faction. If there is any astringent application which will
cause any permanent reduction in their size, I have not
found it. The atomization of the old mineral astringents
and of tannic acid seems only to increase the irritation.
Solutions of cocaine are of far more service, and I know of
no better medical treatment than the application by spray-
ing of a two-per-cent. solution of cocaine hydrochloride, fol-
lowed by a coating of some one of the oily products, such
as liquid vaseline, albolene, or benzoinol ; but these are only
temporary in their benefit, and the constant use of cocaine
in the larynx is to be avoided. I have tried strong solu-
tions of silver nitrate after the spray of cocaine, but have
made little progress. Patients of this class always return
to the physician after a short interval. A slight change in
the weather is usually sufficient to renew the disturbance in
the top of the throat.
In my first case of operative treatment upon the epi-
glottis I used the galvano-cautery to diminish the size of
an enlargement after I had in the same instance reduced the
size of a lingual tonsil by the same method. But I would
state strongly that burning is not the proper way of reducing
the epiglottis. This cartilage resents such treatment to a
remarkable extent; it becomes very much inflamed, oedema-
tous, and painful, and weeks will elapse before the epiglottis
recovers from the burning. The patient will be hoarse, but
it is a little singular that, in spite of the fact that the epi-
glottis is so much swollen, the cough is less severe,
I operated with long-handled scissors in two cases, in
both instances cutting off perhaps an eighth of an inch
from the sides of the epiglottis, where they rested against
the pharynx. The epiglottis was reached by using the
tongue depressor alone. One of these two cases bled rather
freely, but was checked by the application of a sixty-grain
solution of silver. The inflammation following the scis-
sor-cutting was moderate in both cases, and subsided in
two weeks. The larynx was sprayed with a one-per-cent.
solution of cocaine in oil. In view of the bleeding which
is likely to follow the use of sharp scissors, curved or right-
angled cutting forceps may be employed for removing a
little from the sides or the top of the epiglottis. And
here let me emphasize the direction that only a narrow mar-
gin of the epiglottis should be excised. The indication is
390
POWERS: FRACTURE OF THE RADIUS.
[X. Y. Med. Jock.
simply to prevent contact between the epiglottis and neigh-
boring parts.
If both an hypertrophied lingual tonsil and an enlarged
epiglottis exist, the lingual tonsil should first be reduced in
size. When this source of irritation is removed the epi-
glottis will frequently lose something of its swelling and
congestion. It is only as a last resort that the epiglottis
should be reduced in size.
I quote an interesting case reported by Stookes *— that
of a child one year old who suffered for six months with
paroxysms of glottic spasm and choking. Death followed,
and it was found that the laryngeal obstruction was caused
by an epiglottis which was a third to a half as long again
as normal. Sir Morell Mackenzie, in one of his editions,
speaks of his epiglottotome. I have not seen it, but believe
an instrument of the proper curve, acting on the same prin-
ciple as the tonsillotome, would be a useful one for this
operation. There are a number of laryngeal cutting instru-
ments where a knife is drawn across a circle which might
answer the purpose. Dr. William Porter, f of St. Louis, in
an article on Excision of the Epiglottis, refers to a case of
growth upon the epiglottis which involved a large part of
the cartilage. The epiglottis was removed with cutting
forceps, and the inconsiderable bleeding was checked by
applying a sponge wet with Monsel's solution.
In closing, let me repeat that there are many cases
where such troublesome symptoms as fullness in the throat,
tickling, voice fatigue, violent paroxysms of coughing,
vomiting, and glottic spasm are caused by an enlarged,
congested, irritable epiglottis. In most of these cases this
condition of the epiglottis has been caused by an hypertro-
phied lingual tonsil, removal of which will afford relief.
But in some few cases the epiglottis has become so en-
larged as to rub against the lateral and posterior walls of
the pharynx ; and as no medication will reduce the epi-
glottis in size, it will be found necessary to take away a
small portion of the margin of the epiglottis in order to
prevent frictional irritation.
123 East Nineteenth Street.
FKACTURE OF THE KADITJS.
NON-UNION.
RELIEF AFFORDED BY AX EXTENSION APPARATUS.}
By CHARLES A. POWERS, M. I).
Miss 0. M.. a woman of fifty-three years, was brought to
me some two years ago by Dr. W. H. Dustman for advice re-
garding a painful and partially disabled hand.
She had sustained a simple fracture of the right radius
twenty-seven years previously, the repair being perfect and
attended by complete restoration of function.
Sixteen years thereafter, or eleven years before I saw her,
she had again broken the same bone, the seat of this latter
fracture being approximately at the junction of its middle and
* Stookes. Brit. Med. Jour., November 17, 1888.
f Porter. Am. Jour, of (he Med. Sciences, April, 1879.
\ The patient was exhibited some months ago, before the Ortho-
p;n|jc Section of the New York Academy of Medicine.
lower thirds. Union followed in this second instance, but the
radial nerve became involved in the callus, and the fragments
united with very considerable deformity. She suffered marked
and continuous pain in the parts supplied by the radial nerve,
and for the relief of this underwent an operation at the hands
of a surgeon in the West, who cut down upon and freed the
nerve.
Thinking to relieve the deformity in the radius, he made at
the same time a section of the bone, adjusted the fragments, and
wired them. Unfortunately, this operation was attended by
suppuration and non-union of the fragments, although the free-
dom given to the nerve relieved the former pain. As time went
by, the hand became more and more drawn to the radial side,
the lower end of the ulna became quite prominent, and the pa-
tient suffered very considerable pain in the hand over the region
supplied by the ulnar nerve. This pain was relieved by grasp-
ing the fingers and "drawing the hand down.-'
Her condition when she was brought to me was as follows:
The right radius was an inch and a half shorter than the left;
there was a false point of motion at about the junction of its
middle and lower thirds. The fragments were freely movable,
both dropping toward the ulna at the seat of fracture, the lower
end of the upper fragment being somewhat behind the upper
end of the lower fragment.
There seemed but little overriding; rather a loss of sub-
stance. Pronation and supination were short of complete.
The grasp of the hand was less forcible than on the unaffected
side. The hand was thrown well to the radial side, the de-
formity being shown in Figs. 1 and 2. The patient's chief
complaint was of pain in the ulnar side of the wrist and hand.
This was at times excessive, especially when she was fatigued,
and at such times it occasioned almost complete disability. For
its relief she was accustomed, as said, to draw the hand down-
ward and to the ulnar side.
Fig 1. Fig. 2. Fig. 3.
I was loath to advise an operative procedure, as it would very
probably have necessitated resection of the ulna opposite the
seat of fracture in the radius, and suggested the extension ap-
paratus shown in Fig. 3, details in the manufacture of which
were kindly cared for by Dr. Dustman.
It consists simply of two laced leather bands connected by a
April 9, 1892.]. DUNN: ADENOID TISSUE OF THE PHARYNX AND NASO-PBARYNX.
397
double bar which is so arranged that it can be lengthened or
shortened by a screw which traverses it. The upper of these
bands grasps the swell of the forearm below the elbow ; the
lower goes about the wrist and upper part of the hand. The
bar is inserted at each end in a joint which allows motion in
all directions. By lengthening it the hand can be carried
downward to a desired extent, and, as the chief pressure is at
the base of the thumb, it is at the same time carried to the ul-
nar side. Reference to the cut will show that pronation and
supination are easily effected.
The patient wore the apparatus continuously at first and
averred that it gave her complete relief. She was able to re-
sume duties which had hitherto been impossible. She has of
late been able to dispense with it a part of the time, wearing it
when fatigued or when obliged to use the hand more than
usual.
35 West Thirty-fifth Street.
CONCERNING THE
ADENOID TISSUE OF THE PHARYNX AND
NASO-PHARYNX.
By JOHN DUNN, M. D.,
RICHMOND, VA.
Ix the fall of 1890 Mr. S., aged twenty-six, came to see me
about his throat. History as follows : Seven or eight years pre-
viously he had had "an acute attack of sore throat," for which
at the time he had undergone the treatment usual in such cases,
including removal of part of the uvula. Since that time he had
never been free from a sense of discomfort in his throat, which,
often for months at a time, would remain acutely painful. The
pain was not referred to any one place in the throat, but the
"whole throat was painful." During these years he had sub-
mitted to all kinds of treatment, including "having the skin
several times burned off his throat with caustic," removal of
part of the left tonsil with cautery, and all the anti-sore-throat
remedies of the pharmacopoeia, and without relief. Examination
at this time showed the mucous covering of the pillars of the
fauces, soft palate, uvula, tonsils, pharynx, and part of the naso-
pharynx to be fiery red. There was no swelling of the parts;
no exudation. Scattered over the pharyngeal wall were a few
so-called " enlarged follicles." The left tonsil had been in a
ragged manner destroyed by the application of the cautery,
•which had also removed part of the posterior pillar of this side.
The right tonsil lay flat against the posterior pillar of the right
side; this tonsil was enlarged, but not enough to protrude be-
yond the edge of the pillar ; its epithelial covering, like that of
the rest of the pharynx, was fiery red. I asked Mr. S. when
his throat hurt him. His reply was: "It hurts all the time. It
aches. It has been this way for years." There was no nasal
complication, no upper pharyngeal complication, to account for
this state of affairs. There had been some rheumatism in his
family, but not enough to make its existence a part of the family
history. In other respects Mr. S. was healthy. (I have since
then discovered that Mr. S.'s skin is exceptionally liable to in-
flammatory action after the application of bichloride solutions
or of any similar applications.) I advised the removal of the
right tonsil, telling Mr. S. that there was a bare possibility that
it might be the cause of his throat trouble, though I could not
assure him that it was, or that its removal would afford hira the
relief he sought, as I had never seen a case similar to his (/. <■.,
a case of apparently acute inflammation of the coverings of the
pharynx, including the soft palate, uvula, and pillars of the
fauces, which acute inflammation at the same time was
chronic.)
He declined to have the tonsil removed, saying that it gave
him no more pain than the rest of his throat. I then put Mr.
S. on antirheumatic remedies, including salicylate of sodium.
II is throat got a little better after a time, probably as a result of
time and not of the medicines.
In October, 1891, Mr. S. returned to my office saying that
he could stand the pain in his throat no longer. If there was
any possibility of the tonsil being the cause of his trouble he
wanted it removed ; something had to be done. Examination
of the fauces showed exactly the same condition that existed a
year before — the fiery redness of the mucous membrane. The
right tonsil seemed to have decreased somewhat within the past
twelve months, although it w as still considerably hypertrophied.
Examination of this tonsil showed that it was firmly adherent
to, if indeed it had not been in part developed from, the outer
part of the posterior faucial pillar. With the aid of a snare and
a knife to loosen some of the adhesions, the tonsil was re-
moved. After a day or two the throat began to lose its inflamed
appearance and the pain in it to disappear. At the end of two
weeks Mr. S. said his throat felt better than it bad for months.
There were, however, slight recurrences of the inflammatory
condition of the mucous membrane during these two weeks,
though of less severity than the attacks had been prior to the
removal of the tonsil. Further treatment consisted in destroy-
ing with the cautery point the remains of the tonsil, which,
owing to their position and adhesions, could be removed thus
more easily than with a snare. Mr. S. also mentioned that, con-
comitantly with this sore throat, there conies a sore feeling in his
chest just beneath the sternum ; this soreness lasts all the time
that the throat is inflamed, and seems to increase under exer-
cise or exposure. Furthermore, Mr. S. says that the hearing of
his right ear is not so acute as that of his left. Examination
showed some retraction of the drum-head on this side. Three
months after the removal of the tonsil Mr. S. says that the pain-
ful feeling in his throat has virtually disappeared ; his throat,
however, still tires easily, though he has not now the same desper-
ate feeling in regard to it that he had when nothing he could do
would relieve the aching misery that once proceeded from it.
Although the foregoing case at first glance hears only
one point of interest — namely, a suggestion as to a relation
between a hypertrophied tonsil and a chronic pharyngitis
which remains for years more or less acutely painful — fur-
ther consideration of its history brings up questions which,
could they be answered correctly, would throw light upon
the manner of disappearance of the hypertrophied adenoid
tissue of the upper and lower pharynx, and the results upon
the neighboring mucous membranes where this hypertro-
phied adenoid tissue has been allowed to disappear by
natural processes. What constitutes a normal appearance
of the upper part of the pharynx, the region of the so-
called Luschka's tonsil, is still the subject of dispute. The
well-known cut, after Luschka, given in Robinson's Nasal
Catarrh and Allied Diseases, and in Bosworth's excellent
work Diseases of the Nose and Throat, and elsewhere, gives
no idea of what is to be considered a perfectly healthy up-
per pharynx ; and a person possessed of a pharynx resem-
bling this cut in appearance would be very grievously an-
noyed with "catarrh." Luschka's assertion that there is in
the region of the pharyngeal vault always present a mass of
this lymphatic tissue of about a quarter of an inch in thick-
ness is not true. In the typically healthy upper pharynx
398
DUNN: ADENOID TISSUE OF THE PHARYNX AND NASO-PIIARYNX. [N. Y. Med. Jouh.,
of the adult, at least, the mucous membrane is smooth, tits
<-l< >scl \ over llif membrane beneath, and shows no such fur-
rows and folds as arc pictured in the above-mentioned cut.
Judging from pathological conditions, these surface lym-
phatics of the pharynx are most numerously developed in
the region of the vault, the chain extending to and even
partly into the elevations of the Eustachian tubes on cither
side, running thence down the furrows behind the posterior
pillars of the fauces. In severe cases of adenoids in the
negro I have seen the lymphatics along the edge of the
posterior pillars so hypertrophied as to give this edge a
fimbriated appearance. (These cases have always been ac-
companied with phlyctsenulae and some form of facial ecze-
ma). While, naturally, the mucous membrane in which
this lymphatic ring is found is less firmly adherent to the
membrane below than that of the rest of the pharynx, I be-
lieve that whenever this lymphatic tissue is found in such
amounts as to make " folds and furrows " there is some
pathological condition present, either inherited or acquired.
This, at least, seems to be true of the natives of this part
of the United States. The typical Luschka's tonsil with its
bursa pharyngea I have never seen hut once, and then it
occurred in a Prussian woman who had come to America to
live. Whether true hypertrophy of these adenoids of the
upper pharynx is ever congenital is to he doubted. One
has as much right to expect to find congenital hypertrophy
of the tonsils. This hypertrophy takes place most fre-
quently in childhood, and not infrequently in early infancy.
That, in some cases, the lymphatics of the upper pharynx
are more developed at birth than in others is true, and it is
further true that this adenoid tissue is in some individuals
more liable to hypertrophy than in others; furthermore, it
may not be doubted that in many, if not in the majority,
of cases the tendency to hypertrophy of this pharyngeal
lymphatic tissue is inherited. As Bosworth states, the
stimulus of repeated colds seems, in these inherited cases,
to be sufficient to cause hypertrophy of this lymph tissue.
It may be asked, however, if the inherited tendency of this
lymphatic tissue to hypertrophy is not itself sufficient to
cause the hypertrophy ; and, if so, is not the almost con-
stant cold in the head, from which these cases suffer in
childh 1, the result of this hypertrophy \ Apart from
these inherited cases, this lymphatic tissue in other persons
is liable to hypertrophy, especially under the stimulus fur-
nished by measles and diphtheria. The worst of these
cases are found after diphtheria, wdien the glands in the
neck will be found also enlarged and will remain enlarged
for years. It is not improbable in these cases that a spe-
cific poison is the cause of the hypertrophy rather than the
inflammation to which the parts are subjected. The pro-
vision of Nature which prevents this adenoid tissue from
growing indefinitely is to be commented on, though it can
not be explained. Apparently there is no reason why, when
this lymphatic tissue begins to hypertrophy, if should not
grow until it tills all the empty space before it. In reality
it docs not do so, hut when it has attained certain dimen-
sions it begins to diminish in hulk. It is interesting to
note that an acute i 1 1 tl am ma I ion of the third tonsil is rare.
There arc reasons for believing that it does occur in diph-
theria, in scarlet fever, and occasionally idiopathically.
I have seen one case of acute inflammation of the pharyn-
geal tonsil following an operation for removal of a part of
it. Rarely an abscess has been found in this tissue. I have
seen one case. I have seen two or three cases of cyst which
must have had their origin in this lymphatic tissue. At all
events, this lymphatic tissue hypertrophies from various
causes in childhood, often in early infancy. At what period
of life it attains its greatest size depends upon the amount
of this tissue present as a basis, inherited tendencies, and
the circumstances attendant upon iis development. I have
seen these growths, under the stimulus of diphtheria, attain
in a child where the inherited tendency was wanting sev-
eral times the size it attained in another child who, from
both father and mother, inherited this lymphatic throat.
When once hypertrophied, if left to itself, this third tonsil
disappears more or less slowly. I have seen marked
amounts of it still present in a gentleman sixty years of
age. In regard to the growth of this tissue there are some
interesting points. In some cases, under the forceps, it
feels almost like sponge, while on pressure it exudes a
quantity of a juicy substance. In these cases there is prob-
ably an excessive development of lymphoid cells, great in
proportion to the amount of the connective-tissue basis, and
here there is little pain accompanying their removal. In
other cases, the growths are more firm, cut readily under
the forceps, and the cut piece comes away clearly, and is
firm under pressure of the finger. In the third class these
growths are tough, are very painful when removed, even
under cocaine ; have a tendency to tear under the forceps,
and not infrequently one is forced to tear a small piece of
the adjacent membrane of the pharyngeal wall with it. In
these cases the pharynx is often painful after the operation.
In the first two cases the patient suffers little or no incon-
venience from the cutting. The third class of cases is gen-
erally found among those of the lymphatic temperament
where the growths have existed for a long time, most gen-
erally in adults. There exists a tendency in all cases for
these growths to decrease as the person gets older ; in
many cases to disappear. This latter occurs, it is probable,
more rarely in the so-called " inherited" cases.
Having attained a certain size, these adenoid growths
begin to diminish. Bosworth says: " Like other glandular
hypertrophies, these growths show a tendency to apparently
disappear at puberty. This may be explained by a diminu-
tion in the morbid activity of the tissues, and a certain
amount of shrinking which occurs in this peculiar form of
growth at this age, and also by the fact that they occupy a
relatively smaller space in the now more widely developed
pharyngeal vault." It is this " tendency to apparently disap-
pear " that concerns us here, together with an endeavor to
understand what is meant by "a diminution in the morbid
activity of the tissues and a certain amount of shrinking
which occurs in this peculiar form of growth at this age."
Another point of interest for us is whether this so-called
"tendency to apparently disappear" confines itself to the
"adenoid growths," or whether it spreads to the adenoid
layer, which is hut the continuance of the layer from which
these "growths" have their origin. The process by which
April 9, 1892.]- DUNN: ADENOID TISSUE OF THE PHARYNX AND NASO PHARYNX.
399
these growths disappear is in the majority of cases a slow
one, continuing through years, so that we not infrequently
find, and this especially in the " inherited " cases, it still
incomplete in persons forty-five or fifty years old. In some
cases the disappearance of these growths is much more
complete and much less slow than in others. Many condi-
tions seem to be here determining factors, and their relative
importance is little well understood. It is probable that
this "tendency to disappear" is not to be looked upon as
the result of the "diminution of the morbid activity of
these tissues," but as the result of the addition of repeated
inflammations, whereby the lymph cells are partly absorbed
and partly transformed into connective tissue ; or, it may
be that there results the formation of new connective tissue
from the pre-existing connective-tissue cells, the basis of
these growths, during which, in turn, the lymph cells are
absorbed, while later the new formed connective tissue con-
tracts. At all events, the relative amounts of lymph tissue
and connective tissue in these growths change as the
growths get older, the proportion of connective tissue con-
tinually increasing, and perhaps at the expense of the
lymph tissue. It is probable, then, that repeated inflam-
mations are the cause of this " tendency to apparently
disappear." The surface position of these growths makes
them especially liable to repeated inflammations, whereby
there results a sclerosing process, which, when once estab-
lished, is never at rest so long as there remains in them
hypertrophied lymph tissue. In a certain proportion of
these cases involution of these adenoids to the normal
seems possible. In others, especially in the lymphatic con-
stitutions, the sclerosing process sets in.
The reason why the involution to the normal of this
hypertrophied lymph tissue takes place, and seemingly
without ill effect, in the one, while in the other there sets
in a sclerosing process accompanied by such unpleasant ef-
fects upon the hearing, must be sought to a greater measure
in the difference of the constitution than in any process
superadded by disease. This sclerosing process, however,
occurs often enough in persons where the lymphatic tenden-
cy is wanting to show that certain conditions other than
inherited ones can induce this sclerosis. The mucosa, lying
beneath the epithelium of the pharyngeal mucous mem-
brane and that lining the Eustachian tube and middle ear,
is an adenoid tissue composed of loose cellular tissue in-
filtrated with lymphatic cells. This lymph tissue is of the
same character as that of the lymphatic ring, except that it
lacks in those aggregations of lymph follicles which char-
acterize this latter. It is in this adenoid stroma that, it
seems to me, must be sought the starting point of those
changes which are the cause of deafness in the so-called
" inherited " cases. Take, for example, a case which has
inherited a tendency to hypertrophy of this lymphatic tissue
of the upper pharynx. As a rule, the necessary stimulus to
this hypertrophy, whether it be bacillus, the excess of blood
in this tissue due to the process of "taking cold," or a
chemical product the result of disintegration of the mucous
secretions, is found early in life. Hypertrophy of this
tissue follows, usually accompanied by a like hypertrophy
of the faucial tonsils ; when once hypertrophied, involution
does not occur immediately. These masses of hyper-
trophied lymph tissue, however, become smaller ; the " tend-
ency to disappear " makes itself felt. This " tendency "
is, it seems to me, distinctly an inflammatory one, which is
never at rest so long as there remains hypertrophied lymph
tissue in these growths, and which is liable to exacerbations
from time to time. The process resembles that occurring
in cirrhosis of the kidney or liver. There are reasons for
believing that this process of sclerosis, by which this hyper-
trophied tissue becomes smaller, is not confined to these
hypertrophies, but spreads from them alon^ the contiguous
adenoid layer and thus reaches as far as the middle ear. It
may be that the same causes that determine the hyper-
trophy of these adenoids of the naso-pharynx determine
also an excess of cells in the adenoid stroma of the adjacent
mucous membrane, in which case, when sclerosis of the
growths sets in, it spreads or is determined more quickly in
their adjacent mucous membrane. To sum up : The sclero-
sis in these growths, then, seems to me to be the direct
result of repeated inflammations ; this sclerotic process
when once started does not cease as long as there remains
lymph tissue in these growths ; it usually continues for
many years ; its effects are not confined to the hyper-
trophies themselves ; a similar process may be determined
by it in the adenoid stroma of the mucous membrane linino-
the tubes and middle ear.
It may not be out of place just here to say a few words
in regard to the views held as to the mechanism by which
the deafness which often accompanies these adenoids,
though it may not be complained of until these adenoids
have existed for years, or until theyr have disappeared, is"
produced.
Bosworth, writing of adenoids of the naso-pharynx,
says : " A plausible explanation of the (ear) symptoms
is interference with the renewal of air in the middle
chamber, caused by their presence in the pharynx. Any
cause that interferes with free nasal respiration, if con-
tinued sufficiently long, is liable to cause impaired hearing.
The method in which this occurs, I take it, is that nasal
stenosis, arresting the to-and-fro current of air through the
nasal passages, causes a stagnation in the pharyngeal vault,
and necessarily a certain amount of rarefaction of air in
this region. ... As a result, rarefaction of air gives rise
to a condition of hyperemia of the mucous membrane, ex-
tending through the Eustachian tube to the middle ear ;
Eustachian orifice closed; air in the middle chamber rare-
fied ; drum-head retracted." This is plausible, except that
it is hardly ever, if ever, the case that the naso-pharynx
has its exits so closed that there results a rarefaction of the
air contained in it. Furthermore, I see no reason for be-
lieving that it is ever rarefied for such a length of time as
to produce hypera-mia of the mucous membrane. The
orifice of the Eustachian tube remains open, though the
tube mucous membrane may be so swollen as to be imper-
vious to air from the naso-pharynx; but in no case would 1
be willing to admit that this swollen condition of the tube
mucous membrane is due simply to rarefaction of air in the
naso-pharynx. Bosworth thinks it very questionable that
in these adenoid ear cases the ear symptoms are due to
400
ELSNER: PERFORATION OF TYPHOID ULCER.
[N. Y. Med. Joch.,
an extension of catarrhal inflammation, as advocated by
Woakes, Frankel, and others. If by "catarrhal inflamma-
tion " is meant the process in which there is an increase in
proliferation and desquamation of the superficial mucous
cells, with increased secretion, he is probably right, for,
while deafness in these cases occurs frequently enough as
the result of a catarrhal inflammatory process, I do not
think it is the rule. That these growths are frequently
sufficiently developed, and into the tube-mouth eminences
to such an extent as to interfere with the movements of the
tube mouth, and by their continued presence prevent devel-
opment of the tubal muscles, no one will deny who has ever
examined a sufficient number of cases of this affection.
The causes of deafness in these adenoid cases are more
than one. In a not inconsiderable number of the cases it
is due to acute catarrhal and purulent processes ; but these
cases do not concern us here. In another proportion of
these cases it is the result of the development of this
adenoid tissue into the tube eminences, and even into the
tube mouths, preventing the normal movements of the tube
mouth and producing closure of the tube, with its results,
and this proportion of these cases is very much larger than
one is led to suppose from the examination of the post-
nasal space in adults. To give due importance to this
cause of deafness from adenoids, one must examine the up-
per pharynx in young children, where there will be found, I
should say, from one third to one half, probably more, of
all the adenoid cases of any severity, this tissue so devel-
oped into the tubal eminences as to interfere with their
movements. In the majority of these cases this excessive
lymph tissue growth disappears from its encroachment
upon the tube eminences, and there remains no trace of it
in the adult ; the damage to the hearing has been done —
damage which, if left untreated in childhood, makes repair
impossible in adult age.
In the third proportion of cases, where past closure of
the tube can not be proved, where the acute catarrhal in-
flammation has not been present, the cause of the deafness,
it seems to me, must be sought in a slow sclerosing process
affecting the lymph cells of the adenoid layer of the tubal
and middle-ear mucous membrane. This process varies in
degrees of intensity and in the length of time requisite to
produce marked change in the power of hearing. The
length of time before and degree to which the hearing be-
comes impaired are dependent chiefly upon two causes : 1.
The degree of resistance possessed by the lymph cells of
the adenoid layer of the mucous membrane ; this, the in-
herited part of the cause. 2. The character of the inflam-
mations to which the hypertrophied adenoid tissue of the
naso-pharynx is subjected, as well as that of the inflamma-
tions superadded in this layer itself. Here two phases of
the question come up — the sclerosing process by which, in
many cases, the hypertrophied adenomatous tissue disap-
pears may, during its continued existence, cause the appear-
ance of a similar sclerosing process in the adenoid stroma
of the lube and middle ear and thus cause' deafness; or the
lymph cells of this layer may have so little resisting power
that they take on a sclerosing process, not as a result of
their proximity to a similar process in the adjacent hyper-
trophied adenoids, but as a result of repeated slight inflam-
matory attacks — e. g., colds, etc. — the result in time of ex-
posure. So it follows, in these third proportion of cases,
if the deafness that accompanies adenoids of the naso-
pharynx be due to a sclerosing process of the lymph basis
of the tubal and middle-ear mucous membrane, caused by
the persistent existence of a similar process in the adenoids
of the naso-pharynx, then removal of these adenoids will
prevent the deafness that follows when they are allowed to
remain; if, on the other hand, the deafness be due to ;m
inherited lack of resistance in the lymph cells of this ade-
noid layer of the tube and middle ear, although the re-
moval of the hypertrophied adenoids be indicated for other
reasons, we are not to hope that their removal will preveni
deafness.
The case of Mr. 8., related at the beginning of this arti-
cle, shows in an exaggerated way how the whole lymphatic
system of the upper throat may be affected by an inflam-
matory process at work in one part of the system where
hypertrophy has taken place. Had we here to do with
simply a painful throat and an acutely inflamed tonsil, the
case would have nothing worthy of note ; but we have a
different thing — an enlarged tonsil (both having been en-
larged, but one was removed), one which has been hyper-
trophied for seven years, accompanied by an apparently
acutely inflamed mucous membrane of the whole throat
and a condition which for months at a time remained aeut
]y painful. Removal of the tonsil does away, in a great
measure, with the inflammatory appearance of the mucous
membrane and altogether with the pain, while all other
remedies proved useless. It is, then, fair to assume that
in the tonsil was the cause of the inflammatory condition,
and thus of the pain. The process that was going on in
the tonsil was the development of connective tissue at the
expense of the lymph tissue — an inflammatory process. The
process affected the whole lymphatic layer of the upper
throat, and it is not improbable that it had extended to the
ear of the same side in which the tonsil existed.
PERFORATION OF TYPHOID ULCER,
WITH ADHESIVE AND PROTECTIVE PERITONITIS*
By HENRY L. ELSNER, M. D..
SYRACUSE. N. T.,
PROFESSOR OF CLINICAL MEDICINE, SYRACUSE MEDICAL COLLEGE.
In presenting this paper to you for consideration I am
prompted by the importance of the subject, the growing in-
terest manifested by the profession for accurate clinical data
relating to all unusual abdominal complications arising in
the course of typhoid fever, and an appreciation of the fact
that while much has been written and said, both by physi-
cians and surgeons, on the indications for treatment of in-
testinal perforation, medical and surgical, the subject is still
sub judice and requires a flood of light which can only be
supplied by the study of many cases at the bedside and on
the post-mortem table.
* Read before the Medical Society of the State of New York at its
eighty-sixth annual meeting.
April 9, 1892.J
EISNER: PERFORATION OF TYPHOID ULCER.
401
While I am to report but a single case, I find, on con-
sulting the literature of the subject, that it is sufficiently rare
to demand your attention, and from it 1 feel that we can
draw valuable deductions when associated with other experi-
ences which have accumulated in the past.
On the 27th of October, 1891, Gottlieb G., German, shoe-
maker, aged twenty-seven years, was admitted into St. Joseph's
Hospital, Syracuse, N. Y. Previously healthy, with negative
family history. To all appearances he was a temperate man, well
nourished, weighing about one hundred and eighty pounds. He
was sent to the hospital by my assistant, Dr. Werfelman, whom
he had consulted during the day and who diagnosticated walk-
ing typhoid fever. We judged him to be well advanced in the
second week of the disease, for there was already a well-marked
and characteristic roseolar eruption on the abdomen. He had
not been feeling well for three weeks, during which time he
had nose-bleed at frequent intervals, felt nauseated, vomited
several times, and had all of the usual manifestations of ap-
proaching disease. He had no chill, but had felt hot and fever-
ish while at his work; had no diarrhoea before entering the hos-
pital, but complained much of constipation.
On admission, we found the characteristic apathy of typhoid,
tongue dry and heavily coated, abdomen slightly distended and
tympanitic, with but little pain on pressure in the right iliac
region. A considerable amount of hypostatic congestion was
found at the base of both lungs. Temperature 103-2° F., pulse
93, respiration 22.
During the following seven days there were no noteworthy
symptoms, the temperature was easily controlled, never rising
above 103-8° F., the pulse rarely exceeding 100, usually between
90 and 100. There was but little delirium, no diarrhoea, and
aside from the roseolar eruption which persisted, and the usual
tympany found in like cases, no positive symptoms.
He had been carefully watched and nursed, kept on a liquid
diet without antipyretics, treated with intestinal antiseptics. On
the morning of November 3d, while making my daily visit, I
noticed a decided change in the appearance of the patient. The
facial expression denoted serious trouble; it was anxious, with
eyes sunken. He was having constant hiccough, vomiting of a
dark-green fluid, and complained of pain, not severe, however,
in the upper right corner of the hypogastric region. His pulse,
from 90 the night before, had by noon reached 120, while his
temperature was 103° F. Physical examination of the abdomen
gave increasing tenderness on pressure in the right inguinal and
adjacent hypogastric region, while the neighboring regions were
tympanitic. By afternoon a well-marked dullness on percus-
sion was found in the right half of the hypogastric region, ex-
tending into the right inguinal region, though at this time pal-
pation did uot reveal the presence of a tumor. It w,as noticed
that for eight hours there was anuria which was followed by
scanty urination; no movement of the bowels during the day.
At times during the night of November 3d bis pulse reached
140, his hiccough and vomiting continuing without sufficient pain
to demand administration of opiates.
On the morning of the 4th patient's general appearance was
not improved. The anxious expression was still present, his ex-
tremities were cold, the hiccough and vomiting continued. It
was now evident, on making a physical examination, that he had
a tumor, the largest portion of which was situated in the right
Upper half of the hypogastric, slanting downward into the right
inguinal region. This was plainly and easily outlined by palpa-
tion and percussion. It was not exactly in the position usually
occupied by a tumor associated with disease of the vermiform
appendix, and the McBurney point could not be found. The
symptoms simulated an appendicitis so closely, however, that
one was almost tempted to make that diagnosis. On taking into
consideration the rarity of such a complication with typhoid, in
spite of the frequency with which it has been diagnosticated,
the presence of the tumor in a somewhat anomalous position,
the absence of the McBurney point, the unusual amount of vom-
iting and hiccough, with at this time no evidence of perforation,
and the general condition of the patient, a diagnosis of localized
peritonitis over a typhoid ulcer, with adhesion to a neighboring
coil of intestine, was made. Temperature 100-5° F., pulse 124.
During the day there was no material change in the condi-
tion of the patient. The pulse continued rapid, averaging 140,
with rapid thoracic breathing, somewhat more tympany over
lower half of abdomen ; no movement of bowels. Urine scanty,
not albuminous.
On the morning of the 5th he was brought before my class
for clinic. His temperature had fallen to 97'2° F. and remained
there during the day; his pulse was 111 to 140, respirations 30
to 40 ; extremities cold, wrists cold, less hiccough and vomiting.
The tumor was still present, as easily outlined as the day before.
His bowels moved during the day. A careful examination was
made of the abdomen. In spite of the decided fall of tempera-
ture, no other evidence of perforation of typhoid ulcer wTas pres-
ent. Liver dullness was not effaced. At the clinic it was con-
cluded that we had a perforation of the ulcer, following the
localized peritonitis, the escape of gas into the free peritonaeum
prevented by sufficient plastic exudate and recent adhesions.
During the afternoon it was found that while tympanites in the
lower half of the abdomen was increasing sufficient to make the
detection of the original tumor impossible, there was still per-
sistence of liver dullness.
November 6th. — Patient much more comfortable, with tem-
perature 97 5° F., pulse 111. Lower half of abdomen still tym-
panitic; tumor lost; its position could no longer be determined,
its previous area yielding tympanitic percussion. Toward night
temperature gradually rose to 99-2° F., pulse 100. Bowels had
moved during the day. No opiates were administered at any
time, that the symptoms might not be masked; besides, there
were no indications for their administration.
During November 7th and 8th there were no decided changes
in the patient's condition. His temperature remained above nor-
mal, pulse improved in character, though equally rapid as before ;
his bowels moved ; mind remained clear; tympany slowly sub-
siding, so that on the morning of the 9th, though his tempera-
ture was 101° F., pulse 123, he was looking much better and the
original tumor was again palpable and in the same position as
originally found. His hiccough and vomiting had ceased; he
could lie on his side, while before he had rested on his back.
We had now commenced to doubt the correctness of our diag-
nosis and were ready to take a more favorable view of the case
than heretofore.
The morning of the 10th found our patient in better condi-
tion than we had left him the previous night; his temperature
99°, pulse 110, facial expression good, abdominal walls lax, no
tympany, physical signs of original tumor present.
During the day, from 3 p. m. to 8 p. m., he had five largo in-
testinal haemorrhages, and died almost exsanguinated at 8 p. m.
Post-mortem (made by Dr. F. W. Sears, pathologist, St.
Joseph's Hospital, assisted by Mr. Haw ley, student). — There was
nothing noteworthy in the appearance of the body; our atten-
tion being called to the abdomen by the symptoms, it alone was
examined. On opening the abdomen, the intestinal coils were
considerably dilated, and the peritonaeum was abnormally con-
gested and lusterless, without evidences of general peritonitis
save in a few spots where a small amount of plastic exudate was
noticeable. In the right half of the hypogastric and the right
inguinal regions were found well-marked evidences of recent
402
EL8NER: PERFORATION OF TYPHOID UU'FR.
[N. Y. Med. Jorn.,
plastic and circumscribed peritonitis. A coil of the ileum, be-
ginning about, five inches above the ileo-csecal valve, bad folded
itself against the head of the colon laterally, and was there firm
ly held by the recent products of inflammation. Nowhere in
the free peritoneal cavity did we find evidences of any escape of
intestinal contents. Tliis coil of ileum was everywhere sur-
rounded by fibrinous and purulent material sufficient to incap-
sulate it and separate it from the free peritoneal cavity, while it
rested against the colon on a pillow of almost completely organ-
ized fibrinous material. On raising this coil slowly and carefully
from its resting-place without much force, the escape of air from
the intestines was plainly audible. On closer examination, it was
found that there existed in the portion of the intestines resting
directly against the colon a perforation of a typhoid ulcer about
two centimetres in length, and it was futhermore positive that
the peritonitis had spent its greatest force around this ulcera-
tion.
Other portions of the intestines were examined, also the
colon, with a view of determining the origin of the fatal haem-
orrhages, without satisfactory result. Our clinical diagnosis,
therefore, was corroborated by the anatomical appearances. So
perfectly was the perforation sealed by the adhesive and pro-
tective peritonitis that no gas escaped during the post-mortem
until the ileum was lifted from its resting-place, when it was
found that the perforation itself had not closed, but was simply
sealed by its fortunate position against the colon, where Nature's
process held it.
There was no escape of fasces in the inclosure made by the
adhesions.
It appears to me that in this case we have several feat-
ures of unusual interest. The fact that a localized perito-
nitis over a typhoid ulcer may exist before its perforation
and protect the free peritoneal cavity is in itself sufficient
to claim more than passing notice.
The other interesting features of the case are the length
of time that the patient lived after perforation, the gradual
improvement preceding the fatal haemorrhage, the continu-
ation of the performance of intestinal function, the exist-
ence of the tumor, the absence of effacement of liver dull-
ness, and the unhappy termination of the case by copious
intestinal haemorrhages.
Griesinger,* many years ago, when he wrote his mem-
orable article on typhoid fever, in Yirchow's Pathologic und
Therapie, spoke of just such cases as this. The following
is a literal translation : " Evidently, in consequence of deep
ulceration from within and sloughing, there frequently re-
sults, even before perforation, a localized inflammatory pro-
cess, with adhesions of the inflamed patch to the neighbor-
ing intestinal coils. In such cases there is not at once per-
foration into the free peritoneal cavity. There is, however, a
formation of circumscribed exudation, with or without sup-
puration, which may ultimately lead to general peritonitis,
though it may possibly remain circumscribed and gradually
end in recovery. If there has been no adhesive process
before the perforation, gas and intestinal contents escape
into the free peritoneal cavity, and general peritonitis imme-
diately results."
It was a similar case which first led Buhl f to suggest
* Virchow. Hawlburh der xpecietlen Patholor/ie uivl Therapie. Band
ii, II. Abtheilung, p. 196.
f Henle und I'feufcr. Zeitxeh., N. ¥., vii, p. 12.
the possibility of recovery after perforation of a typhoid
ulcer. This, I believe, was in 1857. In Buhl's case death
occurred on the forty-fifth day of the disease and twenty-
three days after perforation. In this case, as in mine, the
perforation was not the immediate cause of death, his pa-
tient dying as the result of haemorrhage from a small artery
opening into the intestine near the piece of mesentery which
covered the hole. In Buhl's case, however, the hole was
completely closed. The report of this case at my command
does not mention the manner of closure.
There can be no doubt, and some of us could corrobo-
rate the fact by clinical experience, that a localized perito-
nitis without perforation around a typhoid ulcer may exist,
giving rise to sufficient adhesion and inflammatory products
to form a tumor which, for reasons which I will enumerate
further on, simulates appendicitis.
In this connection I wish to say a few words in regard
to the differential diagnosis between such tumor formation
as was found in the case reported and appendicitis, and the
prognosis of such cases. In a very interesting and instruct-
ive paper, recently read before the Association of American
Physicians by Professor Fitz, of Harvard University,* he
says : " Most cases of recovery from symptoms of perfora-
tion of the bowel in typhoid fever are those in which an
attack of appendicitis is closely simulated, while the fatal
cases of perforation of the bowel in typhoid fever are, in
the great majority of instances, those in which other parte
of the bowel than the appendix are the seat of a per-
foration. Hence the prognosis of apparent perforation in
typhoid fever is to be regarded as the more favorable the
more closely the symptoms and course resemble those of an
appendicitis."
You will kindly note that the author uses the words
" simulate " and " resemble." This, it appears to me, is a
happy use of the words.
While the diagnosis of appendicitis in typhoid fever
has been frequently made, anatomical proof is wanting to
establish such diagnosis. While there is some difference
of opinion with regard to the exact proportion of cases of
appendicitis occurring in conjunction with typhoid fever,
anatomical evidence would not place the proportion above
three per cent. ; thus Fitz,f in collecting one hundred and
sixty-seven cases of perforated bowel in typhoid fever,
found but five cases, or a little less than three per cent.
Murchison J found it but once in thirty-nine cases.
Other authorities, among them Morin,* found perforation
of the appendix in 18*75 per cent; Heschel,|| in 14-3 per
cent. It is difficult to reconcile these great differences of
the various writers. In New York, at least, where, accord-
ing to Professor Lange,A appendicitis occurs with such as-
tonishing frequency, it would be easy to establish the fact
of ulceration and perforation of the appendix with typhoid
fever if it existed.
* Boston Mrdieal and Surgical Journal, Oct. 8, 1891, p. 365.
\ Ibid.
\ Trcallte on Continued Fever, second edition, p. 623.
* These de Paris, 1869.
I Schmidt's Jahrbucher, 1853, lxxx, p. 42.
A N. Y. medicinixehe Monatxxchrift, Band III, 1891, p. 90.
April 9, 1892.)
EISNER: PERFORATION OF TYPHOID UICER.
403
The records of hospitals and the experiences of physi-
cians fail to establish that fact. It is safer, therefore, for
us as clinicians and therapeutists to adopt the statistics of
Fitz.
Reasoning from our daily clinical and growing experi-
ences with perforative appendicitis, we must conclude that
if perforation of the appendix in typhoid fever is of such
frequent'occurrence, that fact ought necessarily to be estab-
lished by positive pathological appearances.
Perforative appendicitis without typhoid fever is, as a
rule, a fatal disease unless relieved at once by surgical art.
Why, then, in typhoid fever should a perforated appendix
give a more hopeful prognosis ? There is but one way in
which the clinical fact that perforation simulating appen-
dicitis gives a more favorable prognosis can be explained.
The usual seat of perforation in typhoid fever is located in
the ileum, the larger number of perforations near the Lleo-
caecal valve ; but few perforations exist without more or
less plastic exudate. The adhesion of coils of ileum near
the colon, as in my case, would necessarily simulate appen-
dicitis. This is the only clinical explanation which can be
offered.
Among the differential points to be taken into con-
sideration in the diagnosis of appendicitis from typhoid
perforation we must consider the more sudden onset, as a
rule, of general peritonitis without preceding appendical
tumor, the profound change in the facial expression of the
patient, the absence of the McBurney point, and the per-
sistence in many cases of anuria for from eight to twelve
hours or longer.
In doubtful cases a rectal examination might be of
assistance. Certainly the previous history and the pulse and
temperature chart would be considered as factors in reach-
ing a conclusion. Simple perforative appendicitis would
be sudden, without preceding malaise or evidences of ap-
proaching sickness. The occurrence of such an accident
as reported in this case could be more readily diagnosti-
cated in an afebrile condition than at a time when the ty-
phoid process is at its height. Such cases as these teach us
the value of oft-repeated and careful examinations of the
abdominal viscera in typhoid fever.
There is still another point which I wish to bring to
your notice in conjunction with this case. It is the per-
sistence of liver dullness in spite of the fact that we had
intestinal perforation. To those of you who have studied
the views of the various writers on this subject it must ap-
pear surprising to find such a wide difference of opinion as
to the value of effacement of liver dullness in cases of per-
foration or air in the free peritoneal cavity.
Flint* wrote a paper in which he held that effacement
of liver dullness was one of the most characteristic signs of
perforation. In his paper he reports the case of a young
woman who developed an acute, diffuse peritonitis in the
course of typhoid fever, with persistence of hepatic dull-
ness, from which fact he concluded that intestinal perfora-
tion had not taken place, and from the fact that death did
not occur until a week after the occurrence of peritonitis.
* Medical News, Philadelphia, 1882, vol. i, p. 150.
As there was no autopsy in this case, the diagnosis may be
doubted. The time of death ought not to weigh in the
diagnosis. The differences of opinion with regard to the
effacement of liver dullness, it appears to me, can be recon-
ciled if we take into consideration the two great sources of
error :
1. An unusually distended transverse colon by its
presence between the liver and abdominal wall, yielding on
percussion tympany anteriorly over the area of normal liver
dullness without perforation existing.
2. Perforation in those cases where, as the result of
adhesive inflammation, incapsulation, bands, or from other
causes, air or gas is held within a circumscribed area or in
the lower half of the abdomen without effacement of liver
dullness.
The careful examination of the abdomen would reveal
the presence of the first source of error by placing the
patient upon the left side and percussing in the axillary
line on the right side over the liver from the eighth rib
downward, the presence of free air in the peritoneal cavity
showing itself by a disappearance of dullness in that line,
while there would be a persistence of dullness if the ante-
rior tympany had been caused by the distended transverse
colon.
This manoeuvre has frequently assisted me, and is men-
tioned by Leube * and Gerhardt f as a valuable means of
diagnosis.
In the case here reported we had in the persistence of
liver dullness, in conjunction with the other symptoms
which the case offered, abundant evidences of a perforation,
so that while we are all agreed that with air in the free peri-
toneal cavity we have in effacement of liver dullness a most
valuable aid in strengthening the diagnosis of intestinal
perforation, the presence of liver dullness, with symptoms
of perforation, would lead us to suspect protective adhesion
or sufficient incapsulation.
My case is another one to be added to the list of those
which must materially affect the prognosis of typhoid per-
foration. The anatomical appearances were sufficient to
convince all those present at the autopsy that the cause of
death was in no way traceable to the perforation.
Finally, the question of surgical interference in this
class of cases must be taken into consideration. I would
not weary you with a single word in connection with that
subject had I not seen the article recently written by Van
Hook J on Laparotomy for Intestinal Perforation in Ty-
phoid Fever, in which the author reports three cases
operated upon, one of which was successful.
Among his conclusions, he says that "there is no
rational treatment for perforation in the course of typhoid
fever except laparotomy. . . . The only contra-indication
is a moribund condition of the patient."
He also says that " the symptoms of peritonitis should
not be awaited before operating." It appears to me that
these conclusions are too extreme, can not be safely fol-
* Spcciellc Diagnose tier innercn Kranhh<it<n. Leipzig, 1880, p. 345.
f Lehrbuch der Auscultation imd Percussion. Tubingen, 1890, p. 335.
% Medical News, Philadelphia, 1891, vol. ii, p. 591 to 695.
404
STARR: AN INSTRUMENT FOR DETERMINING REFRACTIVE ERRORS. [Jf. Y. Med. Jock.,
lowed, and do not take into consideration the possibility of
preceding adhesive and protective peritonitis to guard the
general peritonaeum and the possibility of recovery from
such an accident.
It would be far safer for us to follow the more conserva-
tive course of Da Costa,* who, in the recent discussion on
the subject, said that he would " never sanction an opera-
tion for perforation unless a causal appendicitis could be
clearly made out, or for the relief of a patient from peri-
tonitis."
The conclusion reached by Fitz \ must have some weight
in our decision, inasmuch as his thorough study of the sub-
ject gives his opinion great value. He opposes immediate
laparotomy for the relief of suspected intestinal perforation,
advising it only in the milder cases of this disease. " In
all others, evidences of a circumscribed peritonitis should
be awaited, and may be expected in the course of a few
days."
If this condition requires surgical interference, it will
be well for us to delay until the strength of the patient
warrants it.
Conclusion. — 1. A localized peritonitis over or in the
neighborhood of a typhoid ulcer may exist without perfora-
tion.
2. Localized adhesive and protective peritonitis over or
in the neighborhood of a typhoid ulcer may precede per-
foration and protect the free peritoneal cavity.
3. In some cases coils of intestine may become ad-
herent, giving rise to tumor formation.
4. Symptoms simulating or approaching perforative ap-
pendicitis may exist, making a diagnosis between appendi-
citis and typhoid perforation with adhesions difficult.
5. Anatomical research proves conclusively that per-
forative typhoid appendicitis is exceedingly rare.
6. The prognosis of typhoid perforation is more fa-
vorable in proportion to the amount of circumscribed peri-
tonitis and the nearness with which ordinary ajjpendicitis
is simulated.
7. Localized peritonitis preceding perforation and ulti-
mate perforation can be diagnosticated in some cases.
8. Persistence of liver dullness does not preclude the
possibility of intestinal perforation. Air and gas may es-
cape into the lower abdominal regions and be held there by
adhesions without changing liver dullness.
9. AYith effacement of liver dullness we must make
sure by physical examination that such change is not due
to the presence of an abnormally distended transverse
colon.
10. Surgeons are not justified in performing laparotomy
for the suturing of perforated typhoid ulcers if circum-
scribed peritonitis of an adhesive or protective character
exists or is in process of development.
The Presbyterian Hospital. — We learn that at the annual meeting in
April the managers will make the following appointments : Three ad-
ditional visiting physicians, an additional consulting surgeon, and sev-
eral consultants in special departments.
* Boston Afrt/ico/ ami Suri/iad Journal, Oct. 22, 1891, p. 441.
f Hid., Oct. 8, 1891, p. 867.
A NEW [NSTRUMENT FOR
QUICKLY DETERMINING REFRACTIVE ERRORS
OF THE EYE.
By ELMER STAKR, M. D.,
, BUFFALO. N. T-,
LECTURER ON OPHTHALMOLOGY IN THE MEDICAL DEPARTMENT OF
THE UNIVERSITY OF BUFFALO.
The refraction of an optically perfect eye is such that
parallel rays of light entering it are brought to a focus on
its retina. Any deviation from this condition constitutes
an error of refraction, and requires for its correction some
variation of the luminous rays from parallelism.
The generally adopted method of determining the re-
fraction of the eye is to use test types placed at such a dis-
tance that the rays of light emanating from them may be
regarded in practice as parallel ; and the deviation from
parallelism necessary to correct a refractive error is effected
by placing a lens in front of the eye. Besides this pro-
cedure there are many other methods of changing the course
of luminous rays coming from a test object. The single
convex lens is the simplest means of varying the direction
of luminous rays, and has for this reason been often used in
optometry.
If an object is placed at the focus of a convex lens, the
rays of light coming from this object will, after passing
through the lens, be parallel. The farther the object is
removed from the lens, the more the rays will converge
after passing through it, and in this way the deviation
necessary to correct an hypermetropia may be obtained.
On the other hand, if the object is brought from the focus
nearer to the lens, the rays which leave the lens will be
divergent ; and this change is such as to adapt it to the re-
fractive condition of a myopic eye.
Cocius, Smee, von Graefe, Badal, and others have made
use of this principle in constructing optometers, the test
objects of which consist of threads or lines, or of letters
and figures placed at the focus of a lens of three or four
inch focus.
All these optometers have the disadvantage that they
provoke a certain effort of accommodation, inasmuch as the
observer is conscious of the proximity of the test object.
It is important that the accommodation be excluded in de-
termining the static refraction of the eye ; otherwise, the
dynamic being added to the static refraction, the real error
may be masked.
Then, too, some of these instruments do not serve to
determine the visual acuteness because of the change in the
size of the retinal image which they produce ; the measure
of visual acuteness is given by the size of the retinal image,
and the acuteness of vision in one eye is comparable with
that in another only when we know the size of the smallest
retinal image that each can distinguish.
An optometer is fitted for the simultaneous determina-
tion of visual acuteness and refraction only on condition
that the retinal images of all eyes examined by it have the
same size.
The instrument here described fulfills these conditions
completely, and has none of the disadvantages of the single
convex lens.
April 9, 1892.] STAR]?: AN INSTRUMENT FOR DETERMINING REFRACTIVE ERRORS.
405
The instrument consists of a cylindrical tube about
15 ctm. long-, mounted on a stand, which admits of its be-
ing regulated for height and inclination. Within the tube
a 16 D. convex lens (P, Fig. 1) is fixed, at a point 6j ctm.
from the proximal end; that is, at just the focal length of
the lens. Beyond the convex lens, and moved by means of
a rack and pinion, is a concave 16 I). lens (M, Fig. 1). The
effect of this concave lens is to render parallel rays diver-
gent, but this effect is neutralized by the convex glass when
the two lenses are in contact. When, however, the two
lenses are separated from each other, the convex glass more
than neutralizes the divergence caused by the concave glass
and the rays are made to converge. The action of the sys-
tem will be better understood by reference to Fig. 1.
V
Fig. 1.— When M and P are in contact, rays a a' continue in their original
direction. The effect of moving M from p to p' is shown by the broken line.
The eye whose refraction is to be tested is situated at
the end of the tube at E. The effect of the concave lens M
upon the parallel rays a a' is to cause them to diverge, so
that they leave the glass in a direction as if they came from
the point o, which is the focus of the lens M, which in this
case is 6j ctm. in front of the glass. The effect of the con-
vex glass P, then, upon the rays a a' is the same as if the
rays proceeded directly from the point o ; in fact, the point
o may be considered, in this respect, as the object. Now,
as already stated, when an object is placed at the focus of
a convex lens, rays of light coming from this object will,
after passing through the lens, be parallel ; and if the ob-
ject be removed from the lens the rays will converge after
passing through it. So that, if the lens M be brought into
contact with lens P so that o falls in the focus of lens P,
the rays a a will leave P parallel ; and if the lens M be
moved away from P so that o falls outside the focus of P,
the rays a a' leave P convergent, and the amount of the con-
vergence depends upon the distance of o from P — that is,
upon the distance the lenses M and P are separated. Cal-
culation shows that for every ctm. the lenses are sepa-
rated, the effect is the same as a one-diopter convex lens,
or +1 1 ). ; or a separation of the glasses 6'25 ctm. is
identical with a + 1 6 D. lens.* It will be seen, then, that
* The formula for determining the effect of a given separation of the
lenses in this instrument becomes the same as the formula for de-
termining the point at which the image made by a convex lens falls
when the distance of the object from the lens is given. For the focus
of the concave lens is virtually the object, and its distance from the
eonvex lens manifestly depends upon the distance the lenses are apart.
Let /' denote the focal length of the convex lens P ; </, the distance
of the object (focus of concave lens) from 1' ; and i the focal length of
the resulting combination.
d-f f
Then the equation . =x_f w^ Slve tne value of any given
movement of the concave lens M.
Suppose the lens M be moved away from 1' o ii5 ctm. ; then the dis-
every possible degree from zero or nothing up to + 16 D.
can be obtained with this combination. For any concave
or minus combination it is only necessary to place in the
proximal end of the tube at E a minus lens of such power
as to neutralize the converging rays coming from the lens P
when M and P are 6J ctm. apart. That is, when the lenses
stand in this position, their effect is just neutralized by a
concave 16 D. lens placed in the end E of the instrument,
and the rays of light then leave this lens parallel again and
the combination once more stands at zero. If now the
lenses M and P are brought nearer together, the result is a
combination weaker than -f- 16 I)., so that the concave lens
at E more than neutralizes this effect, and the rays leave
the instrument divergent, or as they would after passing
through a single concave lens ; so that by this means every
possible degree from 0 up to — 16 D. can be obtained.
In practice the tube of the instrument is graduated with
a scale showing dioptres and half-dioptres, and the frame of
the movable lens M carries a pointer which indicates the
number of dioptres corresponding to the amount of sepa-
ration of the glasses. A disc having a stenopaic slit and
fitting into the end of the tube serves to determine the re-
fraction of each meridian of the eye separately.
The advantages of this combination are decided, as it
allows of the use of the ordinary test type placed at the
usual distance, so that no effort of accommodation is caused
by the proximity of the test object. Then, by this arrange-
ment, the anterior focus of the eye is kept at the focus of
the convex lens of the instrument, so that no enlargement
of the test object is produced. In other words, the condi-
tions are most favorable for determining the actual refrac-
tion of the eye.
174 Franklin Street.
The Sense of Equilibrium. — " Our Vienna correspondent," says the
Lancet, " writes as follows : At a recent meeting of the Vienna Society
of Physicians, Dr. Kreidl, Professor Exner's assistant, reported on the ex-
periments he had made on deaf mutes concerning the physiology of the
labyrinth. Touching the experiments made on this subject by Flourens,
Goltz, Mach, and Breuer, he pointed out that the membranous canals of
the internal ear should be regarded as the peripheral part of the
mechanism of the sense of equilibrium, the sensations of the disturbance
of which he takes to be produced by the flow of the fluid in the ampulla
and in the membranous canals. If the views of physiologists on the
function of the otoliths and the membranous canals be true, it would
have been expected that anomalies of the sense of equilibrium should
be found in deaf-mutes. Purkinje had previously observed that if a
person is made to rotate on his own axis the eyeballs were moved to the
side as in nystagmus. This in Dr. Kreidl's experiments was not ob-
served in deaf-mutes to any very large extent. Dr. Kreidl from other
experiments is led to regard the otolithic organs as a statical sense."
tance of object is 025 ctm. + 6'25 ctm. (focus of M) ; or d = 6'50 ctm.
Focus of P = 6"25 ctm., or /= 6'25 ct:n.
Substituting these values in the equation, we have
6-50 — 6-25 6-25
6-25 =i=WV WhenCe*
162-50.
That is, the focus of sucli a combination falls 162 50 ctm. behind
the lens P. But the lens P is placed 6-25 ctm. in front of the eye-
hole of the tube, hence the focus falls 162-60 ctm. — 6 25 ctm.
= 156-25 ctm. behind the eye. A glass of 156*26 ctm. focus is of
a diopter, or (V64 D. Therefore, separating P and 31 0-25 ctm. equals
■f 0'64 D. From this it is easily calculated that the effect of moving
M ('>! ctm away from P. is equal to a +16 D. lens.
406
BURNETT: NEW OBSERVATIONS IN THE USE OF SULPHONAL. f N. Y. Med. Jouh.,
NEW OBSERVATIONS
IN THE USE OF SULPHONAL.*
By S. GKOVER BURNETT, A. M., M. D.,
KANSAS CITY, MO.,
LECTURER ON DISEASES OF THE MIND AND NERVOUS SYSTEM,
KANSAS CITY MEDICAL COLLEGE ;
CONSULTING NEUROLOGIST, M SsoURI PACIFIC RAILWAY HOSPITAL ;
VISITING NEUROLOGIST TO ALL SAINTS HOSPITAL.
Since the advent of sulphonal into the domain of our
therapeutics in 1888 — for before this it was rather more of
experimental than of therapeutical use — I have been an un-
tiring advocate of its known superiority over other hyp-
notics, as well as a diligent student in searching out other
qualifications with which we are not familiar. Hence in
this brief review it is only intended to mention develop-
mental features.
In the New York Medical Journal for March 2, 1889, I
reported, in connection with a tabulation of cases illustrat-
ing the experimental use of sulphonal, my first ease of poi-
soning by this drug.
Case I. — This patient was a chronic melancholiac, fifty nine
years old, and suffered from arterio-sclerosis, with compensa-
tory cardiac hypertrophy. The drug had been given her in re-
pented doses to overcome the insomnia of melancholia agitata,
without any good results (see Points on the Use of Sulphonal,
by the writer, in the Kansas City Medical Index, August, 1S90).
At that time we were told to give almost any quantity without
fear, and some three thirty-grain doses were given during the
night. When called to see her in the morning she was quite
cyanotic; respiration, 16 and of a labored character; tempera-
ture, 98° F. ; with a we;ik, compressible pulse of 60. She lay
in a comatose state all day, and wai not able to walk for some
ten days or more. Inco-ordination was so great that she re-
mained helpless so far as locomotion was concerned. The re-
flexes were not examined.
Case U. — This case was that of a robust married lady of
thirty years, who at this time was suffering from an acute attack
of dysenteric diarrhoea. A part of the treatment prescribed was
the use of ten-grain doses of salol every two hours and the re-
cumbent posture. She took the first dose at 6 a. m. At noon a
messenger called, saying Mrs. C. was in a deep sleep, and asked
if the medicine would cause it. I replied in the negative, and
expressed my pleasure to hear of her resting so well, at the same
time requesting that she be not molested, only to give her the
powders. At 8 p. m. her brother alarmed me by saying Mrs. C.
could no longer be awakened, and, unless something could be
done, her condition was becoming critical. I knew something
was in error, for no narcotics had been prescribed. The coun-
tenance presented a peculiar blanched, cyanotic aspect, which
immediately recalled one other case (just mentioned) of sul-
phonal poisoning, for which I was accountable, I supposed, and
which has been reported. Examination of the medicine re-
vealed tin- fact, that the apothecary had put up sulphonal instead
of salol, of which seven ten-grain doses had been taken, mak-
ing in all seventy grains. The pulse was 55, full and bounding,
but not strong; respiration, 14; temperature, 98° F.
This case was observed in 1889, and all cases of sulphonal
poisoning coming to my notice have been characterized by low-
ering of temperature. Just what significance the temperature
may have here it is difficult to say. as it registered 102° F. in
the morning, and any conclusion would simply be a supposition.
* Head before the Medical Society of the Missouri Valley, at Lincoln,
Nebraska, December 17 and IS, 1891.
Any such profound state, unless arising from acute causes, might
present a perceptible lowering of temperature without causing
surprise. Some two hours elapsed before any voluntary move-
ments or attempts of recognition on the part of the patient
were made, notwithstanding she was being stimulated and fairly
dragged about the room. Efforts at resuscitation were kept, up
some four hours before intelligent attempts to answer <|iies-
tions were made, and as soon as left to herself she went into a
deep sleep again. The next day the patient experienced a
pleasant stupidity, declined food, and possessed no control over
co-ordination, and, after one or two efforts, could not be induced
to try to walk. Examination of the knee reflex was negative,
excepting when the patient was caused to diveit her mind to
something else, and then only a very slight reflex was found to be
present. Some ten days were required for her to regain her co-
ordinating powers, at the end of which time the knee reflex was •
found to be normal. (Reported in the Kansas City Medical
Index, August, 1891.)
Case III. — A man, aged sixty-nine years, suffering from re-
current mania. Some ten days have elapsed since this attack
came on. Before administering any medicine whatever, I demon-
strated in the presence of the house surgeon, Dr. Thrush, that the
deep reflexes were exaggerated. Friends state that the patient
has not slept to amount to anything for twenty-seven nights;
gave him thirty-five grains of sulphonal and he slept all night.
The same dose was continued for four or five nights, when he
developed inco ordination till he walked with uncertainty, and
would fall if not very careful. The dose was then reduced ac-
cording to symptoms, varying from twenty to thirty grains for
about fifteen days. During this time he slept well every night,
and finally got to sleeping some during the day. I now exam-
ined his reflexes in the presence of Dr. Thrush and Dr. Willis
I'. King, and found them to be entirely absent. Diverting the
patient's mind, causing him to close his eyes and pull on his
hands, would not cause the reflex to return. After the discon-
tinuation of the sulphonal for five days, his reflexes returned to
their former condition, with entire recovery from his inco-ordi-
nation.
Case IV. — This was a case of profound insomnia, which
condition had been present for more than a year, and the patient
was referred to me by Dr. Frick. The knee reflexes were exag-
gerated and their condition was noted. After the pacient had
taken twenty-five- grain doses of sulphonal for four successive
evenings, inco-ordination appeared with reduction of the ex-
cessive reflex to considerably below normal.
Now, the point to which I wish to call attention is the
loss of reflex after large or continued doses of sulphonal,
and also to ask upon what hypothesis are we to account for
this change ? I regret to say that I have neglected in each
rase to examine the peripheral sensory condition.
Without a question there is a close connection between
this loss of reflex and the inco-ordination, for in no case
have I seen any change in the reflex until after symptoms
of inco-ordination were manifest.
The only mention of a case in which the reflexes have
been affected is in the Satellite for December, 1891, where
a fifteen-year- old boy had taken a hundred grammes (over
three ounces) of finely pulverized sulphonal, which he
washed down with a large quantity of water. He walked
in the open air for three quarters of an hour, after which
he could give no account of himself, and in six hours was
found unconscious. Mis temperature was 96° F. ; pulsa
100, small but regular. Second day, sleeping quietly, face
April 9, 1892.-]
BLACK: EFFECTS OF ALTITUDE ON MUCOUS MEMBRANES.
407
slightly suffused, respiration quiet (18) and deep; pulse,
96 and extremely unsteady; reflexes uncertain, excepting
the corneal reflex being distinct. Pupils reacted to light.
Shaking, pricking of face, bands, and feet produced no
effect except distinct widening of pupils. On the third and
fourth days he slept soundly, reacting' Letter to irritants
without awakening. The subnormal temperature of 96° F.
rose to 101 F. on the fourth day; fell again to normal,
then rising to 100-8° F., and then falling to normal, where
it remained. On the fifth day his eyes opened repeatedly,
but still entirely unconscious. Pupillary reaction sluggish.
On the sixth day consciousness returned, and he imagined
himself on a ship, probably due to the dizziness. He could
not walk or stand without assistance.
Now, I have no knowledge of any record of abolished
reflexes from the use of sulphonal, excepting this one men-
tioned, and it only states that the "reflexes were uncertain."
From a standpoint of diagnosis, it is important to know if
the loss of reflex be due to disease or the use of sulphonal
before coming to he examined, as a prognosis based on the
loss of reflex due to organic disease would be quite dissimi-
lar to the same condition due to the use of sulphonal.
By accepting the reflex theory advanced by Growers, and
that sulphonal, as a hypnotic, act,- upon the cells of the
cerebral cortex, we can account for the absence of the reflex
in these cases. Gowrers infers that we have a restraining or
inhibiting power over the reflexes situated in the corpora
quadrigemina or optic thalarai, as has been demonstrated
to exist in the optic lobes of the frog. Again, these in-
hibiting centers are controlled by a power residing within
the higher or motor cortical cerebral centers, providing they
are in a healthy state of activity. Now, if from any cause
these cortical cells are prevented from exerting their power
of control over the center which inhibits the reflex, this
center goes uncontrolled and holds our reflex in check — that
is, abolishes it. This would seem the most lucid explana-
tion, for certainly all cortical functions seem suspended
when under excessive doses of sulphonal, especially when
toxic manifestations exist. Time and again of late I have
been able to diminish the reflex by continued full doses of
sulphonal, and to allow it to appear again by diminishing
the dose or discontinuing it entirely.
THE EFFECTS OF ALTITUDE
UPON THE MUCOUS MEMBRANES OF THE
UPPER AIR PASSAGES.
WITH REPORT OF CASES*
By G. MELVILLE BLACK, M. P.,
DENVER. COL.,
EX-HOUSE SURGEON TO THE MANHATTAN EYE AND EAR HOSPITAL. N. T. ;
LECTURER ON DISEASES OF THE EYE, EAR, NOSE, AND THROAT
IN THE MEDICAL DEPARTMENT OF THE UNIVERSITY OF COLORADO.
I ii ave observed that people coming to this altitude, of
one mile above sea level, from about sea level, experience
within a day or so after arrival more or less symptoms at-
tributable to an irritable condition of the mucous membranes
* Read before the Denver and Arapahoe County Medical Society,
January 12, 1892.
lining the upper air passages, especially that portion lining
the nasal cavities. This irritable condition may develop
into an inflammation, usually of a mild form, but may be
quite severe. They attribute this, in a large proportion of
cases, to "having caught cold." That this may be the case
I will not dispute, and which I will try and show further on
acts as the exciting cause with the low atmospheric pressure
as the predisposing cause.
Taking Denver as our objective point, we have an at-
mospheric pressure of twelve pounds to the square inch,
whereas at sea level the atmospheric pressure is 14-98
pounds to the square inch, a difference of about three
pounds. Let a person come here who has been raised under
this latter pressure ; his vaso-motor nerves have been receiv-
ing a certain amount of nervous force to maintain an equilib-
rium of the vascular supply of the mucous membranes of the
upper air tract. We know that the amount of blood in the
sinuses of the turbinated bodies is very variable, owing to
various atmospheric and systemic causes, but, notwithstand-
ing, the equilibrium, day in and day out, remains about the
same. This individual steps suddenly into this altitude and
is maintained by an atmospheric pressure of three pounds
less than that he has been accustomed to. What is the re-
sult ? There is a greater amount of stimulus sent out to
the vaso-motor inhibitory nerves, to arrest the vascular dila-
tation of the superficial capillary system of the whole body,
and especially so to the mucous membranes of the upper air
tract, inasmuch as the blood-vessels are much more ex-
posed here than in cutaneous surfaces. This amount of
nerve force is unusual and can only be kept up for a certain
length of time, and finally gives way, the result being capil-
lary dilatation, more or less over the whole body, but very
slight, except in exposed mucous surfaces; and, inasmuch
as the amount of nerve force required for cutaneous surfaces
is very slight, as compared with exposed mucous surfaces, it
is possible in a large percentage of cases for the extra amount
of nerve force to be supplied to cutaneous surfaces without
giving way. These individuals are particularly liable to
catch cold, inasmuch as our days are warm and nights cold,
and, by virtue of the fact of their depressed nervous vitality,
a slight loss of bodily heat results in a much more marked
relaxation of the vaso-motor control ; and as the vessels of
the upper air tract are already in an advanced stage of dila-
tation, we have the symptoms of a cold in the head setting
in, a modified form of acute rhinitis with an accompanying
inflammation of the mucous membrane down to the trachea;
but the principal symptoms are referable to the nose. The
patient complains of a sensation of fullness in the nasal re-
gion, extending up over the eyes, frontal headache, insom-
nia, some elevation of temperature — one to two degrees.
Upon arising in the morning a tired, "used-up" feeling and
a general feeling of exhaustion prevails all day. The nose
discharges a thin watery fluid which may be quite profuse in
the course of forty-eight hours ; this continues unchanged for
some days, then becomes somewhal thicker from exfoliation
of epithelial cells, but does not become purulenl at anytime,
as a rule. Resolution gradually sets in, beginning usually
about the tenth day ; the patient begins to feel very much
better at this time, but is not free from some of the promi-
408
VALK: TONIC SPASM
OF A CCOMMODA TION.
[N. Y. Med. Jour.,
nent symptoms until about the twentieth day. The nose
remains considerably " stopped up," however, after all the
acute symptoms have subsided. The system is now becom-
ing more accustomed to its new environments, and is able
to supply more vaso-motor nerve force, but the least impru-
dence in exposure is liable to set our patient back. I do
not mean to say that every one who comes to Colorado has
to undergo this ordeal, but a large number do, and these
cases are subjects who have been more or less troubled with
catarrh for some years.
The nose, as we know, secretes about one pint of fluid
in twenty-four hours, which is taken up by the inspired
air. The amount of moisture required by this air depends
upon how much water it is holding in suspension. The
humidity at Denver will average about forty-nine per cent.>
whereas the average humidity in our Eastern States will be
from eighty to ninety per cent. The amount of fluid se-
creted by a normal mucous membrane in Colorado I don't
think has ever been estimated, but, if a pint is secreted in
New York in twenty-four hours, the nasal mucous membrane
in Colorado will have to do almost double duty to provide
the air with the same amount of moisture. This additional
activity undoubtedly brings about changes by virtue of this
fact. The mucous membrane covering the turbinated bodies
undergoes a true hypertrophy, and the vascular sinuses are
constantly dilated to supply sufficient serum for the additional
osmosis required. This finally results in a hyperplasia from
the irritation caused by the approximation of turbinated
bodies to the sseptum ; the vacuum behind the point of contact
increasing the vascular dilatation, connective tissue is thrown
out between the vascular plexus until we have a true hyper-
plasia resulting. The patient finally gets some relief from
the stenosis and accompanying symptoms by the contrac-
tion of this newly formed connective tissue, thereby reduc-
ing the size of the turbinated bodies somewhat and afford-
ing more air space. It is not my intention to go into the
treatment of these conditions further than to say that in
the acute condition a one-per-cent. solution of cocaine, with
five grains antipyrine to the ounce, used as a spray every
few hours, will afford much relief. In the resulting chronic
condition local astringent applications have but little effect,
but the judicious application of trichloracetic acid to the
turbinated bodies has worked admirably in my hands. Any
nasal deformities should be corrected, such as removing
with the nasal saw or trephine septal protuberances, straight-
ening septal deviations, snaring out nasal polypi, etc. In
short, first removing any previous existing nasal deformities,
and, if the result is not adequate, touching the turbinated
bodies with trichloracetic acid. The following cases are ex-
amples of a number on my case-books :
Case I. — C. F. R., male, aged nineteen. Been in Colorado
about four years. Lived in Virginia formerly. Never any
trouble with nose until be came to Colorado. Remembers of
having "caught cold" the first day in Denver; says it troubled
him for some time very much ; thinks he has never got over it.
Says his nose is stopped up a great deal of the time ; can usually
get some air through • side, lias to hawk every morning to
expel a large quantity of mucus from throat, and does more or
less of it all day. Thinks be is not so bad now as be was for
the first three years; had a good deal of headache then, very
little now. An examination revealed both inferior turbinated
bodies very much enlarged. Cocaine had the power to shrink
them up about one half. Middle turbinated bodies were also
found enlarged to a great extent. The septum was in fair con-
dition— so much so that I did not meddle with it, but confined
my treatment to applications of trichloracetic acid, burning a
long furrow at the lower surface of both inferior and middle
turbinated bodies. 1 bad to repeat the treatment once, burning
in the old tract. Gave him a spray composed of two ounces of
benzoinol and one drachm of eucalyptol. He has been relieved
of all bis symptoms.
Case II. — Mr. T., aged thirty-five. Moved here from New
York about three years ago. Thinks he used to have some catarrh
in New York ; never gave him much trouble, except when he bad
a cold. The first week he was in Denver he " caught cold " ;
thinks it was different from any cold he ever had, lasted longer,
and made him feel worse. Nothing but a watery fluid came
from nose. Says he " lias never been able to breathe out of
nose well since.'1 To cut a long story short, he had typical
hyperplasia of all the turbinated bodies, with quite a large spur
projecting from lower part of Left side of sajptum. This I re-
moved, and reduced the size of turbinated bodies by use of tri-
chloracetic acid. He thinks he is in about the same condition
now as when in New York.
REPORT OF A CASE OF
TONIC SPASM OF ACCOMMODATION*
By FRANCIS VALK, M. D.
In one thousand cases of refraction on my note-books, I
do not find a case of true tonic spasm of accommodation ex-
cept the present case to be reported, and in a note by Pro-
fessor P. P>. St. John Roosa, in his translation of Schmidt-
Rimpler's book, I find these words in reference to tonic
spasm : " Certainly cases are very rare with us when atro-
pine is to be used for months for spasm of the accommoda-
tion." The report, therefore, of the following case may be
not only interesting, but also in showing some reason for a
division of spasm of the ciliary muscle by Schmidt-Rimpler
as tonic spasm of the accommodation and what he terms
abnormal accommodative tension.
History as follows : Mr. C. N. A., aged forty-one, sent to me
by Dr. Ford, Morristown, N. J. His family history perfectly
good. In 1882 he was an Indian scout on the Western plains.
He was brave and courageous and was in many dangerous places,
having a rifle ball put'through the rim of his bat, and at another
time one struck the pommel of his saddle. After the shot through
the hat, his left eye " felt badly " and he kept it tied up for a
day or so. He states that his vision at this time was perfect, so
that be could see at any distance. In 1884 he came East, and
was writing in the editorial rooms of the North American Re-
view. In that year he had an attack of paresis on the left side,
with diplopia. He could not walk well without a cane ; was deaf
in the left ear, with dizzy sensation. These symptoms in time
all passed away and his bodily health was good ; some time after
this, when his present troubles began, he bought a farm in the
country and commenced living out there.
His friends state that he is extremely irritable, and will use
* Read before the Ophthalmological Section of the New York
Academy of Medicine, December 21, 1891.
April 9, 1892.]
VALE: TOXIC SPASM OF ACC0MM<>1>ATI<>X.
409
profane language on the slightest provocation — a habit foreign
to his usual temperament. He was found to be green blind com-
pletely, and partially so for red.
He can read very well, but feels tired and sleepy when doing
so, while his distant vision is not good. When coming to the
city the streets appear contracted like long lanes — evidently a
narrowing of the field of vision, and, as he expresses it, " a dry
contraction about the eyes." This contraction feels like a band
drawn around them. His vision at the first visit was as fol-
lows :
R. E. V. = |f w. - & = If L. E. V. = ff w. -fV = «,
lie reads No. I J. at nine to nineteen inches, giving a region
of accommodation, with diamond type, of about ten inches.
The examination by retinoscopy, using the plane mirror,
shows myopic astigmatism in each eye, with the axis at 180° and
45°, respectively. I could not get any satisfactory examination
with the ophthalmoscope, as the eyes were very sensative to
light, but the refraction appeared to be myopic. I at once or-
dered a four-grain solution of atropine to be used four times a
day, and on his return in two days I found that his vision was
ff in each eye with — -fa combined with — J- cylindric axis 180°
in right and 45° left, but the vision was not steady.
Testing his extrinsic muscles at this time, I found a very pe-
culiar effect, as with the apex of the prism over the right inter-
nus, with the candle placed at twenty feet, it would at once cause
severe pain, and make him weep bitterly; while placing the apex
over the left internus, he would laugh hysterically. Turning the
prism around, and placing the apex over either of the externi, he
would have a slight chill.
Considering that he was still under the effects of spasm of the
ciliary muscle, I continued the atropine, and, not to weary you
with details of the examination made at various times, I will
state that the atropine was continuously used from February 21,
1891, the date of his first visit, till July 10, 1891, nearly five
months, when the final examination revealed simple myopic as-
tigmatism as follows:
R. E. V. = Jg +, w. -TiTc.ax. 170° = f|. L. E. V. = §£+,
w. — c. ax. 80° = f f, and all other tests gave the same re-
sults, including the objective examination with Javel's ophthal-
mometer, which showed an astigmatism of less than 0-5 I), at
the same axes. These glasses were ordered for continuous use
at this time. I again tested the extrinsic muscles of the eyes,
and found that the irritation as above noted with the prism test
had entirely passed away, and that the interni can fuse the images
with a prism of 15°, base outward, and the externi one of 6°, with
the base inward. My last examination was made on November
20, 1891. He was perfectly comfortable, his vision normal, a good
region of accommodation, and now uses his glasses only for
reading.
During this course of treatment he was given strychnine in
small doses for a month, and twice the temples were leeched.
In view of the history and. result in this case, I think
that we may consider tonic spasm of the accommodation
exceedingly rare, and though I have seen those cases that
may be classed as clonic, and. in which we find spasm of
the ciliary muscle taking place when the eyes are used for
any distances, yet, as a rule, simple spasm of the accommo-
dation or abnormal accommodative tension entirely disap-
pears when the eye is examined with the ophthalmoscope
and the true state of refraction is revealed, being either
emmetropic, hypermetropic, or myopic. If, then, I should
define the condition as it exists in the above case ; the
circular fibers of the ciliary muscle are in a state of con-
tinued contraction, producing a condition of accommoda-
tive myopia with an increase in the refractive power of the
dioptric apparatus. This condition was constant and was,
no doubt, the cause of the many peculiar reflex symptoms
shown in this case. There is no pathological condition
existing in this spasm, and the only objective symptom is
the apparent myopia that does not agree with the usual
tests for this myopic condition of refraction ; and it is only
by the ophthalmoscopic tests that we can differentiate that
of true spasm. Hence, in the examination, when we com-
pare the two conditions of tonic spasm and abnormal ten-
sion in both, we find the distant vision reduced ; that it will
be improved by concave glasses, but not up to that point
usually observed in simple myopia of the same degree.
That we have the same advancement of the near point, or,
in other words, the near point is brought closer to the eyes ;
that in both cases the examination by retinoscopy will show
myopia, giving reversed movements of the retinal reflex
with the plane mirror. But that we will find our crucial
test in the examination with the ophthalmoscope, as in sim-
ple spasm or abnormal accommodative tension, the apparent
myopia will now disappear ; for I believe the eye is un-
able to exercise its accommodative power and remains at
rest when the ophthalmoscope is brought very close to it.
While if we have this condition of true spasm, even with
the ophthalmoscope, the refraction appears myopic. And
yet the refraction with glasses does not agree with that
usually found in simple myopia.
As regards the cause of true spasm of the accommoda-
tion, I can only suggest eye-strain as in the above case. I
think that it was produced by the radical change in the use
of the eyes from that of the Plains to the editorial rooms —
in fact, from a condition of almost constant rest for the
ciliary muscle to one of continuous work, until the stimula-
tion became so great that there was no relaxation or rest at
any time.
Again, as another possible cause, we have the peculiar
axes of the weak minus cylindrics, being at 170° in the
right eye and 80° in the left.
I think this condition might produce a certain amount
of irritation in the ciliary muscle, ending in spasm.
Another point to which I would call your attention in
this case is the peculiar effect produced upon the patient
when the extrinsic muscles of the eyes are tested with
prisms. You will see from his history that it was impos-
sible to place a prism before his eyes with the base either
in or out, as they would at once cause those peculiar seem-
ing hysterical symptoms — crying or laughing if the base is
placed outward, and a slight chill with the base inward ;
but these symptoms entirely disappeared after complete
relaxation of the accommodation, w hen the balance of the
muscular power was restored, giving over 15° for adduc-
tion and nearh 6 for abduction.
As regards the treatment of these cases, 1 do not think
that I can suggest anything new. We must continue the
use of atropine until the accommodation is completely re-
laxed, and this condition I find when all the examinations,
both objective and subjective, agree in all particulars — in
other words, when the ophthalmoscope, retinoscopy, and
the test by glasses will give the same results — and not till
410
L EA DING A R Tl CLES.
[N. Y. Med. Joub.,
then should we stop the use of the mydriatic, even though
the treatment must necessarily extend over several months.
In conclusion, I wish to report the following case that
has some similar features : Clare B. was sent to my clinic
at the Post-graduate Hospital by Professor Dana for ex-
amination of the eyes; her mother stated she was suffering
from slight epileptoid attacks, having several during the
day and night, generally commencing in the calf of the
leg, and the medicine she had been taking seemed to have
no effect in reducing their frequency. On examination, her
vision was normal, with minus cylindric glasses of 2 D.
axis 180° each eye. But as the other examinations did not
agree with this, and suspecting tonic spasm, I ordered a
four-grain solution of atropine to be dropped into the eyes
four times a day, and after the accommodation was com-
pletely paralyzed, her vision now was found to be normal
with convex cylindrical glasses of 1 D. axis 90° in each
eye, and the convulsions were rapidly stopping, becoming
less frequent, though all medical treatment was suspended
at the time the atropine was ordered.
After the last examination she was ordered to wear the
convex cylinders constantly and the atropine stopped, when
we found the convulsions returning and the vision reduced.
During the last two months she has been constantly under
the effects of atropine, her vision is normal with the glasses,
and has not had any return of the convulsions since No-
vember 18th.
Since the foregoing was written, Dr. George M. Gould,
of Philadelphia, has mentioned a very similar case in his
statistics of refraction. I report the history of these two
eases, Imping they will be interesting to the members of
the Section, because the effects of the use of the atropine
seemed to be so marked and the relief and final results so
interesting to me, and because I have never met any7 similar
cases among the large number I have examined in private
and clinical work.
The New York Academy of Medicine. — The programme for the
meeting of Thursday evening, the 7th inst., announced the following pa-
pers : An Efficient Means of controlling Haemorrhage after Suprapubic
Prostatectomy, by Dr. E. L. Keyes ; A Peculiar Case of Renal Haemor-
rhage, etc., with some Observations upon the Value of Cystoscopy in the
Diagnosis of Renal Diseases, by Dr. Samuel Alexander ; and Some Re-
sults of " Withdrawal," by Dr. L. Bolton Bangs.
At the next meeting of the Section in General Surgery, on Monday
evening, the 11th inst., Dr. C. A. Powers will read a paper entitled A
Case of Spina Bifida in an Adult ; Removal of the Tumor ; Cure, and
Dr. Robert F. Weir will read one on A Unique Derangement of the Knee
Joint demanding Surgical Interference.
At the next meeting of the Section in Paediatry, on Thursday even-
ing, the 14th inst., Dr. J. E. Kelly will read a paper entitled The Prac-
titioner's Anatomy of the Respiratory Passages as applied to Intuba-
tion, Laryngectomy, Tracheotomy (high and low), and Bronchotomy.
At the next meeting of the Section in Orthopaedic Surgery, on Friday
evening, the IBth inst., Dr. V. P. Gibney will read a paper on The Indi-
cations for Operative Interference in Orthopaedic Surgery.
The Harlem Hospital. — The Commissioners of Public Charities and
Correction have appointed Dr. S. T. Armstrong a member of the medi-
cal board. Dr. Armstrong has had an extensive professional experience
in his ten years' service as a medical officer in the Marine-Hospital
Service, and will render efficient service in this new field.
TFIE
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by Edited by
D. Appleton & Co. Frank P. Foster, M. D.
NEW YORK, SATURDAY, APRIL 9, 1892.
ATHENIAN HOSPITALS.
In a letter from Athens, Greece, Dr. Frederick Peterson, of
New York, writes that the general hospital in that city, known
as the EvangeUsmos, is quite equal to any institution of the
kind in the world in its structure, arrangements, care of pa-
tients, neatness, cleanliness, and attention to the latest medical
and surgical details ; records are religiously kept by the in-
ternes, who are students or graduates of the medical depart-
ment of the Athenian University; and work of a high order is
done in its laboratory, which is provided with every appliance
needed for chemical, bacteriological, and pathological investi-
gation. The operating-room for general surgery and the
laparotomy room are models of cleanliness and attention to anti-
sepsis, and are perfectly equipped with every surgical requisite.
The various means of treatment of typhoid fever — medicinal,
stimulant, and hydrotberapeutic — are being carefully tried in
order to determine their relative merits. There seemed to Dr.
Peterson to be an unusual number of such cases among the
sixty or seventy inmates of the hospital at the time of his visit.
Driving out of town, past the site of the ancient grove of Plato
and Socrates, along the " Sacred Way " to Eleusis, one reaches
in half an hour the new Phrenocomio, or lunatic asylum, of
Athens. For years Greece had had but one asylum, situated at
some distance on the island of Corfu, and patients of the better
classes wTere sent to Italy, France, or Germany, or elsewhere;
but a few years ago a wealthy Athenian gave a million francs
toward an establishment of this kind to be located near the
city, so this site of several hundred acres of land on a slope 01
the Parnes hills, overlooking the Bay of Salainis, and with
Hymettus, Pentelikon, and the Acropolis looming up in the
foreground, was selected. At present, says Dr. Peterson, there
are a hundred patients in five or six pavilions. Most of the
patients are private, but all classes, including paupers, are :i> -
commodated, and new pavilions are being added continually.
One of the features of the asylum is a hydrotberapeutic estab-
lishment with every known form of douche and bath apparatus
more complete than Dr. PetersoD remembers ever to have obi
served elsewhere, although he has visited most of the asylums
and hospitals of Europe in .former years. This hydrotheraj
peutic installation is the work of an- Italian firm in Bologna.
The number of cases of general paralysis — fourteen — was
noticeably large. Alcoholic insanity, strange to say, is exceed-
ingly uncommon, although many Grecian w ines are well known
to be of fiery quality. Dr. Cirigotti, the medical superintend-
ent, said he believed the cause of this to lie in a certain pe-
culiarity of the wines drank by the people in general — viz.:
April 9, 1892.] -
LEADING ARTICLES.— MINOR PARAGRAPHS.
411
the large quantity of resin of the Aleppo pine that they con-
tain. The flavor Of pine resin is so strong that few foreigners
care to essay a second mouthful after the disgust and surprise
aroused by the first. The Greeks drink the resined wines by
preference. Whether Dr. Cirigotti is correct in ascribing to
pine resin properties antagonistic to the poisonous effects of
alcohol, Dr. Peterson does not presume to say, but the matter
he says, may merit some investigation, for the almost complete
absence of alcoholic insanity in an intemperate people is a
singular circumstance.
PYOCTANIN IN DISEASES OF THE EYE.
Stilling, of Strassburg, the apostle of this coal-tar " pus-
killer," lias had some of his allegations confirmed and some of
the strongest of them denied, and new uses of it have been
proposed about which he was in ignorance. A short paper by
Dr. Herbert Harlan, in the Transactions of the Medical and
Chirurgical Faculty of Maryland for 1891, illustrates this state-
ment in an interesting way. First, it confirms the usefulness of
pyoctanin in ulcer of the cornea; secondly, in purulent ophthal-
mia the drug is shown to be well-nigh useless or, at least, less
efficient than other older medicaments ; and, thirdly, new uses
with gratifying results have been developed in regard to oyster-
sbuckers' keratitis and to phtheiriasis palpebrarum.
In and about Baltimore the corneal lesions of oyster-open-
ers are well known, and they are commonly described as a form
of keratitis. They are of the nature of corneal ulcers, and are
caused by small particles of shell or slime impinging upon the
eye in the process of shucking oysters. The appearance of the
eye and the limited locale of the disease point to a causation by
some peculiar micro-organism not yet discovered. These cases
of oysterman's keratitis are not readily cured, although eserine
in solution has done well in the practice of the author of the
paper. Latterly he has made use of pyoctanin in twenty of
these cases, and in every case with marked benefit. The method
of treatment is usually to drop into the eye a solution of cocaine,
and then after a moment rub the ulcer with a pencil of yellow
pyoctanin. In the milder cases one application has sufficed ; in
one very severe case, with an ulcer occupying a quarter of the
corneal area, a cure was obtained at the end of ten days, a
slight opacity remaining. One effect of the pencil was to stain
the diseased spot bright yellow. In three cases of mucocele
the injection of blue-pyoctanin solution seemed to be more
promptly remedial than the use of any other astringent or anti-
j septic solution before employed by the author.
On the very day when the author obtained his first supply
of the drug there came to him a boy of fifteen having the eye-
! lashes of the right eye infested with lice (pediculi puhis).
Now, these cases are not very common in this country, and are
interesting therapeutically. The patient complained of an in-
tense itching and irritation of the eyes. Close inspection showed
a few lice moving about on the lashes and a vast number of
eggs firmly agglutinated to the lashes. It is very difficult to
destroy these eggs, or to prevent their development, under the
usual treatment with red-precipitate or yellow-oxide-of-mer-
cnry ointment. The destruction of the living lice is effected
by either of these ointments, and, if the latter is persistently
used for a week or two, the newer crops of lice are killed as
they are successively hatched out; the unguents, however, do
not penetrate the glue-like covering of the eggs. In the case
of this boy, Dr. Harlan at once proceeded to make trial of a
solution of blue pyoctanin, one part to a thousand. The living
parasites were stained blue and were killed ; nearly all the eggs
took the stain, and none of them subsequently, during the pe-
riod of two weeks for which the boy was under observation,
were developed. Two applications were all that were made,
the second application having been made because a few of the
eggs had not taken the stain so thoroughly as the others on the
first application, which, however, was probably fatal to the en-
tire brood.
Regarding the use of pyoctanin in some forms of intra-
ocular trouble, Dr. Harlan has had some favorable results, and
he purposes to use the remedy in other cases.
MINOR PARAGRAPHS.
ALBUMINOUS PERIOSTITIS.
According to the Lancet for March 12th, Dr. Dzierzawski
has published an article on the "periostitis alburninosa" of
Poncet, Terrier, and Lannelongue, of which he has collected
twenty-seven cases besides one of his own. It is characterized
by a clear, tenacious exudation from the periosteum that resem-
bles synovial fluid or the white of an egg. The author does
not believe it a disease sui generis, as Nicaise, Riedinger, Al-
bert, and Duplay do, but thinks it is comparable to those cases
of contagious osteomyelitis in which a clear fluid exudation is
formed owing to a low type of inflammation, or to those tuber-
cular cases in which there is infiltration or cold abscess. This
view coincides with that of Schlange, who, however, ascribes
the small number of pus-corpuscles to their deficient formation
in consequence of the weakness of inflammation ; and Garre
supposes that there is secondary liquefaction of these bodies by
the serous exudation. These theories the author does not be-
lieve necessary, as under certain conditions the periosteum may
give rise to an exudation containing mucus, and he proposes
that the disease be called "non-purulent osteo-periostitis."
DYSPNCEA AFTER TEA-DRINKING.
Mr. Jonathan Hutchinson, in the January issue of the Ar-
ch i rex of Surgery, describes a case of alarming attacks of dyspnoea
that were probably due to tea-drinking. The pal ient was a rat her
delicate man, of nervous temperament, and there was a suspi-
cion of gouty heredity. The attacks occurred after breakfast, at
which lie drank tea freely, the meal being brought to him while
he was yet in bed. During the attacks he had a corpse-like pal-
lor, and seemed quite unable to take a respiration, on account of
a pain like that of angina pectoris caused by the effort. The
pain was referred to the epigastrium and lower part of the chest,
rather than to the shoulder. Inspiration was accompanied with
the greatest pain. The pulse was feeble during the time of the
attack, and the patient could speak only in a whisper. The du-
ration of the attacks was about an hour. An injection of mor-
phine terminated the seizure quite promptly on two or more oc-
casions. A careful thoracic examination, made by Dr. Gowers,
resulted for the most part negatively. At any rate, no organic
412
MINOR PARA GRAPHS.— ITEMS.
[N. Y. Med. Jour.,
affection was discovered that could explain the difficulty. The
man was not a user of tobacco, but would imbibe tea freely, and
this was sometimes followed by flatulence and a feeling of dis-
tention of the stomach. An over-indulgence in tea, especially
with little or no food taken at the same time, will in some per-
sons produce a sense of constriction behind (he sternum, with
some feeling of dyspnoea. In the case of a medical man who
partook of tea of unaccustomed strength, and without eating any
food, a distressing attack of dyspnoea occurred which lasted over
thirty minutes. The recurrence of somewhat similar attacks
having followed other indiscretions of tea-drinking on subse-
quent occasions, the mind of that physician became strongly im-
pressed with the agency of strong tea in causing such attacks ;
so much so that for a long time he never ventured to drink tea
except in his own home, where he knew its strength and quality.
Mr. Hutchinson states that the painful attacks of the patient
first above referred to bring to mind very distinctly those from
which John Hunter suffered, and which he himself so graphic-
ally described.
A SUCCESSFUL LAPAROTOMY IN THE SEVENTEENTH
CENTURY.
The following note in the Diary of John Evelyn would in-
dicate that our professional brethren of two hundred and titty
years ago were not very far behind us in the matter of abdomi-
nal section for foreign bodies. It is dated Leyden, August 19,
1G41, and reads: " Among a great variety of other things I was
shewn the knife newly taken out of a drunken Dutchman's guts
by an incision in his side after it bad slipped from his fingers
into his stomach. The pictures of the chirurgeon and his pa-
tient, both living, were there."
THE COLLEGE OF PHYSICIANS AND SURGEONS, OF
CHICAGO.
We have received the first decennial catalogue and the an-
nouncement for the coming college year. Roth documents
show abundant evidence that the institution is decidedly pro-
gressive in its means of teaching and in its requirements for en-
trance and for graduation. It may be said, indeed, to be in the
first rank of American medical colleges.
ITEMS, ETC.
The Medical Association of Georgia will hold its forty-third annual
meeting in Columbus on the 20th, 21st, and 22d inst, under the presi-
dency of Dr. G. W. Mulligan, of Washington. In addition to the presi-
dent's address, the preliminary programme announces the following
papers : Cough — Some of its Causes and Treatment, by Dr. C. D. Roy,
of Atlanta ; So-called Tvpho-malarial Fever, by Dr. W. P. Williams, of
Waycross ; Preliminary Observation on the Behavior of Iodine in the
Presence of Camphor, Menthol, Thymol, etc., by Dr. R. J. Nunn, of Sa-
vannah ; Some Observations upon Cataract Operations and After-treat-
ment, by Dr. A. W. Calhoun, of Atlanta; Remittent Fever, by Dr. A. C.
Plain, of Brunswick; Extirpation of the Rectum for Carcinoma, by Dr.
J. McF. Gaston, of Atlanta ; Some of the Fads and Fancies of the Medi-
cal Profession, by Dr. J. C. LeHardy, of Savannah ; The Treatment of
Pneumonia, with Report of Cases, by Dr. II. Perdue, of BarnesviUe;
How shall we manage the Uterus after Abortion '? by Dr. K. P. Moore,
of Macon ; Plaster of Paris in Surgery, by Dr. W. F. Westmoreland, of
Atlanta; Report of Surgical Cases from my Note-book, by Dr. J. B.
Binkle, of Americus ; What i- Gynecology '! by Dr. R. R. Kime, of At-
lanta; A Case of Ovarian Cysts, by Dr. J. M. Spence, of Waresboro ;
Some Remarks on Tomil Kxeisions, with the Presentation ami Desciip-
tion of a New Instrument, by Dr. A. G. Hobbs, of Atlanta; How to best
conduct Labor to prevent Injuries to the Os Uteri and Perina um, by Dr.
A. W. Griggs, of West Point ; Gunshot Wounds of the Eye — Unusual
Results, by Dr. G. A. Wilcox, of Augusta ; The Treatment of Abortion
and Some of the Complications, by Dr. Walter A. Crow, of Atlanta;
Report of ii Case of Catalepsy and its Treatment, by Dr. A. Sydney
Johnson, of Bowman; Typhlitis and the Report of a Case, by Dr. S. M.
.Mathews, of Quitman; The Relations and Dependencies existing be-
tween the Specialist and the General Practitioner of Medicine and Sur-
gery, by Dr. J. W. Griggs, of West Point ; The Relation between Skin
Diseases and the General Health, by Dr. M. B. Hutehins, of Atlanta ;
The Treatment of Haemorrhoids by Carbolic-acid Injection, by Dr. J. W.
Hallum, of Carrollton ; Hemeralopia, or Night-Blindness, by Dr. S. Lati-
mer Phillips, of Savannah ; A Combination of Carbolic Acid and Cam-
phor as an Antiseptic, by Dr. W. Peri in Nicolson, of Atlanta ; Chorea,
by Dr. Hugh Ilagan, of Atlanta ; Antiseptic Surgery, by Dr. Ralph E.
Smith, of Atlanta ; Radical Surgery the Best Surgery in the Treatment
of Extensive Lacerated and Contused Wounds of the Extremities, by
Dr. E. II. Richardson, of Atlanta; Tvpho-malarial Fever, by Dr. J. Wi
Duncan, of Atlanta ; The Action of Fibroid Tumors after the Meno-
pause, by Dr. Virgil O. Hardon, of Atlanta ; Intestinal Obstructions,
their Varieties, Diagnosis, and Treatment, by Dr. J. B. Hinkle, of Amen
cus ; A Report of Perineal Sections for Stricture, Stone in the Bladder,
and Cystitis, by Dr. Floyd W. McRae, of Atlanta ; Suprapubic Lithoto-
my, with a Report of Cases, by Dr. W. S. Elkin, of Atlanta ; and Typh-
litis, by Dr. William O'Daniel, of Bullard.
The late Dr. D. Hayes Agnew. — The secretary of the College of
Physicians of Philadelphia, Dr. Charles W. Dulles, has sent us the text
of a minute adopted by the college on March 24th. It reads as fol-
lows :
The death of Dr. D. Hayes Agnew, recently president of the col-
lege, in the seventy-fourth year of his age, and after a life crowned with
honor and usefulness, calls for an expression of the sense entertained
by the college of the gravity of the loss which it suffers, in common
with the profession he adorned, the charitable institutions he served,
and the community in which his skill did so much to lessen suffering
and death.
He began his professional life with no adventitious aids ; yet, by in-
cessant industry, indomitable perseverance, and singleness of purpose,
he attained to its highest rank. No temptation distracted his attention
from the goal of his life: neither extraneous science, nor general litera-
ture, nor the allurements of art, nor the pleasures of society.
The undivided strength of his mind and his affections were devoted
to enlarging the domain of surgery, not only in its operative methods,
which he always subordinated to the welfare of his patients, but also in
preparing for his profession a literary monument that might speak for
him when his voice should be no longer heard.
His minute acquaintance with anatomy and his ambidextrous skill
enabled him to perform, with ease to himself and safety to his patients,
operations which less accomplished surgeons hesitated to undertake.
He possessed a certain magnetism of manner, quite independent of
formality, that evidently proceeded from the heart and drew all hearts
to himself. Never frivolous, but always cheerful, he was dignified,
grave, and earnest, making all who heard him as a teacher and speaker,
or in familiar intercourse, recognize in him, above all other things, the
upright man. For he possessed eloquence of conviction and the force
of absolute honesty in all his statements, and thereby drew to himself
as enthusiastic admirers and disciples the successive classes of students
whom he taught.
The college, desiring to show respect for the purity, uprightness,
unselfishness, and modesty of Dr. Agnew's character, its admiration
for the noble example of life, and its sense of the value of his contri-
butions to the science and art of surgery, directs that this minute shall
be duly recorded, and a copy of it, signed by the president and secre-
tary, be conveyed to Dr. Agnew's family. Also, that the college will
attend the funeral in a body, and that the president be requested to ap-
point a fellow to prepare a memoir of our late colleague.
The American Academy of Medicine will hold its seventeenth an-
nual meeting in Detroit on Saturday, June 4th, and Monday, June 0th.
In the preliminary programme we find the following titles : Essentials
and Non-essentials in Medical Education, the address of the retiring
April 9, 1892.].
ITEMS.— LETTERS
TO THE EDITOR.
413
president, Dr. P. S. Conner, of Cincinnati ; The Value of the General
Preparatory Training afforded by the College as compared with the Spe-
cial Preparatory Work suggested by the Medical School in the Prelimi-
nary Education of the Physician, by Dr. T. F. Moses, of Orbana, <>. ;
Does a Classical Course enable a Student to shorten the Period of Pro-
fessional Study ? by Dr. V. C. Vaughan, of Ann Arbor, Mich. ; The Value
of a Collegiate Degree as an Evidence of Fitness for the Study of Medi-
cine, by Dr. L. II. Mettler, of Chicago ; The Value of Academical Train-
ing Preparatory to the Study of Medicine, by Dr. II. B. Allyn, of Phila-
delphia, Dr. W. D. Bidwell, of Washington, and Dr. Elbert Wing, of
Chicago ; The Newer Medical Education in the United States, by Dr. W.
J. Herdman, of Ann Arbor, Dr. Charles Jewett, of Brooklyn, and Dr.
Elbert Wing, of Chicago; and a paper on some phase of the State
supervision of the practice of medicine, by Perry II. Millard, of St.
Paul.
Meetings of State Medical Societies for the Month of May. — Ken-
tucky State Medical Society, 3d, Louisville ; Kansas Medical Society, 3d,
Fort Scott ; Ohio State Medical Society, 3d, Cincinnati; State Medical
Society of Wisconsin, 4th, Milwaukee ; Michigan State Medical Society,
5th, Flint ; Nebraska State .Medical Society, 10th, Omaha ; Indiana State
Medical Society, 12th, Indianapolis; Missouri State Medical Society, 1 7th,
Pertle Springs ; Illinois State Medical Society, 17th, Vandalia ; Pennsyl-
vania State Medical Society, 17th, Harrisburg ; Iowa State Medical Soci-
ety, 18th, Des Moines; Connecticut Medical Society, '24th, New Haven;
North Carolina State Medical Society, 24th, Wilmington.
The Association of Military Surgeons of the National Guard of the
United States will hold its second annual meeting in St. Louis on the
19th, 20th, and 21st inst., under the presidency of Dr. N. Senn. In-
formation in regard to the meeting may be obtained from Colonel E.
Chancellor, of No. 515 Olive Street, St. Louis.
The Mississippi Valley Medical Association. — Members who w ish
to go as delegates to the meeting of the American Medical Association
at Detroit are requested by the secretary, Dr. E. S. McKee, of No. 57
West Seventh Street, Cincinnati, to send their names to him.
Change of Address. — Dr. Burdette P. Craig, to No. 258 Montgomery
Street, Jersey City.
Marine-Hospital Service. — Official List of the Changes of Stations
and Duties of Medical Officers of the United States Marine-Hospital
Service for the four weeks ending March 26, 1892 :
Bailhache, P. II., Surgeon. To inspect unserviceable property at Port
Townsend, Wash., March 9, 1892. Detailed as member of Board
for Physical Examination of Officers of the Revenue-Marine Service.
March 26, 1892.
Puryiance, George, Surgeon. Ordered to Washington for temporary
duty. March 5, 1892.
Austin, H. W., Surgeon. To inspect service at New Orleans, Savan-
nah, and Charleston, and the Gulf and South Atlantic Quarantine
Stations. March 3, 1892.
Irwin, Fairfax, Surgeon. Detailed as Medical Inspector of Immigrants,
port of Boston, Mass. March 3, 1892.
Parmichael, D. A., Passed Assistant Surgeon. To inspect the San
Francisco Quarantine Station. March 7, 1892.
White, J. H., Passed Assistant Surgeon. Ordered to South Atlantic
Quarantine for temporary duty. March 26, 1892.
Kisvorx, J. J., Passed Assistant Surgeon. To proceed to New York
on special duty. March 7, 1892.
Perry, T. ]!., Passed Assistant Surgeon. Granted leave of absence for
thirty days. March 1 and 14, 1892.
Guitkhas, G. M., Assistant Surgeon. Ordered to examination for pro-
motion. March 23, 1892.
Brown, B. W., Assistant Surgeon. Assigned to temporary duty at San
Francisco Quarantine. March 14, 1892.
Eager, J. M., Assistant Surgeon. Granted leave of absence for thirty
days. March 1, 1892.
Pecker, C. E., Assistant Surgeon. Detailed as Recorder, Board for
Physical Examination of Officers of the Revenue-Marine Service.
March 26. 1892.
Promotion.
Cobb, J. O., Passed Assistant Surgeon. Commissioned by the President
as Passed Assistant Surgeon. March 23, 1892.
Society Meetings fcr the Coming Week :
Monday, April 11th: New York Academy of Medicine (Section in Gen-
eral Surgery) ; New York Ophthahuological Society (private) ; Lenox
Medical and Surgical Society (private); New York Medico-historical
Society (private) ; New York Academy of Sciences (Section in Chem-
istry and Technology); Boston Socict\ for Medical Improvement;
Gynaecological Society of Boston ; Burlington, Vt., Medical and Sur-
gical Club ; Norwalk, Conn., Medical Society (private) ; Baltimore
Medical Association.
Tuesday, April 12th : Medical Association of the State of Alabama
(first day — Montgomery) ; Medical Society of the State of Tennessee
(first day — Knoxville) ; New Yo'-k Medical Union (private) ; Kings
County, N. Y., Medical Association ; Medical Societies of the Coun-
ties of Jefferson (quarterly — Watertown), Oneida (quarterly — Utica),
Ontario (quarterly), and Tioga (quarterly — Owego), N. Y. ; Newark
and Trenton (private), N. J., Medical Associations ; Bergen (annual
— Hackensack) and Cumberland (annual), N. J., County Medical So-
cieties ; Fairfield, Conn., County Medical Association (annual) ; Bal-
timore Gynecological and Obstetrical Society.
Wednesday-, April 13th : Medical Association of the State of Alabama
(second day); Medical Society of the State of Tennessee (second
day) ; New York Surgical Society ; New York Pathological Society ;
Metropolitan Medical Society (private) ; American Microscopical So-
ciety of the City of New York ; Tri-States Medical Association (Port
Jervis, N. Y.) ; Medical Society of the County of Albany, N. Y. ;
Pitts field, Mass., Medical Association (private); Philadelphia County
Medical Society; Kansas City, Mo., Ophthalmologic^ and Otological
Society.
Thursday, April lfrth : Medical Association of the State of Alabama
(third day) ; Medical Society of the State of Tennessee (third day) ;
New York Academy of Medicine (Section in Paediatrics) ; New York
Laryngological Society ; Society of Medical Jurisprudence and State
Medicine ; Brooklyn Pathological Society ; Medical Societies of the
Counties of Cayuga and Fulton (quarterly), N. Y. ; South Boston,
Mass., Medical Club (private) ; New London, Conn., County Medical
Society (annual) ; Pathological Society of Philadelphia.
Friday, April 15th : Medical Association of the State of Alabama (fourth
day) ; New York Academy of Medicine (Section in Orthopaedic Sur-
gery); Baltimore Clinical Society; Chicago Gynaecological Society.
Saturday, April 16th : Clinical Society of the New York Post-graduate
Medical School and Hospital.
Answers to Correspondents :
No. 379. — An examination is required. For particulars, address
the Board of Regents of the University of the State of New York,
Albany.
fetters to tbe debitor.
THE PRESERVATION OF HYPODERMIC-SYRINGE TUBES.
Greenville, Plumas County, California, March 28, 1892.
To the Editor of the New York Medical Journal:
Sik: Apropos of Dr. T. A. Lancaster's letter upon the Pres-
ervation of Hypodermic Needles with Unguentum Petrolei, 1
would suggest the use of a small collapsable ointment-tube con-
taining half a drachm of the unguent, the screw thread retain-
ing its cap having a similar gauge to that of the syringe, and
the cleansed needle to he screwed on to the tube, pressure till-
ing the needle with the lubricant. The manoeuvre would be
simple, and the tube would take up little space in a case.
G. Willis, L. R. C. P. Edin., L. R. C. S. Edia
4U
PROCEEDINGS OF SOCIETIES.
[N. Y. Mei>. Jour.,
flrorccbings of Societies.
NEW YORK NEUROLOGICAL SOCIETY.
Meeting of March 1, 1892.
The President, Dr. L. C. Gray, in the Chair.
Hysteria in a Child.— Dr. W. M. Leszynskt presented a
patient, a young girl, whom he said he had brought to demon-
strate that we did have in this country cases of hysteria in
children. She was, he said, only thirteen years of age. Two
years and a half ago, after fright from a dream, the hysterical
symptoms had manifested themselves in paroxysms of laughing
and crying. In 1891 she had commenced to menstruate, and
had then begun to have convulsive seizures, which had been
usually worse at, the menstrual periods. She had passed
through conditions of prre motor aphasia, and at the present
time there were attacks of mutism lasting for a week or more.
She also now had convulsions lasting sometimes many minutes,
and at other times for hours. There were now developed hys-
terogenic zones over various parts of her body. She had visual
hallucinations, and occasionally maniacal attacks and move-
ments of rotation and of combined rotation and retropulsion.
Her visual fields had been contracted. Lately there was a
transient hemiplegia. There were no sensory disturbances.
Knee-jerk was present, but only slightly marked. There was
no history of onanism, and none of ovarian trouble, and the
general health of the child was good. This was the patient he
had referred to on a previous occasion as becoming worse after
hypnotism. The speaker then touched the patient upon the
head in one of the alleged hysterogenic zones, when a convulsive
seizure promptly occurred.
Morvan's Disease. — Dr. 15. Sachs presented a patient and
gave the history of his case. (To be published.)
Dr. M, A. Starr said that, in a late discussion on syringo-
myelia, it had been stated that no case had come to autopsy in
which a diagnosis had been made during life. He had lately
received photographs of four spinal cords from cases from the
Salpetriere in which the diagnosis had been so made.
Dr. C. L. Dana said he was far from being convinced that
there was at present anything the matter with the patient's
spinal cord. He had seen a similar condition which had been
really one of peripheral neuritis. He thought it possible for
Morvan's disease to exist as an independent trouble. The case
before them was interesting and in many respects a connecting
link, but he should hesitate in unreservedly accepting it as one
of syringomyelia.
Dr. Sachs said that some improvement had taken place in
the areas of sensory disturbance which would be hardly ex-
pected in a case of peripheral neuritis.
The Diseases and Conditions to which the Rest Treat-
ment is adapted. — Dr. Wharton Sinkxer, of Philadelphia,
read a paper with this title. He said the treatment indicated
consisted mainly in absolute rest, over-feeding, passive exercise
in the form of massage and electricity, isolation from friends
and relations in hysterical and neurasthenic patients, and in other
details. In placing a patient under treatment, no matter for what
disorder, it must be made clear what the plan was, in order
that Bucl) patient might assist the physician to a speedy result.
The degree of rest which should be enforced might vary, but, as
a rule, patients were permitted to do but little for themselves.
They should remain constantly in bed, rising only to attend the
calls of Nature, and even this was not always to be allowed.
Usually the patient was rolled from the bed to a lounge or cot
once a day during the airing or changing of the bed linen. Be
youd this no exertion must be permitted, and everything must
be undertaken by the nurse. Isolation was an important part
of the system, and visitors and messages should be excluded.
Massage, the toilet hour, the doctor's visit, the electricity, and
the meals gave sufficient occupation. It was rarely possible to
treat patients in their own home, no matter how isolated the pa-
tients might be. The moral effect of removal from home was
frequently of an enormous benefit in cases of neurasthenia or
listeria. Massage was an essential element in the treatment,
and one of its objects was to produce tissue waste in order to
admit of a larger amount of food being given. Faradaic elec-
tricity should be used once daily for half to three quarters of
an hoar. After giving the conventional dietary list, the author
said that, as a rule, at the end of six weeks the patient was al-
lowed to sit up, lengthening the time gradually day by day.
The judicious selection of a nurse with special qualifications was
a sine qua non. Hysteria and neurasthenia were the diseases to
which the rest treatment had been most extensively applied, and
in which it gave the most satisfactory results. Some of the
organic diseases of the cord, Pott's disease, acute myelitis, loco-
motor ataxia, spastic paraplegia, peripheral nerve troubles, mi-
graine, certain brain troubles dependent upon malnutrition,
such as melancholia and the insanities of exhaustion, had all
been wonderfully helped by the rest treatment. Success had
also attended the treatment of chorea, epilepsy, the opium habit,
and alcoholism by this method. Gynaecologists had also used
it with benefit in uterine and ovarian diseases. Some very good
results had been obtained by the plan in the treatment of
Bright's disease. The relation of lithaernia to nervous diseases
had of late attracted much attention. Many forms of nervous
troubles, such as migraine and some neuralgias and certain
forms of neurasthenias, were dependent upon the litliasmic di-
athesis. The best method of eliminating uric acid was by exer-
cise and diet with an abundance of diluent drinks. The rest
treatment was particularly adapted to the management of these
cases. The speaker emphasized that Swedish movements should
be used in combination with massage.
Dr. E. D. Fisher did not advocate the carrying out of the
rest-cure principles too rigidly. He had seen a patient with
nervous disease, sent to Philadelphia for the purpose of isolation
from her family, make a very rapid retrograde march toward the
grave. This bad been noted in time to apply the remedy, which
consisted in bringing her back to this city.
Dr. Starr said it was his custom to send his patients to Dr.
Weir Mitchell. Pcssibly one half the benefit from the course
arose directly from the hypnotic suggestion with which it was
associated, and this could be better carried out in a special in-
stitution. He believed the rest treatment to bea dmirahle
and applicable to many cases, but not to all. It would be the
more likely to succeed where mental suggestion was of direct
benefit.
Dr. Sachs thought that in cases proper for such treatment
it might be just as effective here as in Philadelphia. It was
more satisfactory when used in its more modified forms. A
goodly number of cases in females classed as hysterical were
really hypochondriacal, and for these patients isolation with one
attendant*was not to be advocated.
Dr. G. W. Jacoby called attention to the very pronounced
obesity which often ensued from the rest in bed.
Dr. S. B. Lyon, alluding to the possible objection to manual
massage by reason of the personal element, said that at one in-
stitution massage was effectively carried out by mechanical
methods.
The President said that he had used the method for twelve
years, and was willing to accord the genius of Dr. Mitchell all
it deserved. Experience had not demonstrated the plan as uni-
April 9, 1892.]
BOOK NOTICES.
415
versally efficient. In genuine hysteria, hv<terin associated w ith
malnutrition, emotional liysteria, cases of over-draft upon the
physical capacity by work or other causes in which the disturb-
ance was functional, not organic, he believed the treatment in
most instances would be found invaluable, while in melancholia it
was not so useful. The plan must always be modified to suit
special requirements. He did not believe in the massage pari
of it. Patients became beautiful to look upon, but their muscu-
lar capacity amounted to nothing.
Dr. Sixkler thought that in Dr. Gray's cases massage could
not have been given thoroughly; it was essential to the treat-
ment as a whole, but should always be combined, if possible,
with the Swedish movements.
siiook iloticcs.
The ^Etiology, Pathology, and Treatment of Diseases of the
Hip Joint. By Robert W. Lovett, M. D., Out-patient Sur-
geon to the Boston City Hospital, etc. Boston: George H.
Ellis, 1891. [Fiske Prize Fund Dissertation, No. 42.]
Whatever may be said of prize essays in general, and nu-
merous objections have been urged regarding their utility, the
trustees of the Fiske Fund of the Rhode Island Medical Society
have manifested careful judgment in the selection of the essays
to which they have awarded the prize in several years past.
In this volume the author has confined his discussion of the
subject to the three topics prescribed by the trustees, dividing
diseases of the hi]) joint into acute and chronic diseases and
miscellaneous conditions. The first class includes acute arthri-
tis and acute synovitis, both serous and purulent. The second
class includes serous and purulent chronic synovitis, tubercular
and gummatous chronic osteitis, arthritis deformans, Charcot's
disease, malignant and other tumors affecting the joint, and
loose bodies in the joint. The third class includes congenital
dislocations and functional affections.
The author's presentation of the aetiology, pathology, and
treatment of these varieties of hip-joint disease includes the
latest data on the subject. In tubercular osteitis he believes
that where injury causes the disease it must be assumed that
tubercle bacilli were present in the circulation and were
localized by the injury, though he believes that, as a rule, hip
disease occurs only in those having an hereditary or acquired
tendency to tuberculosis. In the treatment of the disease
Knight's protection method and Hutchinson's physiological
method are mentioned ; while the author accepts Phelph's view
that fixation per se does not produce ankylosis, still he thinks
: that method incomplete because it is almost impossible to obtain
fixation unless the whole body is immobilized, and, further,
that the absence of traction is an objection. His preference is
for the long traction splint, with the routine use of crutches.
He believes that excision is proper and necessary where me-
chanical treatment is not practicable and where, after careful
and intelligent trial, it has failed.
In congenital dislocation of the hip joint Hoffa's operation
is held to be still on trial, while mechanical measures and most
methods of operative treatment have been useless.
The book is a comprehensive survey of the subject of hip
diseases.
Physical Diagnosis. A Guide to Methods of Clinical investiga-
tion. By G. A. Gibson, M. D., D. Sc., F. R. C. P. Ed., Lect-
urer on the Principles and Practice of Medicine in the Edin-
bugh Medical School, etc., and William Russell, M. D.,
F. R. C. P. Ed., Pathologist to the Royal Infirmary of Edin-
burgh, etc. With Illustrations. New York : D. Appleton&
Co., 1891. Pp. 367.
So many works on physical diagnosis have recently appeared
that it wTould seem that there could be no room for more, but
this work occupies a somewhat peculiar position, inasmuch as
its scope is greater than that of a mere treatise on physical diag-
nosis. It might, rather, be entitled A Condensed Manual of
Clinical Diagnosis, since in a concise manner the authors have
given us chapters upon methods of examination ; the tempera-
ture; the integumentary system; the respiratory system; the
alimentary system, including the abdominal viscera; the urin-
ary system ; the nervous system ; and examination of the eye,
the ear, the larynx, and the naso-pharynx. All these subjects
are treated by the authors in a clear, concise, and vigorous style,
and w ith sufficient attention to details to satisfy the reader who
simply wishes to learn certain definite facts in regard to the
physical and clinical signs of diseases.
The chapters on the respiratory system and the circulatory
system and on urinalysis may be mentioned as especially full,
but all the chapters are good. The illustrations and diagrams
are plentiful and handsomely executed, and the typographical
appearance of the book is excellent. It can be recommended to
those who desire a condensed treatise on physical and general
clinical diagnosis.
.1 Manual of Hypodermatic Medication: the Treatment of Dis-
ease by the Hypodermatic or Subcutaneous Method. By
Roberts Bartholow, A. M., M. D., LL. D., Emeritus Pro-
fessor of Materia Medica, General Therapeutics, and Bygi-
ene in the Jefferson Medical College of Philadelphia, etc.
Fifth Edition, revised and enlarged. Philadelphia: J. B.
Lippincott Company, 1891.
The present edition of this familiar work is larger by two
hundred pages than its predecessor. In addition to the new
remedies mentioned, many new observations upon the hypoder-
mic use of older ones have been added. If the author has erred,
it has been in speaking of too many remedies only to condemn
them. Particular attention has been paid to the subcutaneous
method in its application in the treatment of the diseases caused
by pathogenic organisms. The work is arranged according to a
new classification, which is an improvement upon that in the
former editions, the best features of which have been largely re-
tained. Altogether it is a work to he highly recommended.
The Chinese, their Present and Future : Medical, Political, and
Social. By Robert Coltman. Jr., M. D., Surgeon in Charge
of the Presbyterian Hospital and Dispensary at Teng Chow
Fu. etc. Illustrated with Fifteen Fine Photo-engravings.
Philadelphia and London: F. A. Davis, 1891 Pp. viii to
212. [Price, $175.]
While the medical part of this book is not satisfactory to the
scientific student of disease, the volume is intensely interesting.
The author gives a vivid picture of the peculiar customs and
manner of life and thought of the Chinese. His knowledge of
the social and political situation receives a striking confirmation
in the accounts lately published in the daily papers of the at-
tempts by the ruling classes in China to stir up popular hatred
against foreigners.
BOOKS, ETC., RECEIVED.
A Treatise on Diseases of the Nose ami its Accessory Cavities. By
Greville Maedonald, M. I). (Lond.), Physician to the Hospital lor Dis-
eases of the Throat. Second Edition. London and New York : Mac-
roillan and Co., 1892. Pp. xix to 381. [Price, $2.50.]
41 ti
BOOK NOTICES.— MISCELLA X V.
[N. Y. Med. Jour.,
Practical Midwifery : A Hand-book of Treatment. By Edward Rey-
nolds, M. P., Fellow of the American Gynaecological Society, etc. With
One Hundred and Twenty-one Illustrations. New York: William Wood
& Company, 1892. Pp. xiv to 421.
Influenza and the Laws of England concerning Infectious Diseases.
A Paper read before the Society of Medical Officers of Health, January
18, 1892, by Richard Sisley, M. D. Lond., M. R. 0. P. Lond. To w hich
is appended ( 'ounsi I's Opinion on the Powers of Sanitarj Authorities as
to Influenza, and the Proclamation issued at Dover by the Borough Au-
thorities. London : Longmans, Green, & Co., 1892.
Les tumeurs de la vessie. Par J. Albarran, Chef de clinicpie des
maladies des voies urinaires, etc. Preface par le professeur F. Guyon.
75 figures et 9 planches. Paris : G. Steinheil, 1892. Pp. xi to 494.
Nouvelles doctrines de neuropathology, d'apres les lecons elemen-
taires de clinique medicale professees a l'Hotel-Dieu de Toulouse. Par
le Docteur Caubet, Professeur de clinique medicale, etc. Examen cri-
tique par le Docte\ir I., t'habbcrt, ancien interne des hopitaux. Paris:
V. Babe et cie., 1892. Pp. 112. [J'/t/d/ca/ioits de V Echo medical.]
Reaction of the Amide Group upon the Wasting Animal Economy.
By Professor Samuel G. Dixon, M. D., and Professor W. S. Zuill, M. D.,
D. V. S. [Reprinted from the Times and Register.]
Neuroma, with Report of a Case. By Edmund J. A. Rogers, M. D.,
Denver. [Reprinted from the Medical Xeirs.~\
Laparotomy under Cocaine. By Emory Lanphear, M. D., Kansas
City, Mo.
Transactions of the Medical and Chirurgical Faculty of the State of
Maryland. Semi-annual Session, held at Cambridge, Md., November,
189o. Ninety-third Annual Session, held at Baltimore, Md., April,
1891.
Seventy-eighth Annual Report of the Trustees of the Massachusetts
General Hospital and McLean Asylum, 1891.
A Primer of Materia Medica for Practitioners of Homoeopathy. By
Dr. Timothy Field Allen. Philadelphia : Boericke and Tafel, 1892. Pp.
iv-5 to 408.
The Responsibilities of the Medical Profession. An Address to the
Graduating Class at the Commencement of the Albany Medical College,
March 16, 1887. By Andrew S. Draper, State Superintendent of Public
Instruction.
Psycho-therapeutics ; or, Treatment by Hypnotism and Suggestion.
By C. Lloyd Tuckey, M. I)., Member of the Medico-psychological Asso-
ciation. Third Edition, revised and enlarged. London: Bailliere, Tin-
dall, and Cox, 1891. Pp. xvi to 321. [Price, $2.]
9 i s r c 1 1 an \) .
A Year's Work in Minor Surgical Gynaecology at the Kensington
Hospital for Women, Philadelphia, was reported upon recently by Dr.
Charles P. Noble, at a meeting of the Philadelphia County .Medical
Society. Speaking of operations on the uterus, Dr. Noble said :
I have made it an invariable rule to re-examine all patients before
beginning the operation. This can lie done most thoroughly when the
patient is anaesthetized. If the uterine appendages are found inflamed
and adherent, any proposed operation upon the uterus is abandoned. I
believe this to be the only safe rule of practice. For sutures, silk, cat-
gut, and silkworm gut have been used. For general purposes I like
silk ; but it should not be used where the sutures can not be removed
in one or two weeks. Catgut I have found very useful for sutures hav
ing but little strain to bear, as, for instance, the upper sutures in
perineal operations. Silkworm-gut has the advantage that it is non-
aliMirlient ; hence it i- to be preferred where sutures must be left in a
long time — as, for instance, in the cervix, w hen the cervix and perinaeum
are repaired a l the -ame sitting. It has the disadvantage of being stiff,
which property makes it somew hat hard to remove, and gives the pa-
tient some pain. Alter operations the vagina is carefully dried, a pen-
cil of iodoform (twenty-five grain-), together with a strip of iodoform
gauze, is introduced, the vulva is sprinkled with a powder of iodoform
(one part) and boric acid (seven parts), anil then a cotton pad is placed
over the vulva — held in place by a T-bandage. For perineal operations
the urine is drawn for two days, after which the patient is allowed to
urinate. The gauze is removed after forty-eight hours, after which a
sublimate douche (1 to 2,000) is given daily. The bowels are moved on
the second day and regularly thereafter. An abundant -oft diet is per-
mitted. The external sutures in perineal operations are removed about
the eighth day; the internal sutures at the end of the second week.
When the cervix has been repaired at the same time, the cervical
sutures are removed at the end of the third week, or even later. One
should err on the side of leaving the sutures in long rather than that of
removing them early.
Patients having perineal operations are permitted to sit up in two
weeks ; those having a curetting, in three or four days ; those having a
trachelorrhaphy, in a week, etc.
The secret of success in plastic surgery is good asepsis, and careful,
pain-taking, and accurate denudation and suturing. 1 have never failed
to secure good union, which has always been primary throughout, with
two exceptions — one stitch-hole abscess and one small hiemorrhage
(haematoma).
On the procedures of dilatation and curetting of the uterus the
author said : Within the past ten years professional opinion concerning
these operations has fluctuated widely. Before the antiseptic era curet-
ting was considered a dangerous operation. Its danger at that time I
feel satisfied was due partly to lack of antiseptic measures, and partly
to bad diagnoses. At that time our knowledge of the diagnosis of
chronic salpingitis was very imperfect, and many accidents (peritonitis)
resulted from operating on the uterus when the tubes contained pus or
other septic fluid. Since the antiseptic era, in the hands of men capable
of making a diagnosis of uncomplicated disease of the uterus, and of
excluding chronic pelvic inflammation, these operations have been done
with impunity. Of late, the legitimacy of the operations has been ques-
tioned by Dr. Joseph Price, on the ground that many cases of salpingitis
and pus tubes have come under his care in which dilatation or curetting
has been done. This fact is no argument agaii^t the legitimacy of the
operations, nor against the fact that, when properly done in uncompli-
cated cases, the operations are perfectly safe and free from danger.
Did the women seen by Dr. Price (and by others, including myself)
have the tubal disease before the uterus was dilated or curetted ? Were
the operations done under rigid asepsis '? I believe that blunders in
diagnosis and blunders in asepsis should bear the blame in these most
unfortunate cases, and not legitimate surgery. In my own hands no
such untoward results have occurred. On the contrary, under the strict
limitations laid down, my confidence in the value and safety of the
operations increases as my experience grows.
Dyxtnenorrhoea. — Three cases of dysmenorrhea, due to partial de-
velopment of the cervix, with anteflexion, and characterized by
" cramps " during the flow, were treated by dilatation. Dilatation in
this class of cases has always given good results. The cause of the
" cramps " is a poorly developed cervix with a narrow canal, whose
caliber is further lessened by the anteflexion. A broader experience
has induced me to use the dilator for dysmenorrhea much less fre-
quently than formerly. I consider it absolutely contra-indicated if
there is tubal inflammation, and believe that it is of little use in re-
lieving pain, unless the latter is distinctly intermittent and cramp-like
in character. The pains accompanying menstruation due to inflamma-
tion of the uterine appendages, or of the uterus, or due to a depressed
state of the blood, with pelvic neuralgias, are not benefited by dilata-
tion, and in such eases it should not be done.
Endometritis. — Fifteen cases of uncomplicated endometritis have
been treated by dilatation and curetting. Nine of these were cases of
fungoid endometritis with resulting uterine haemorrhages. I believe
that this procedure best meets the indications in all eases of uncomplij
eated chronic endometritis. f>\ removing the thickened portion of the
diseased endometrium and providing a freer vent for the uterine secre-
tions, most cases of endometritis can be cured promptly, and the re-
mainder are much improved. The number of cases in which it is
necessary to make intrauterine applications is thus much reduced,
and these women are saved the necessity of undergoing a prolonged
course of painful intra-uterine treatment. By promptly curing women
April 9, 1892.]-
MISCELLAXY.
417
with chronic endometritis another important point is gained — the dis-
ease is cured before it spreads to the tubes.
The results in inv hands have been most satisfactory in cases of
fungoid endometritis, especially those of short duration, resulting from
abortions. Cases of chronic endometritis with purulent leucorrhoea
have been most intractable, and in these eases it has been necessary to
make weekly applications to the endometrium (by means of the appli-
cator) of pure carbolic acid, Churchill's tincture of iodine, or a satu-
rated solution of chloride of zinc for some weeks after the curetting.
I wish to call attention to the small number of cases of uncomplicated
endometritis in this series. Omitting the fungoid cases, there were 6
out of 12K women admitted to the hospital. This is about the average
in my practice.
In fungoid endometritis I have found the curette so valuable and
other methods of treatment (in marked cases) so futile that I am unable
to understand how those gentlemen who oppose the use of the curette
treat these cases. The only other resort is electricity ; but the curette
\\ ill accomplish in a few minutes what it requires weeks or even months
to accomplish by electricity.
The results obtained by the curette in uncomplicated endometritis
are so good that of late, forgetting the teachings of past experience,
certain operators have proposed to treat cases of endometritis compli-
cated by chronic tubo-ovarian inflammation in the same way. It seems
to me that careful men can not protest too strongly against such treat-
ment. In the first place, the danger of setting up fresh salpingitis and
peritonitis is acknowledged (except by the few) to be great ; and in the
second place, should the endometritis be cured (which is doubtful, be-
cause of pelvic congestion kept up by the tubo-ovarian inflammation),
the graver disease of the appendages remains. The wiser plan, if the
appendages are diseased, is first to remove them, and then actively treat
the endometritis ; or, if the appendages are but slightly diseased and do
not require ablation, to treat the patient by applications of iodine to the
vaginal vault, and the use of glycerin tampons, at the same time using
every measure to improve the local conditions by general medication.
It happens not infrequently that when the inflamed uterine ap-
pendages are removed, an endometritis is left which causes the patient
some annoyance. These cases are often reported by those hostile to
modern surgery, as showing that the abdominal section has failed to
cure the patient. These gentlemen have a mental strabismus, and do
not see that the section has accomplished the end aimed at — the abla-
tion of the diseased uterine appendages. Whether this alone will cure
the patient depends upon whether the particular patient has any other
disease. If she has an endometritis, this must be cured ; if anaemia, or
indigestion, or malnutrition, these must be treated.
I wish to protest against the view that endometritis, as a rule,
causes much distress, except the annoyance of a leucorrhoea, unless it
induces hemorrhage. Where women having endometritis suffer much
9 pelvic pain and are semi-invalids, the cause of the pain or invalidism
is to be sought elsewhere — in the uterine appendages or in the vital
organs or blood state. It is a narrow man who attributes all the symp-
toms complained of by women to disease of the pelvic organs, and who
forgets that women have an unstable nervous system, easily influenced
by morbid conditions of the general economy.
In discussing endometritis it should not be forgotten that other
conditions besides endometritis can cause a discharge from the uterus.
AN hatever will cause congestion of the uterus will cause uterine dis-
charge. For example, subinvolution, constipation, feeble heart, lazy
habits, malnutrition as from phthisis, erotism, etc. Treatment ad-
dressed to the causative disorder will stop such uterine discharge. This
class of cases calls for no treatment of the endometrium.
A Pernicious Osseous Disease (Lymphadenia Ossium). — The Journal
<>/ the American Medical Association for .March 1 '2th contains the fol-
low intr editorial article :
A pernicious form of osseous disease is the subject of a Vienna clini-
cal prelection by Professor Xothnagel, given in full in two recenl n
bers of the Press and Circular. The changes of structure discovered
bj autopsj were unusual in extent, having invaded the entire skeleton
Old obliterated the medulla of the bones by a perversion of that force
or those forces whose "elaboration should constantly proceed in the
healthy haematic organs." The case was that of a male, aged twenty-
four years, hitherto healthy, with good family history, and living in fair-
ly hygienic surroundings. He was first a " Schwizer," or cow herd, and
later a soldier in a small Tyrol barracks. His attack dates from eight-
een months ago, with fever and pain in the breast and limbs, without
appreciable cause. The temperature was not recorded accurately until
a month before death. Sweating was profuse at the outset of the at-
tack, and also in the later months. Intermissions in the paroxysms of
pain and fever were about two weeks in duration, with excellent health,
as regarded subjective symptoms, in the intervals ; later, however, the
attacks became more frequent and more intense, occurring in the even-
ing and with a periodicity resembling that of tertian malarial fever.
The patient became pale and emaciated. The sternum and long bones
of the extremities showed deformity from thickening. There was a
right-sided exudative pleurisy which increased gradually until death.
The spleen was slightly increased in area. The urine exhibited no albu-
min or sugar, but indican was in excess. The blood revealed oligocy-
themia and oligochromaemia, and under Ehrlich's coloring commingling
apparatus there was reported poikilocvtosis, the erythrocytes showed a
marked disparity of diameters — ranging from microcytes to the normal
red cell — and a few of the red corpuscles were observed to contain single
nuclei ; the leucocytes were not greatly changed. The blood was ex-
amined at different times for the parasites of malarial fever, but none
were observed. Bacterial examinations obtained only negative re-
sponse.
The autopsy was made by Professor Kundrat on November 17th, or
six weeks after the patient's entrance into the hospital. The condition
of the bones was the most striking feature of the case. Every bone of
the spine, pelvis, shoulders, the sternum, ribs, clavicles, all the long
bones, the carpals and tarsals, were affected. The unchanged bones
were the phalanges and those of the head and face. A thick layer of
osseous deposit, as if covered with a thick infiltrated periosteum, caused
the exterior deformity. All the long tubular bones were expanded at
their upper portion by a grayish-white infiltrated earthy matter. The
interior of the long bones, and of the larger spongy bones, was occupied
by the same metamorphic deposit as appeared on their exterior. In a
few places the muscular insertions were infiltrated with the same sub-
stance. The marrow of the bones, with the exception of a remnant here
and there, had disappeared. No bending or twisting of the bones was
present as is described to occur in osteitis deformans. The lymphatic
glands were found enlarged, in some cases twice and even thrice their
normal size. During life they could be felt to be soft and large, and
the post-mortem confirmed this condition, they being in no way indu-
rated. When cut, the glandular tissue appeared congested, due to a
hyperplasia of the follicular elements, but otherwise it had a normal ap-
pearance.
The pathology of the disease seems to hinge upon a deranged hae-
matic process, affecting chiefly the regeneration of the red corpuscles.
The leucocytes remained almost unchanged, indicating that they were
derived from lymphatics and spleen and not from the marrow of the
bones. The red corpuscles were greatly reduced in number and pre-
sented a wide range in regard to their diameters, thus conveying the
thought that they were the imperfect product of the spleen, unaided by
the better results afforded normally by the marrow of the bones. All
investigators are not agreed as to the part which the bone marrow plays
in the formation of the red corpuscles, but this case would appear to
bring that function as far to the front as has been taught by any of
them. The argument by analogy disposes us to believe that the patholo-
gy in any case which would arise from a functional or anatomical disor-
der of any one of several organs, physiologically working together for
the same end, would overtax the others and create in them a compen-
sating hypertrophy. Thus, when the spleen is extirpated, a compensa-
tory activity is found by Mosler to be thrown on the medulla ossium and
lymphatic glands. In this ease the medullary structure was almost ob-
literated, and practically inverted the splenic experiment, throwing back
a compensation of function on the spleen and lymphatic glands and aug-
menting the volume of those organs. These changes were recognized
dining life ami abundantly eonlir d at the post mortem table, This
remarkable case is differentiated by Nothnagel from acromegaly, and
one or two other forms of osseous disease, anil designated " 1\ mpliadcniii
418
MISCELLANY.
[N. Y. Med. Jour.,
(or lymphadenonia) ossium," due to a gradual obliteration of the me-
dulla, " in a manner not yet demonstrated by experiment, but probably
induced by a compensating force for the altered state of elaboration
that should constantly proceed in the healthy haematic organs."
The Ambulance Service in New York. — The newspapers have pub-
lished the following letter, dated March 26th, signed by Dr. Charles
McBurney and Dr. Lewis A. Stimson :
Within the last few weeks the newspapers have printed a number
of articles criticising with considerable severity the ambulance service
of this city. This criticism has usually accompanied and been based
upon reports of alleged negligence or ignorance on the part of ambu-
lance surgeons, or of such lack of sympathy in the performance of
their duties as would amount, if true, to actual brutality. The other
side of the case has been partly presented in an occasional article and
in editorial comments, but the great majority of the publications have
been occupied solely with the alleged errors and defects of the service.
In view of this fact, it has seemed desirable to friends of organized
charity that some of those who are familiar with the subject should
make to the public a statement of the character of the ambulance
service, and of the conditions under which it is performed, to the end
that an opportunity may be given to those who are interested in the
matter to form a trustworthy opinion as to its merits and demerits.
The undersigned are now, and for some years have been, attending
surgeons at the Roosevelt and New York Hospitals, respectively; they
take part in the selection of the ambulance surgeons, supervise their
work, and have charge of the patients brought in by the ambulances.
They have also served in the same capacity at Bellevue and other hos-
pitals.
The ambulance service of the city is carried on partly by the Com-
missioners of Charities and Correction at Bellevue, Gouverneur, and
Harlem Hospitals, and in part by a few of the private hospitals — the
New York, with its Chambers Street branch ; the Roosevelt, the St.
Vincent, the Presbyterian, and the Manhattan.
The statement- that wre have to make are based in detail upon the
conditions existing at the New York, Chambers Street, and Roosevelt ;
but, to the best of our knowdedge and belief, they are equally true in
general of the other hospitals, both public and private.
Each of these three hospitals provides two ambulances w ith relays
of horses, drivers, and stablemen. The stable and harness arrange-
ments are similar to those in use by the Fire Department, so that with-
in a minute after the signal has been given from the office of the hos-
pital the ambulance has departed on its errand. This is the invariable
practice, and the rule of the hospital is and long has been rigid that an
ambulance surgeon while on duty shall not go out of hearing of the
gong that summons him to a call. At night the signal sounds simul-
taneously in his bedroom and, at the New York, turns on the electric
light. One ambulance surgeon is always on duty, and is required in-
stantly to leave whatever other work he may be engaged in when the
call sounds. A second surgeon is required to hold himself in readiness
to answer any call that may come during the absence of the first. It
occasionally happens that a third call comes while both ambulances are
out, or a second call while one ambulance is temporarily disabled, and
those are the only occasions on which any delay in answering a call
arises within the hospital. The Grand Jury stated officially last July
that the ambulance habitually reached the farthest points in the largest
district within eight minutes after the receipt of the call, and that delay
occurred only in the transmission of the call to the hospital.
The call for an ambulance is transmitted to the hospital by one of
two routes ; it may be sent from a station-house to Police Headquarters
and thence by private telephone to the hospital, or it may come over
the Fire Department wires, for the fire-alarm boxes are so fitted that a
policeman can send a call for an ambulance from most of them. These
latter calls sound simultaneously in all the hospitals, and the case be-
long- to the ambulance that gets to it first. In connection with this it
may be mentioned that a great deal of harsh newspaper criticism has
been based on the theory that an ambulance surgeon refuses to take a
patient who is not in his district. On the contrary, he is anxious to
take him, for almost the only break in the monotony of a duty that
deals solely with sickness and suffering is the satisfaction t tint comes
from a "beat" of the ambulance of a neighboring hospital. These
fire-alarm calls are known as "hurry call-," and they are the one- that
especially bring the young man down stairs three steps at a time to
swing himself bareheaded to the tailboard and urge the horse to a run.
A book is kept in the office in w hich the time of the departure and
return of the ambulance, the place where the patient was found, and
the diagnosis are recorded.
The ambulance surgeon is a member of the re-ident staff, who is
assigned to this duty during the middle period of his hospital course —
that is, after he has already passed one term in preparation for it. The
members of the staff are selected, after a competitive examination,
from among candidates who are many times more numerous than there
are positions to be filled, anil they are beyond question the very best of
those w ho are graduated from Harvard, Vale, and Philadelphia, to trj for
the positions. All of them have had previous experience as dressers in
dispensaries and as substitutes in hospitals. At Chambers' Street the
men are not selected by competitive examination ; the peculiar charac-
ter and activity of that service make it exceptionally advantageous to
men of experience, and consequently the member- of its staff are usually,
(three fourths of the time) men who have previously served a full course
in some other hospital.
What is the work for the doing of which this elaborate preparation
is made ? It is to respond to any call that is sent in by the police ; to
respond instantly, unhesitatingly, at any hour day or night, abandoning
everything else, and without stopping to inquire as to the character or
the urgency of the call. Primarily, it was intended only for the care
and comfort of those who need to be received into a hospital, but it has
grown into a vast additional system of outdoor relief, of the treatment
of the immediate wants of those who do not need hospital care. This
needs to be borne in mind in criticising alleged refusals to receive pa-
tients. In a large proportion of calls neither the sender of the call nor
the patient has any expectation that hospital care w ill be required or
accepted.
The amount of the work is indicated by the following figures : Dar-
ing the year 1891 the Chambers Street ambulance was called out :j,'.»I6
times; the New York, 1,200 ; the Roosevelt, 1,500. The Grand Jury
found the daily average for the city 47 calls.
It can hardly be necessary to say that a private hospital is a private
charity and is under no obligation to maintain this service (in leeJ,
many hospitals do not maintain it), or that it receives no pay for doing
it, or that no member of its professional staff receives any pay for it.
And vet, so easily does the notion of a vested right arise from a recur-
rent favor, that one of our hospitals was severely criticised by the press
because it objected to going to the expense (some $2,000) of making a
new connection with the Fire Department wires after the latter had been
placed in the subway.
Much of this work is work that the city pays other people to do
Police surgeons are employed and paid to attend to sick and injured
policemen and to such sick or injured citizens as are brought to the station
houses. But it is very much easier, as well as more certain in its re-
sults, to press a button and summon an ambulance than it is to send a
messenger a mile or tw o for a physician who may or may not be at home.
Further, a considerable number of the calls are made needlessly for
trifling injuries, for bruises received in a drunken altercation, for ma-
lingering tramps who want a night's rest and a breakfast and had rather
ride than walk. The habit of calling increases with use, and without
stopping to consider the urgency, the signal is rung, and horse, driven
and surgeon are brought out to put on a piece of court plaster. The
hospitals make no complaint of this abuse ; they look upon it as an in-
evitable accident of the service. It means to the management a little
more money spent for repairs, or for horses, or perhaps for wages. It
means nothing to the attending staff, for it brings them no cases to be
treated, but to the ambulance surgeon, who has not even the privilege
of an audible grumble, it means a great deal ; it means the needless in-
terruption of other work, the loss of food or sleep, and the strain on
nerves and temper which that interruption and that Heedlessness create,
Even w ithout such avoidable additions the work is heavy enough and
trying enough to call for all the sympathy and all the charity in judg-
ment that their critics can command. A few days ago the Press ( lull
made an appropriate and touching recognition of the fidelity of a re-
April !), 1892.]
MISCELLANY.
419
porter who recently died of typhus fever contracted in the discharge of
his duty. For the last two months the ambulance surgeons of this city
have been going daily, and several times a day, to cases which they
knew might be, and many id' which proved to be, typhus ; and within a
week one of them, called to such a case, saw every friend of the patient
rush from the room when the dreaded word was spoken, and he was
compelled to take him in his arms and carry him to the ambulance
alone and unaided. With the experience and prospect of such expos-
ures and of personal violence frequently threatened and occasionally in-
flicted, the life of the ambulance surgeon does not excite much envy;
and when to it is added the constant exhaustion of exacting duties we
can only feel surprise that men are willing to take the places. They
frequently fall ill from overwork or through contagion, and occasionally
one dies. Look at the great tablet in Bellevue Hospital covered with
the names of young men w ho have " died in the discharge of duty."
These young men are the best of their age in the profession ; they have
eagerly competed for the opportunity to assume their onerous duties,
and they perform them with a fidelity and zeal that are rarely exhibited
in other places, for their work is done under the stimulus of a desire
for self-improvement, not for money.
This side of the story is not generally known. The public hears
nothing of the good work faithfully done beyond the half dozen items
in each day's newspaper that "an ambulance was called and the injured
man taken to the hospital." Attention is aroused only by the occasional
error or by the picturesque and imaginative accounts for which our long
indulgence in sensationalism has created a demand.
It is sometimes urged by critics who are apparently without a
personal knowledge of the wu. kings of the service that it should
be in the hands of older men in order that mistakes, presumably
due to ignorance and inexperience, should be avoided. But older
men of more experience and knowledge, and of equal ability, are
not to be had. An older man who would accept such a position
for such a salary as a hospital could pay would be a self-confessed
failure, and any expectation of better work from him would certainly
be disappointed. Such extraordinary exertions as are made by the
young ambulance surgeons in the performance of their duties can be
made continuously only by the young, the vigorous, the enthusiastic. If
they were not earnest and eager in their work they would not remain in
the service a week. The elderly man of experience, for whom the
coroner's jury yearns, who should attempt to take the place of one of
these young men, would at the end of a few days be in as pitiable a
condition as if he had acted as a substitute on one of our college foot-
ball teams.
Of course, we admit that occasionally an important mistake is made.
That mistake is almost always the same — a fracture of the skull with-
out symptoms is overlooked in a drunken man, or the symptoms pro-
duced by it in a sober man are thought to be those el' drunkenness. It
is not necessary to plead in extenuation that for each of these mistakes
there are hundreds of cases in which the same judgment is exercised
and a correct decision reached, or that little or no actual harm arises
from it. The defense has a much broader and more solid foundation.
Those mistakes have always been made and are now being made everv-
% here, and by the most experienced, and they w ill doubtless continue to
be made so long as our perceptions and our knowledge have their pres-
ent limitations. The science and art of medicine has not yet made it
possible to recognize a fracture of the skull that gives no symptoms, or
surely to discriminate between some of its symptoms and those of alco-
holic intoxication. To the retort that, such being the case, every doubt-
ful ease should be taken to the hospital, we reply that that very course
is the one that is habitually followed. The occasional mistake is made
in eases which, after due consideration, have been thought not to be
doubtful. The doubtful cases which are taken in are never heard of out-
side the hospital, and yet they are to be counted by the hundreds. I'p-
ward of ten per cent, id' the patients brought in by ambulance arc just
those doubtful cases; they are brought in on the chance; they prove to
lie nothing but drunkenness, and they are discharged the next day. The
hospitals do not pretend to take care of the drunken ; they do not re-
fuse a sick man because he is drunk or violent or abusive',' but they do
not take him if they think he is only drunk.
Finally, we beg leave to add a few extracts from an official state-
ment made by the Grand Jury last July. A committee of five members
was appointed "to make a thorough examination of the ambulance sys-
tem of the city of New York." That committee reported as follows :
" Regarding the private hospitals, . . . we can only say that we
found in their ambulance equipment, and in their administration of the
service, only that which calls for our hearty approval."
" We note with commendation a feature that seems universal in the
hospitals named (the private ones), to wit, that the ambulance doctors
are all graduates, and that they are not detailed for ambulance service
until after they have performed six months of active duty in the hos-
pital wards."
" In all these hospitals, both private and public, we found admirable
equipments for the performance of the important labor discharged by
them, and a commendable zeal to be very prompt in responding to the
demands for the service."
" While we find very much to commend regarding the response by
all hospitals to ambulance calls on them, we are compelled to criticise
very severely the present lack of adequate official means of conveyimr
prompt notification to the hospitals of the necessity for an ambu
lance . . . ."
The following communication on the same subject, entitled Youth-
ful Ambulance Surgeons, and signed " An Old ' Doctor and Surgeon ' "
appeared a few days ago in the Evening Post :
The innate and inalienable sapience of the average juryman, and the
eminently sagacious result-* of crowner's-quest laws, have seldom been
more admirably illustrated than in the verdict recently delivered upon
the " Harper case," condemning the youth of the ambulance surgeons
and house staff of our hospitals, and urging that "the authorities'*
(what particular " authorities," imagination is left to surmise) should in-
sist that "experienced doctors and surgeons" be assigned to such
positions.
From a strictly nosocomial point of view, it must be admitted that
an ideal perfection of medical relief would be attained if, for example
Dr. Lewis A. Sayre and Dr. Stephen Smith were kept at a hospital, day
and night, to attend to ambulance calls, and if the resident staff were
entirely composed of men like Dr. Weir, Dr. Gouley, Dr. Bull, Dr. Mc-
Buruey, Dr. Bryant, Dr. Dennis, Dr. Janeway, Dr. Loomis, and others
of equal professional eminence. But, unfortunately, even under our
present somewhat arbitrary method of legislation, no way exists of forc-
ing these gentlemen to relinquish a lucrative practice, to abandon their
families and homes, and to devote their whole time to gratuitous work.
The system of hospital administration seems to be strangely misun-
derstood by the public, and sometimes by the press. The ablest and
most " experienced doctors and surgeons " have, for generation after
generation, been "placed in charge" of our hospital wards, and have
given their service without remuneration as members of the visiting or
consulting staff. In their daily rounds of the hospital, it is not too
much to say that the poorest patient receives more skilled treatment
than the ordinary coroner's juryman could afford to pay for, and it is
certain that the most brilliant triumphs of surgery anil medicine have
been achieved in hospital practice.
As regards the younger men who constitute the resident staff al-
ways under instruction of the " visiting," except in manifestly minor
cases — it is probably not generally known that these are all graduated
physicians and surgeons who, after a course of instruction which now
includes more clinical experience than the graduate of the last genera-
tion could acquire in ten years of private practice, undergoes after re
ceiving his diploma, a competitive examination to win his hospital an
pointment, in which he rises, progressively, from the lowest to the
highest grade. In fact, these younger men form a corps d'ilite by
selection from our best medical schools.
It is possible that drunkenness may mask an injury to the skull or
its contents, or, more rarely, that such an injury may simulate drunken-
ness; but, in such cases, time for the development of further symptoms
is usually needed to form an accurate diagnosis, even by the mosl c\
pert seniors.
On the other hand, the Timrx ami lirr/l.i/n; a medical journal edited
in Philadelphia, in an editorial article headed Great Charities ami
Puerile' Administration, has this to say of the hospital interne.- of New
York :
420
MISCELLANY.
[N. Y. Med. Jocr.
New York is having trouble with her ambulance system. The
youngest and most inexperienced resident, still top-heavy with the dig-
nity of his newly acquired doctorate degree, is the one usually sent to
answer calls for the ambulance. The result is seen in two cases re-
cently described in the journals. An aged woman was run over and
seriousi* "•; 1 The Roosevelt Hospital ambulance was summoned,
but the doctor in charge refused to receive the woman and drove off,
although urged by two physicians present to take the woman to the
hospital. So indignant were the bystanders that they pelted the doctor
and ambulance with snowballs as they drove off.
What a comment is this <>n the description of this hospital by a
British visitor, quoted in a recent New York medical publication! He
speaks of the magnificent operating theatre, the finest in the world, and
of the difficulties experienced in finding ways of expending the enor-
mous sum ($400,000) given to the hospital for that purpose.
In another case the coroner's jury censured the ambulance surgeon
(it Manhattan Hospital for shameful neglect of a man with a fractured
skull, their verdict ending as follows :
"We condemn the treatment of the ambulance surgeon who had
charge of the case, as well as the surgeons of Bellevue Hospital, under
whose charge the deceased was placed. We further condemn the
practice of the hospitals of having young and inexperienced doctors,
and we strongly recommend that the hospitals be censured, and that if
the authorities have the jurisdiction they should insist that experienced
doctors and surgeons be placed in charge, so as to protect the lives of
the unfortunates who may be placed in their charge."
It is thus seen that the grandest designs of philanthropists may be
brought to naught by the selection of improper instruments. It is one
of the grave defects of the examination system that it can not deter-
mine the fitness of candidates beyound their proficiency in study.
" Though 1 have the gift of prophecy, and understand all mysteries and
all knowledge, and though I have all faith, so that I could remove mount-
ains, and have not charity, I am nothing.''''
[Our own view of this subject was given in the Journal for Febru-
ary 6th.]
Mortality in Cities in the United States. — The following table
represents the mortality in the cities named, as reported to Dr. Walter
Wyman, Surgeon-General of the Marine-Hospital Service, and pub-
lished in the Abstract of Sanitary Reports for April 1st :
New York, N. Y
Brooklyn, N. Y
Boston, Mass
Baltimore, Md
Cincinnati, Ohio. . .
Cleveland, Ohio . . .
"New Orleans, La. . .
New Orleans, La. . .
Pittsburgh, Pa
Washington, D. C
Minneapolis, Minn.
Louisville, Ky
Rochester, N. Y
Providence, R. I.
Binghamton, N. Y. .
Mobile, Ala
Galveston, Texas...
a
L
E> i
&
o
« =
S |
£
i
■= p
3 "
1
i6
o
t-
Mar. 26.
1,515.301
872
Mar. 19.
1,099,850
448
Mar. 1<).
1,046,964
504
Mar. 26.
806,343
397
Mar. 26.
44K.477
237
Mar. 26.
434.-139
220
Mar. 25.
296,908
137
Mar. 26.
261,353
109
Mar. 5.
242,039
128
Mar. 12.
242,039
134
Mar. 19.
238,617
107
Mar. 19.
830,392
mi
Mar. 26.
164.738
43
Mar. 2(5.
161.129
50
Mar. 26.
133,896
55
Mar. 12.
132,716
29
Mar. 2iJ.
132,146
44
Mar. 19.
106,713
33
Mar. 2c.
81,434
24
Mar. 26.
76,168
39
Mar. 25.
74,398
33
.Mar. 26.
36,425
15
Mar. 26.
35,005
12
Mar. 26.
31,076
16
Mar. Is.
29,084
10
Mar. 19.
16,159
6
Mar. 19.
11,750
5
DEATHS FROM—
Phthisis pul-
monalis.
>
Small-pox.
Varioloid. |
Varicella.
Typhus fever.
W
Scarlet fever.
—
a
I
105
32
4
is
31
fi
30
an
15
2
2
3
1
4
5
2
2
3
1
1
12 is as
48
24
30
11
10
17
9
5
9
12
3
16
3
1
15
m
16
8
2
1
'3
2
1
4
2
1
1
3
1
1
1
3
1
i
i
l
1
T
2
11
7
6
2
2
2
1
9
....
5
2
1
1
2
l
1
Moliere and Physicians. — The New York Times publishes a notice
of a book by M. Georges Monval, entitled L' Amour medrcin, from which
we take the following: Several Molierists, and Monval is one of them,
think that Moliere hated physicians because he was ill and the physi-
cian- could not cure him, but Moliere knew well that his malady came
of his stage life ; the monster public had to be incessantly tamed, and
there was abuse of exasperated strength, excess of mental labor. The
remedy was to be found in an abandonment of the theatre. He was
too sensible to blame the physicians for his ill-health ; still he hated
them, as V Amour rnederin proves, and perhaps his sentiment may be
explained by pure professional jealousy. In love with truth and frank-
ness, Moliere felt deeply the pain of playing a part that he unjustly com
demned in his enemies — the part of a physician who does not cure.
Comedy does not transform men and manners ; it can not more real-
ize this anti-natural miracle than medicine can change a temperament.
It has higher and grander achievements. It shows in the work of
Moliere instinct, youth, love, unconquerable forces triumphant over the
human vices at war against them, and all-powerful Nature, protected
by an invincible armor of adamant, a tamer of the false and fictitious
in misdirected civilization. Like medicine, comedy has for its function
to prevent Nature from deviating. It does not cure the incurable. In
attacking the phy.-ician.- Moliere confe—ed figuratively hi- own inability
to repair the irreparable. He never missed an opportunity to express
contempt for books ; he feigned to believe that the dramatic poet can
not live and remain in the memory of men except by representation on
the stage.
To Contributors and Correspondents. — The attention of all wlia purpose
favoring us with communications is respectfully called to the follow-
ing :
Authors of articles intended for publication under the head of " original
contributions " are respectfully informed that, in accepting such arti-
cles, we always do so with the understanding that the following condi-
tions are to be observed: (1) when a manuscript is sent to this jour-
nal, a similar manuscript or any abstract thereof must not be or
have been sent to any other periodical, unless we are specially notified
of the fact at the time the article is sent to us ; (2) accepted articles
are subject to the customary rules of editorial revision, and will be
published as promptly as our other engagements will admit of — we
can not engage to publish an article in any specified issue ; (3) any
conditions which an author wishes complied with must be distinctly
slated in a communication accompanying the manuscript, and no
new conditions can be considered after the manuscript has been put
into the type-setters' hands. We are often constrained to decline
articles which, although they may be creditable to their authors, are
not suitable for publication in this journal, either because they are
too long, or are loaded with tabular matter or prolix histories of
cases, or deal with subjects of little interest to the medical profession
at large. We can not enter into any correspondence concerning our
reasons for declining an article.
All letters, whether intended for publication or not, must contain the
writer's name and addrtss, not necessarily for publication. No at-
tention will be paid to anonymous communications. Hereafter, cor-
respondents asking for information that we are capable of giving,
and that can properly be given in this journal, will be answered by
number, a private communication being previously sent to each cor-
respondent informing him under what number the answer to his note
is to be looked for. AH communications not intended for publication
under the author's name are treated as strictly confidential. We can
not give advice to laymen as to particular cases or recommend indi-
vidual practitioners.
Secretaries of medical societies will confer a favor by keeping us in-
formed of the dates o f their societies' regular meetings. Brief notifi-
cations of matters that are expected to come up at particular meet-
ings will be inserted when they are received in time.
Newspapers and other publications containing matter which the pierson
sending them desires to bring to our notice should be marked. Mem-
bers of the profession who send us in formation of matters of interest
to our readers will be considered as doing them and us a favor, and,
if the space at our command admits of it, we shall lake pleasure in
inserting the substance o f such communications.
All communications intended for the editor should be addressed to him
in care of the publishers.
All communications relating to the business of the journal should be ad-
dressed to the publishers.
THE NEW YORK MEDICAL JOURNAL, Apeil 16, 1892.
(Original (!l o m m u n i ta 1 1 o n s .
THE ELEMENT OF
CONTAGION IN TUBERCULOSIS*
By T. MITCHELL PRUDDEN, M. D.
The two great achievements in medicine which espe-
cially mark the decade now closing are the gaining of pre-
cision in our knowledge of the cause of infectious diseases,
and directly hased upon this the discovery that, in a degree
scarcely dreamed of before, these diseases are preventable.
The medical world was all ready for Dr. Koch's an-
nouncement, when it came early in 1882, that tuberculosis
was caused by a living germ whose life history he then
made known. It is a small rod-like germ, very persistent
in the maintenance of its form and life, but so sensitive in
its growth and reproduction that it has no breeding places
in Nature outside of the bodies of those men and animals in
which it has lighted up disease. Finding lodgment in this
congenial soil, it may grow, stimulating and poisoning, as it
does so, the tissues where it lies, so that, sooner or later, the
tendency is for the new tissue which is formed and the old
which is robbed of life to disintegrate, and if favorably
situated be by degrees cast off from the body together with
more or less of the virulent germs.
While the tubercle bacillus does not grow in Nature out-
side the bodies of warm-blooded animals, and while its life
is destroyed by a few moments of boiling, by contact with
many chemical agents, and by prolonged exposure to the
sunlight, it yet may retain its vitality and virulence during
months of drying and the ordinary exposure to the weather,
and may be found alive after long burial in the earth.
The places outside of the bodies of living beings in
which the bacillus of tuberculosis is to be especially found
under ordinary conditions with us are in the flesh and milk
and discharges of tubercular cattle and in the excretions of
tubercular persons, especially of those who are the victims
of tuberculosis of the lungs. But by far and away the most
common and abundant lurking place of this germ is the spu-
tum in pulmonary tuberculosis.
When the tubercle bacilli are cast off from the body in
the sputum, they are closely imbedded in a moist, tenacious,
albuminous material from which they can not escape so long
as moisture is maintained, no matter where they lodge or
what air currents may blow over them. So that, so far as
specific contamination of the air is concerned, this can not
occur while the sputum stays moist. This same tenacious
envelope also prevents such ready access of disinfectants to
the bacilli in the sputum as would assure their easy destruc-
tion. When the sputum dries, the bacilli are still firmly
held in place so long as the desiccated mass remains intact.
But let this once be pulverized by the foot on floor or car-
pet, by rubbing between folds of cloth or in any other way,
and these virulent particles can mingle at once with other
* Head before the Section in Hygiene of the New York Academy of
Medicine, January 21, 1NH2, as the introduction to a discussion on the
prevention of tuberculosis.
dust and become subject to the same physical laws of trans-
port and diffusion.
It is to be distinctly understood that the breath of con-
sumptives, apart from solid particles which may now and
then be cast off in coughing, conveys no germs.
It is not necessary for me to go over the story of re-
search and experiment which have led to the universal con-
viction that the tubercle bacillus stands in an absolute and
direct causal relationship to tuberculosis, and that in this
relationship it stands alone.
That there are*many contributory factors in the acquire-
ment of this disease — vulnerabilities of the individual, both
hereditary and acquired, predisposing vicissitudes of envi-
ronment— one can not, it seems to me, deny, nor should he
measure lightly. But the one thing without which tuber-
culosis can not come to man or beast is the living tubercle
bacillus. All the vulnerabilities and predispositions and fa-
voring vicissitudes which we either know or can conceive of
can not without this particular germ light up this particular
disease. It is not a vapor in the air, it is not a mysterious
miasm, it is not an inscrutable enzym which does this thing,
but a definite physical body which we can see and measure
with our lenses, which we can cultivate and handle and
kill.
Precision in our conception of the nature of. the disease
tuberculosis, definiteness in our knowledge of its cause —
these were the first fruits to ripen in this newly opened
field.
But then came the question, If tubercle bacilli are cast
off alive from the bodies of its victims or can be consumed
in the meat and milk of tubercular cattle, are not these cast-
off or consumed germs the sources from which new disease
is propagated ? If this were true, then tuberculosis is a
communicable disease. I will not weary you, full as it is
of practical significance, with the oft-told tale of Cornet's
convincing researches, nor with a summary of other studies
which at last have proved beyond a doubt that living viru-
lent tubercle bacilli are present in the dust of the air of
places in which uncleanly consumptives live, and that close
attendance upon and association with such persons, without
intelligent precaution, frequently involves acquirement of
the disease. The evidence of the communicability of tu-
berculosis finds a most dramatic index in the yearly death
roll of its victims.
Slowly but suraly we have learned that what once was
thought to be hereditary transmission of the disease is often
only household poisoning, or, at most, an entailed vulnera-
bility in the presence of the germs derived from whatever
external source. The possibility of extremely infrequent
direct hereditary transmission of the tubercle bacillus need
have no serious consideration here, in view of the immedi-
ate practical purpose which calls us together. The main
point is that tuberculosis is a communicable disease, and
that the chief element in its conveyance is the uncared-for
sputum of the victims of pulmonary tuberculosis. This pos-
sibility was distinctly foreshadowed in Dr. Koch's first Com-
munication on this subject, and has since been steadily grow-
ing into a fixed conviction among intelligent physicians.
422
PRUDDEN: THE ELEMENT OF
CONTAGION IN TUBERCULOSIS. [N. Y. Med. Jock.,
And yet well-nigh ten years have gone without that persist-
ent and concerteil action on the part of medical men in this
country which both intelligence and humanity would seem
to make imperative. The varied reasons for this apathy we
need not here discuss.
But now, at last, when all seems ready for decisive meas-
ures, we must not forget that our own ideas of the danger
to be met must be precise and definite, in order that we may
by individual counsel, as well as by public urgency, make
plain and comprehensible to all the thing we strive to do.
There should be among ourselves none of the old indefinite-
ness of conception regarding the exact meaning of such
terms as infection, infectious disease, contagium, conta-
giousness, and the like.
The meaning of these terms was of necessity uncertain
and hazy when the things themselves which they were in-
tended to specify were largely matters of speculation and
conjecture. It were well, perhaps, if they were dropped
wholly from our speech and replaced by new words coined
in the new light. But as this may not be, the next best
thing is to remodel the meaning, and with this to reinvest
the words.
I think I do not err in saying that those who can justly
speak most authoritatively in this matter are agreed that in
the light of to-day an infectious disease is one which is
caused by the invasion and reproduction within the body of
pathogenic micro-organisms; not necessarily an invasion by
bacteria, because in one case at least — malaria — the invad-
ing pathogenic micro-organism is not a bacterium, but be-
longs to a wholly different class. The invading micro-or-
ganisms which we must assume to cause the exanthemata
are wholly unknown to us, but the nature of these diseases
justifies us in grouping them with those infectious diseases
whose causative agent is definitely known. Itifiction is the
condition produced by the entrance and multiplication of
pathogenic micro-organisms within the body.
The word contagious no longer covers infinite possibili-
ties in the unknown, or carries with it the mysterious ter-
rors of the unknowable. The contagium in any infectious
disease is for us to-day the particular pathogenic micro-
organism itself, whose advent in the body ushers in those
reactions of the body cells which we call disease. The con-
tagium of an infectious disease is a particulate thing, which
has length and breadth and thickness and weight and the
varied powers of lowly forms of life.
An infections disease is contagious when its contagium
— that is, the micro-organism which causes it — under the
ordinary conditions of life, can be freed from the body of a
diseased person and, by whatever means, conveyed to the
bodv of another in a condition capable of lighting up the
disease anew. The old indefinite distinction between infec-
tion and contagion, by which one strove to express, among
other things, a fundamental difference between the convey-
ance of disease by personal contact and by aerial transmis-
sion, has become impracticable and valueless now, because
we know to-dav that the differences in the mode of com-
municabilitv of infectious disease are largely depen ent upon
the physical qualities of the contagia, upon the places and
wa\s in which these aie freed from the body, and upon the
places and ways in which they enter the bodies of new
victims.
The moment we know exactly what we mean when we
speak of a contagium, the moment we have learned to fol-
low the movements of these particulate contagia as they
leave the bodies of their victims — in one case in the stools,,
in another from the skin, in others from the mucous mem-
branes— and can trace their diffusion and life stories in earth
or air or water : the moment, I say, we can bring the light
from these varied factors to bear on the clinical stories of
infectious disease, we are not only in a condition to talk
intelligently about degrees of contagiousness, but to study
the conditions under which degrees of contagiousness may
vary in nature or be varied by art.
It is an unfortunate circumstance that the most common
notion of a contagious disease is derived from those which
are most dreaded and most liable to spread — from such dis-
eases as small-pox and scarlet fever — so that the common
conception of a contagious disease is of one which neces-
sarily taints the air about the victim — surrounding him, so
to say, with an infectious atmosphere. But this notion is
wholly groundless in any disease common with us outside of
the exanthemata, and is apparently reasonable here only be-
cause the contagia of these diseases are unknown to us and
are probably largely cast off through the skin, and so easily
di If used.
The fact is that such infectious diseases as typhoid
fever, diphtheria, and tuberculosis can be highly contagious
or made scarcely at all so, depending upon the care or lack
of care which is taken by the victims or their attendants in
the disposal of their varying exudates or discharges.
How contagious tuberculosis actually is under the con-
ditions which prevail to-day, it is not within the scope
of my theme to consider now. lint I do not see why it
should not continue just as ominous, or become even more
so, if the present unsanitary habits continue in public and
private places. If the vile and increasing practice of well-
nigh indiscriminate spitting goes on urn .-becked in nearly all
assembling places and public conveyances ; if the misguided
women who trail their skirts through the unspeakable and
infectious filth of the street are to be admitted uncleansed
into houses and churches and theatres ; if theatres and
court-rooms and school-houses and cars are to remain the
filthy lurking-places of contagia which their ill ventilation
and their mostly ignorant and careless so-called cleaning ne-
cessarily entail ; if in sleeping-cars and hotel bedrooms the
well are to follow consumptives in their occupancy without
warning or even the poor show of official disinfection ; if in
ill ventilated and ill-cared-for dwellings the well must breathe
again and again the dust-borne seeds of tuberculosis; if no
persistent warning is to be given to the ignorant of the
dangers w hich lurk in uncleanliness — then our task will be
most complex as well as difficult in limiting the contagious-
ness of tuberculosis.
The task of reform is not less than colossal at best, nor
is it by anything less than long-continued and well-directed
labor that substantial good can come. It will not do for
physicians to say that people will not follow their direc-
tions when the danger to the well is not individually more
April 10, 1892.J
WAYNES:
VICIOUS UNION FOLLOWING POTT'S FRACTURE.
423
imminent than this of the acquirement of tiiherculosis, and
so stand idle. Nor will it answer to hold our hands be-
cause, under the imost favorable conditions, all will not be
reached. Every little helps much when, as here, each vic-
tim of tuberculosis may lie discharging thousands, if not
millions, of virulent germs every day upon our ill-kept streets
and in places where the well must go.
It is not logical and it is not humane to do nothing lie-
cause we may not accomplish all.
How the sputum in tuberculosis can be best rendered
harmless it does not fall within the scope of my theme to
discuss, nor is the question of tubercular meat and milk
upon my list.
But this seems certain : that whatever public and pri-
vate measures for the prevention of tuberculosis we may
decide upon as wise must be so conceived that education
will go hand in hand with the law. Tuberculosis is conta-
gious ; wise teaching can show that its degree of conta-
giousness depends largely upon the comportment of the
victims themselves.
For humanity's sake the stricken must be made to know
that the necessary measures of reform in this matter do not
involve ostracism, do not entail isolation.
To make our way between the rigors of necessary legis-
lation on the one hand and the demands of the humanities
on the other is a task requiring tact as well as wisdom and
large knowledge withal of the daily ways of the world as it
goes on outside of laboratories. But, wisely choosing thus
the way with caution, let us not forget that death mean-
while holds carnival.
VICIOUS UNION
FOLLOWING POTT'S FRACTURE.
OPERATIVE TREATMENT. PRESENTATION OF A CASE*
By IRVING S. HAYNES, M. D.,
DEMONSTRATOR OF ANATOMY IN THE UNIVERSITY MEDICAL COLLEGE.
A I'ott's fracture is a fracture at the ankle produced
by eversion and abduction of the foot.
In a typical case there are three points of fracture, oc-
curring in the following order:
1. A fracture of the internal malleolus.
2. A fracture of the outer margin of the lower articular
surface of the tibia adjacent to the fibula.
:5. A fracture of the fibula from two to three inches
from its lower end.
Often, however, instead of the internal malleolus being
fractured, the internal lateral ligament is torn away from its
attachment to the malleolus or os calcis, and, instead of
fracture of the lower articular margin of the tibia, the in-
terosseous ligament is severed from the tibia or fibula.
The immediate consequences to the limb after such an
injury are eversion and outward displacement of the foot
and widening of the ankle, due to the separation of the
hones forming the mortise of the ankle joint.
There are also disability and three characteristic points
* Head before the Society of the Alumni of Bellevue Hospital,
October 7, 1891.
of pain : First, over the seat of fracture of the internal
malleolus or rupture of the internal lateral ligament. Sec-
ond, over the seat of fracture of the fibula. Third, over the
front of the ankle corresponding to the injury of the in-
terosseous ligament or adjoining portion of the tibia.
Occurrence. — Pott's fracture occurs frequently. As the
statistics in the various surgeries are accessible to you all, I
will only speak of unrecorded cases. In one hundred and
forty -two cases of fracture seen while an interne in Belle-
vue Hospital, and of which I took full histories, there were
twenty-five cases of Pott's fracture pure and simple, or
1 7*6 — j— per cent. The other cases were distributed as follows :
Head and thorax, sixteen ; upper extremity (and clavicle),
sixteen ; lower extremity (excepting Pott's), eighty-five.
These figures are defective in that they do not include the
cases for the same time treated as outdoor patients.
Treatment. — This consists of immediate reduction of the
deformity by inverting, adductmg, and flexing the foot, using
an anaesthetic if necessary, and fixing the foot with plaster-
of-Paris bandages over a liberal layer of cotton in a posi-
tion of superinversion and flexion — hyperinversion so as
to be sure that the internal malleolus will unite in proper
position, or, the internal lateral ligament being ruptured, so
that it will unite with the least possible lengthening, and
that the fibula shall be brought snugly up against the tibia
and the mortise of the foot restored. By flexion we seek
to prevent posterior displacement of the foot, also recovery
with the foot in an extended position, which is a source of
discomfort to the patient when he begins to walk.
If there is considerable inflammation, the cotton should
be kept soaked with lead-and-opium solution and the limb
elevated. The splint should be cut open if there is any
constriction as shown by the condition of the toes, which
should always be left uncovered for inspection.
When the inflammation subsides, a new plaster splint
should be applied over an ordinary Canton-flannel bandage,
maintaining the hyperinversion and flexion of the foot. It
is not enough to have the toes inverted ; be sure the heel is
also. Union is usually firm in four weeks. The patient
can begin to walk without the plaster splint about the sixth
week.
Sequela after Proper Treatment. — A stiff ankle which
lasts from two to four weeks. If the foot has been kept
well flexed during treatment, this will not cause the patient
much discomfort. Swelling of the leg, due to the oblitera-
tion of some superficial veins, will disappear when the cir-
culation is fully established — usually in from six to eight
weeks.
After improper treatment, or failure of treatment, vari-
ous degrees of deformity result, due to a greater or less
outward displacement of the foot, with eversion, a condi-
tion similar to that at the outset before the fracture has
been treated.
Without speaking further of the varieties of viciously
united Pott's fracture, I desire to present the following case
as a typical illustration of such an unfavorable result that
may occur to any one from a failure to maintain hyperin-
version and flexion from the very beginning of the treat-
ment :
IIAYXES: VICIOUS UXfOX FOLLOWING POTT'S FRACTURE. [N. V. Med. JouE.r
424
The patient, Daniel McC, an Englishman, aged thirty-eight,
a truckman by occupation, entered Bellevue Hospital May 27,
1888, and gave the following history :
February 8, 1888. — Fie jumped from his truck, striking on
some ice; he slipped and his left foot turned outward. He
was treated at home by placing the ankle between two side-
splints taken from a cigar box, and his toes carefully kept in
line.
In six or seven weeks he was out of bed, and then it was
noticed that his foot was turned outward. He tried to use his
foot, and could walk around some with the aid of a cane, but
his ankle soon tired and then became painful and caused him
so much discomfort that he entered the hospital to secure re-
lief by operative means.
Examination on Entrance. — The patient walked with the aid
of a cane with difficulty, and could not stand for any length of
time on account of the pain on the inside of the ankle. The
foot was everted and displaced outward, as shown in Photo-
graph I. (The photograph does not represent the eversion very
well, as the knee is swung outward until the sole of the foot
rests squarely on the floor. The photograph will also illustrate
the usual deformity after this kind of fracture.) The axis of
the leg, prolonged downward, fell to the inner margin of the
sole. There evidently had been a fracture of the internal mal-
leolus at its base, and of the fibula, about three inches from its
lower end; the angular deformity between the two fragments
was marked, and is well shown in ttie photograph.
Union was firm and complete, motion at the ankle joint
nearly normal, there being a slight diminution of flexion. The
patient was anxious for any operation that would give him a
useful leg, for in his present condition he could not attend to
bis usual work.
In looking up the case in such works as I then had at
hand, I found in Dr. Stimson's work on Fractures that the
following operations had been done for the relief of vicious-
ly united Pott's fractures :
I. Le Dentu refractured in a case of vicious union after
Pott's fracture of three months' standing, using an osteo-
clast. A solid plaster splint was applied and retained for
six weeks.
Result. — A useful leg, with slight deviation outward,
but the sole rested squarely on the ground.
II. Dr. Fenger, of Chicago, had operated on several
cases by removing a wedge-shaped piece of bone from the
tibia two inches above the internal malleolus. The base of
the wedge was an inch wide and on the inside of the leg,
the apex at the outside. The foot was brought into posi-
tion after fracturing the fibula. The operations were said
to be satisfactory, but full details of the condition of the
joint were not given.
III. Dr. Stimson also states that he saw Dr. Sabine in
1881 operate for this deformity by dividing each bone with
a chisel through separate incisions an inch above the base of
the malleolus. He could then bring the foot into the axis
of the leg without removing a wedge-shaped riiece of bone.
The patient made a good recovery. In commenting upon
this operation, Dr. Stimson says that it meets only one in-
dication ; it brings the foot into line, but does not correct
the separation of the malleoli, and it changes the direction
of the articular surface of the tibia so that it faces inward
instead of being horizontal.
IV. Excision of the ankle with various modifications
has been done. Ankylosis is aimed at and the results
are more or less satisfactory.
None of the above operations was performed. The de-
formity was corrected by the following method, and three
years of continuous use of the limb in heavy work attests its
value. The aim was to reproduce the original injury. The
operation was performed with strict attention to antisepsis,
and under a continuous bichloride irrigation of 1 to 4,000. An
incision an inch and a half long in the long axis of the fibula
was made over the seat of fracture, and the bone divided by a
chisel at this point. This allowed the foot to swing partially
into place, its further inversion being blocked by the internal
malleolus which had united to the tibia in a position of out-
ward displacement (see Fig. 1). The base of the internal
malleolus was next exposed through a vertical incision, the peri-
osteum peeled up, and the chisel entered transversely at its base
an inch and a quarter from its lower end, and driven obliquely
into the joint, to come out at the angle of junction between the
articular surface of the malleolus and tibia. This of course
opened the joint, which was irrigated with the bichloride solu-
tion. The foot could now be fully inverted and the deformity
reduced.
The periosteum and skin over the internal malleolus were
separately sutured, a drain being omitted. The fibular wound
was closed over a drain of a few strands of catgut. The foot
was strongly inverted and flexed to a right angle with the leg
and a heavy plaster-of- Paris splint applied over a thick antisep-
tic dressing. The foot was firmly held in position until the plas-
ter hud fully set.
The operation was performed on June 2d, and I might state
here that while the patient was on the table it was noticed that
be had a large hydrocele. This was first treated by Volkmann's
open incision, and excision of a portion of the tunica vaginalis;
in this case a strip two inches ...
and a half by half an inch was ?$p>
Fig i.
removed. The wound healed rapidly and the hydrocele has
never returned.
June 5th. — The patient had a temperature of 103° F. Fenes-
tras were cut in the splint and the wounds examined. Internal
one healed by primary union. Outer one showed retention of
secretions; sutures were removed and wound packed.
On the tenth day the old splint was removed and a new one
reapplied. Motion in ankle two thirds. On the twelfth day the
April 16, I892J ROBINSON: NASAL. THROAT, AND
AURAL SYMPTOMS IX INFLUENZA.
425
patient was out of bed. The case went rapidly on to recovery,
a new plaster splint being put on on the nineteenth day.
July fyth. — The last plaster was removed. Wounds entirely
healed. Full ankle motion.
lGth. — Photograph No. II taken. The superficial ulcer shown
in the photograph was due to the pressure of the plaster splint
ami soon healed. The swelling of the leg soon disappeared.
With these changes the photograph would do to illustrate the
present condition of the ankle.
17 tli. — Discharged cured.
The subsequent history is as follows:
The patient went home and to work; for about six months
he wore an iron support to his ankle, an arrangement made by
the village blacksmith, but he soon discarded this, and ever since
has been doing the hardest kind of work without any ankle sup-
port, and states that he can work all day without fatigue or
weakness in the ankle, and on Sundays, lie says, in pleasant
weather he walks from seven to fifteen miles for pleasure.
Present condition of the ankle: As above stated, the posi-
tion of the foot is well illustrated by Fig. 2. There has been no
outward deviation of the loot whatever. There is a slight, thick-
ening over the internal malleolus which makes the ankle look
slightly wider than the other. Extension is perfect, flexion is
resisted beyond a right angle, due to a slight shortening of the
tendo Achillis, which will probably be overcome by use.
The operation here described for the relief of not too
long standing cases of vicious union after Pott's fracture is
a rational one. It aims to restore the limb to the condition
it was in at the time of the injury, and then treat it as a
case of recent fracture. To do this, the internal malleolus
and fibula are divided at the seat of old fracture; the foot
then is to be superinverted and flexed and this position
maintained for four to six weeks by plaster-of- Paris dress-
ing.
The operation is simple and practicable. It is less for-
midable than a cuneiform or linear osteotomy of the tibia
above the malleolus and does what these do not do; — name-
ly, preserves the horizontal articular surface of the tibia and
restores the mortise of the ankle to nearly its normal condi-
tion. For, though there may have been a gap between the
tibia and fibula at the beginning, and this filled in with new
tissue, by the pressure exerted upon this by the fibula when
the foot is kept fully inverted for four or six weeks, we have
reasonable assurance that the most of this tissue, if it be
present, will be absorbed.
The final result is all that could be desired. Motion will
probably be normal, the foot stand as much work as its fel-
low, and no tendency to a return of the deformity exist.
316 East Eighty-sixth Street.
The Secretion of Bile in Uraemia. — "In order to elucidate the char-
acter of the secretion of bile in artificially induced uraemia, Dr. Lokia-
noff, of Warsaw, tied the ureters close to the bladder in twelve guinea-
pigs, collecting the bile of six of these during the first day and of the
remaining six during the second day of uraemia. He found, among
other results, that uraemia tends to reduce the body temperature; as a
rule, the liver increases in weight to a slight extent, the blood and the
kidneys become richer and the liver and brain poorer in watery con-
stituents, and the secretion of bile is rather less than normal. The pro-
duction of hepatic tissue is diminished, especially as the uraemia pro-
gresses. The bile secreted is poorer in water and richer in solid
matters than in the normal condition or in the first stage of starvation."
— Lancet.
SO.ME NASAL, THROAT, AND AURAL
SYMPTOMS AND DISORDERS MET WITH
IN INFLUENZA*
By BEVERLEY ROBINSON, M. I).,
CLINICAL PROFESSOR OF MEDICINE
AT TOE BELLEVUE HOSPITAL MEDICAL COLLEGE, NEW YORK.
Aside from the fact that the nasal, throat, and aural
symptoms and disorders met with in influenza accompany
general phenomena which establish their probable nature,
we can not affirm that they are invariably characteristic or
different from nasal, throat, and aural affections encountered
separately and in no sense indicative of an infection of the
entire system. Thus we may have a nasal catarrh in in-
fluenza, with sneezing, local irritation, heat, and obstruction,
which resembles an acute coryza due to chilling of the
surface or exposure following fatigue or the inhalation of
foul air. Again, we may have an attack of pharyngeal in-
flammation or of acute amygdalitis, which wholly resembles
these disorders when occasioned by ordinary causes, except
for the accompanying symptoms of generalized pains,
higher febrile reaction, and more bodily and mental de-
pression than is usually produced by like local conditions
under other circumstances. This is equally true of the
forms of acute aural or laryngeal catarrh occurring during
the course of influenza. But when this has been said we
must add that there are occasionally some noticeable pecul-
iarities about the affections referred to, and others still
of the nose, ear, and throat, as observed in epidemic in-
fluenza.
In one very interesting case of influenza that I have
treated, the initial stage of the disease was ushered in by
repeated and profuse attacks of epistaxis requiring re-
peated plugging of the nasal passages in order to stop it.
These nose-bleeds were especially interesting, because while
there could be no doubt that they were in part due to in-
tense venous turgidity of the pituitary membrane under the
dependence of the general blood dyscrasia they were also
accentuated and made much more serious by the rupture or
ulceration of the sasptal artery in one nasal passage. It.
seemed possible that the latter source of haemorrhage was
developed by the act of picking the nose to remove a semi-
hard blood clot, and the artery had been in part opened by
the patient himself. The case was that of a lawyer of
middle age, who, previous to the recurrent nasal haemor-
rhages, bad never suffered from nose-bleed or nasal catarrh,
and who had always enjoyed remarkably good health. Im-
mediately subsequent to the attacks of epistaxis he had
the rational symptoms of severe influenza. During the
course of this disease both the soft palate, fauces, and lar-
ynx were deeply congested. Indeed, the veins of the
palate and fauces seemed so distended that I thought for a
day or two that it was possible to have them rupture and
bleed during the efforts of cough. The interior of the lar-
ynx was red and swollen, notably the ventricular bands. I
could not, however, detect in this organ any distinctly marked
ecchymotic areas or any characteristic venous dilatation.
* Head before the Section in Laryngology and Khiuology of the
New York Academy of Medicine, March T.'>, 1892,
426
ROBINSON: NASAL. THROAT, AND AURAL SYMPTOMS IN INFLUENZA. [N. Y. Med. Jouh.,
In some late autopsies on influenza patients, very care-
fully reported by Ilelweg, it was noted that the pia mater
and brain were extremely hyperaemic. It was also ob-
served that the arteries of the base of the brain were dis-
tended to an excessive degree " and stood out as cylindrical
cords, as if they had been injected with wax." This
pathological condition, according to Althaus, is not due to
a simple vaso-motor hyperemia, but to a process which
tends toward a real inflammatory state, which does occur
in persons particularly disposed to it. ( Vide the Lancet,
February 13, 1892, p. 387.) In view of these statements,
we can readily understand how profuse nasal lucmorrhage
may take place as an intercurrent complication, either in
the beginning or during the course of influenza.
The erythematous sore throat of influenza has seemed
to me to be accompanied with and followed by more
marked local pain in the throat than is noted in a sore
throat apparently similar- in nature when not dependent
upon influenza. This form of sore throat sometimes ex-
tends upward, producing considerable irritation and ob-
struction of the naso-pharyngeal space, as shown by the
local distress and the difficulty of free nasal respiration.
The latter is especially aggravated at night when the
patient lies down, owing to the tendency of the blood to
fill up the distended posterior extremities of the turbinated
bodies. It is in these instances, even without the nasal
occlusion, that we are apt to observe an extension of the
catarrhal inflammation to the Eustachian tubes and to the
middle ear, which is followed by pain in the ears, im-
paired hearing, tinnitus, and dullness of the mental faculties.
The membrana tympani may become thickened and
sunken, and effused mucus and fibrin may be thrown out
around the ossicles and their articulations, which ulti-
mately leads to partial ankylosis and permanent deficient
hearing. Occasionally the nasal catarrh, with occlusion of
the nasal passages, precedes the faucial irritation, and in
more than one instance closely observed by myself the
sensitiveness of the peripheral nerves of the pituitary
membrane was very considerable, so that the slightest con-
tact with a foreign body of certain limited areas caused
intense suffering, which, however, disappeared as soon as
this contact was broken. On other occasions I have ob-
served follicular amygdalitis adjoined to phenomena of acute
gastric catarrh and characterized by excessive stomachal
intolerance, so as to cause the rejection of nearly all food
and medicine for a day or two. The follicular amygdalitis
cleared up in less time than usual, and fewer follicular de-
posits were visible at any one time than is habitual.
There was a tendency to repetition, however, of the
follicular deposits, and there were occasionally very7 severe
paroxysms of pain in the tonsillar region, which returned
witli well-marked periodicity.
1 have known the tonsils also to become suddenly very
much enlarged and occasion very great obstruction of the
breathing. In this case, that of a child nearly three years
old, there was no follicular deposit on the tonsils, but their
enlargement was quickly followed by the perforation of
one, and twelve hours later of the other membrana tympani.
Both ears were affected with quite abundant suppuration
for many days. As is sometimes observed in scarlatina
and other febrile disorders, the perforation of the drum
membrane of the ear was preceded by relatively slight
pain, and even this pain lasted but a short time before the
perforation occurred.
This statement 1 regard as important for the following
reasons : One is often blamed by parents or patients for the
occurrence of a perforation which was practically unavoid-
able. Besides, the reproach which might be made that we
had not instituted sufficiently careful measures to prevent
it is not merited, because neither the time nor the symp-
toms would indicate the necessity of too much local inter-
ference.
Finally, it may be observed that the perforation of the
membrana tympani, if it takes place early and without much
pain, is perhaps properly estimated as a conservative and
judicious effort of Nature to prevent further and more in-
jurious destruction of aural structure. It is true, at any
rate, and most fortunately, that many such cases, if regularly
douched and cleaned, get well before many weeks have
elapsed, and with retention of very good, if not absolutely
normal, hearing. Of course there are many unfortunate
and pitiable cases, but these occur mainly among victims of
ignorance, neglect, and of already depraved constitutions.
In writing on the effects of influenza on the middle ear,
Sir William Dabby (vide Lancet, Feb. 20, 1892, p. 416) says
that in his experience suppurative complications are infre-
quent. Besides, he states that this disease rarely attacks
healthy ears, even in the form of non-purulent catarrh with
obstruction of the Eustachian tubes. What this distin-
guished aurist has particularly noted is the fact that pa-
tients who formerly suffered from purulent median otitis,
and whose ears have been in a quiescent state perhaps for
several years, again suffer from otorrhea owing to an attack
of influenza. And to this statement he adds what he con-
siders as apparently showing the influence of the general
disease, that the condition of the ears previously had been
good, " notwithstanding ordinary colds and exposure to all
sorts of variations in climate." "Thus," he continues, "a
person with healthy ears has little to dread from influenza
so far as this mucous surface " (referring, of course, to that
which lines the middle ear) " is concerned, but it may be-
come a serious trouble to one whose ears have formerly
been the seat of inflammation."
I am scarcely in accord with this latter affirmation, since,,
as a matter of fact, the aural complications I have had to
care for have usually occurred in ears previously healthy,,
or, at all events, which never before caused any rational
symptoms indicating aural disease.
I would, of course, consider my observations less impor-
tant were I not in a position to see many cases which ordi-
narily7 seek aid from a professed specialist for the treatment
of diseased ears. In one patient whom I took care of this
winter, the attack began with generalized pains in the head,
body, and limbs, some mental hebetude, marked prostration
of the forces, and considerable febrile reaction. The fol-
lowing day, in the morning, the pains had diminished, ex-
cept those located in the chest anteriorly, which were in-
tense. I auscultated the patient carefully, but could find no
Apri 1G, 1892.] ROBINSON: NASAL, THROAT, AND AURAL SYMPTOMS IN INFLUENZA.
427
signs of either pneumonia or pleurisy. The chest pains
appeared to be of myalgic character. During the afternoon
the patient expectorated repeatedly small quantities of dark
blood which apparently came from the larynx or trachea.
The stethoscopic signs in the chest still remained negative.
I made a laryngoscopic examination, but, on account of the
patient's intolerance of the mirror, I was unable to deter-
mine whether or no there were any ecchymotic spots in the
larynx. The soft palate, however, was very much con-
gested, and in two places there were hsemorrhagic areas,
bright red in color, underlying the mucous membrane.
Both of these areas were at least one fourth of an inch in
length and two or three lines in width. No other hsemor-
rhagic spots were seen in the throat, nor were any petechias
remarked on the cutaneous surface.
In this instance, if I had been able to make a satisfac-
tory laryngoscopic examination, I would have doubtless dis-
covered ecchymotic areas in the larynx and upper portion
of the trachea. I am justified in this belief by the reported
cases of Moure and other observers abroad, and in view of
the history of my own patient.
Occasionally there is very little or no irritation or in-
flammation of either nose or fauces, at least in the begin-
ning, but the laryngeal catarrh is most pronounced. Usu-
ally the laryngitis is not exclusively localized, but the in-
flammatory condition extends more or less to the trachea
and bronchi. Whenever there is very considerable cough,
due apparently to a laryngitis, it is wise to inspect the
larynx with the small mirror. Oftentimes we shall find red-
ness and slight thickening of a portion or the whole inte-
rior of the larynx. Now and then the patient's throat is so
sensitive, and gagging so easily produced, that our examina-
tion is necessarily short and imperfect.
In the laryngitis of infiuenza there is not the amount of
local soreness, hoarseness, or pain on swallowing, which we
expect to find when the ocular appearances reveal so much
local inflammation.
I have never observed within the larynx either the ul-
cerations, pronounced (edema, or the membranous deposits
which have been noted in Europe. Singular to say, at
times when there .has been a most rebellious and painful
cough, and when the larynx seemed especially affected, the
local signs of the inflammation were very slight. Indeed,
the true vocal cords were seen to be almost of normal col-
oration. In these instances particularly the cough was
harassing, paroxysmal, often dry, with frequently a pro-
longed noisy inspiration at the end, which resembled the
" whoop " in pertussis, and was obviously due to laryngeal
spasm.
All general remedies fail in these cases to relieve ; and,
on the other hand, I have known an intralaryngeal appli-
cation of iron, or some other ordinary astringent, to be evi-
dently useful in diminishing paroxysms of cough. I could
explain such examples only by assuming that I had to do
with peripheral nerve irritation (neuritis ?) in the larynx,
very similar in nature to that met with in many other or-
gans of the body.
On one occasion, when there was very intense gastric
catarrh, shown by numerous symptoms, the regular system-
atic exhibition of milk and old brandy appeared to relieve
intense paroxysms of cough, and even though there was
present at the same time a great deal of bronchial catarrh.
I have little doubt in my own mind at present that a
depressed state of the nervous centers is also an additional
and efficient cause of more, frequent cough, by reason of
the increased impressibility that this condition gives to all
infiamed nerve filaments. In this way I can appreciate
how fatigue, lack of food, emotional strain of any kind dur-
ing influenza, will immediately augment and intensify cough.
I would add, however, that I have been much impressed dur-
ing the prevailing epidemic, as I have been at times previ-
ously in other general acute affections, that local artificial
irritations within the larynx will often relieve cough, when
one, aside from this fact, might find sufficient cause for
cough in the bronchial catarrh.
I rather believe, therefore, that, except for the super-
sensitiveness of the laryngeal mucous membrane, much spu-
tum would remain many hours at times in the bronchial
tract without being coughed up and expectorated. The
distressing, recurrent paroxysmal, almost dry cough of in-
fluenza may last for many weeks, and resist all remedial
influences for its cure, except, perhaps, complete change of
air and scene. This affirmation is made in view of my ex-
perience, and of having tried uselessly all rational methods
of relief.
In this connection I would direct attention to {vide
Prosser James, Lancet of February 27, 1892, p. 498) some
laryngeal affections occurring after influenza. Among them
may be particularly noted paralyses, commencing in the
throat after convalescence, and extending later to other re-
gions of the bodyr. These instances are of such a charac-
ter as to simulate the paralyses taking place after diphthe-
ria, and to have led more than once to a reasonable doubt
being evinced in regard to the correctness of the original
diagnosis of influenza. Other paralyses more localized than
the former have come on after the patients had returned to
their ordinary vocations. In this number are described
paralyses of the tensors and adductors of the vocal cords.
Neuroses of sensation as well as neuroses of motility have
been observed, and different degrees of anaesthesia or hy-
peraesthesia are not infrequent.
Choreic movements and spasmodic conditions affecting
the larynx are rare and late sequelae. It would appear, ac-
cording to James, that " these cases of late sequelae are in-
dications that the effects of influenza remain for a con-
siderable period, and the proportion of neuroses shows how
profoundly the disease affects the nervous system."
In one instance I have seen a very sudden inflammation
in the muscles of the neck, which was accompanied with
pain, redness, and rigidity, and so much localized heat that
I feared abscess during twenty-four hours. The latter symp-
tom— viz., heat — quickly subsided under soothing applica-
tions, but the pain and stiffness of the neck lasted nearly a
week.
In this patient there was no complicating sore throat.
In another patient now under observation the neck is stiff
and painful, and there is also present an erythematous sore
throat.
42*
CORXrXG: PALY.
[N. Y. Med. Joce.,
I have tried many of the drugs which have been recom-
mended during the present epidemic. The following com-
bination has appeared to me at once the most reasonable
and the most successful. The prescription, made up in
tablet form by Mr. Eraser, pharmacist, of this city, is as
follows : Half a grain of citrate of caffeine, one grain of
phenacetine, and three grains of ammonium salicylate. I
order one of these to be taken every hour, every two hours,
everv three hours, according to the amount of pain, depres-
sion, and general disturbance which are observed during
the attack. In addition, I make use of such local or other
treatment, adjoined to rest, protection from cold, and proper
nutriment, as I may deem advisable. The formula made
use of by me is extremely rational ; the caffeine stimulates
the heart and promotes elimination through the kidneys ;
phenacetine, in small, repeated doses, diminishes pain and
fever and promotes perspiration, thus making use of another
great emunctory of the economy — viz., the skin ; the salicy-
late of ammonium agrees with the stomach. By the use of
salicvlic acid, I employ a well-authorized anti-microbic, anti-
zymotic agent. With ammonia set free in the stomach, I
give an alkaline remedy, but one that is not depressing, as
the salts of potash undoubtedly are. And this sort of medi-
cation is specially essential, even in large, repeated doses, as
witness the statement made by English practitioners of re-
pute during the present epidemic, and referred to interroga-
tivelv, but with some belief on account of the testimony in
its favor, in an interesting editorial in the Lancet, only a
few weeks since.
Of course I vary my combination in certain instances,
and at times leave out one or other of the ingredients, ac-
cording to the circumstances of the case. Again, I have
treated certain forms of disease which I have believed were
caused by inrluenza, or. indeed, were unusual or aborted
manifestations of it, in which I have not made use at all of
my compound salicylate tablets. The specific treatment of
inrluenza has not yet been found, and perhaps may not be
found for many years to come ; still, such a discovery is
not impossible, and some fortunate searcher in our art may
yet happilv light upon it almost unawares. Meanwhile the
suitable medication to employ is that which united experi-
ence tells us is the most rational and successful.
In regard to local medication for cough and bronchial
catarrh, I would add that after using steam inhalations with
turpentine and benzoin in the initial stages of inrluenza, I
have found dry pine-needle oil vapors, used persistently and
frequently with the perforated zinc inhaler, worthy of espe-
cial commendation and real confidence.
In the way of prophylaxis, there is one precautionary
measure which may be utilized by every one and which ap-
parentlv has its value — viz., occasional gargling the mouth
and throat with an appropriate antiseptic solution. In this
connection 1 have permission to cite the following lines
taken from a personal letter to me, received on January 26,
1892, from Dr. Charles A. Siegfried, Surgeon in the United
States Navy, now stationed at Newport, K. I. Dr. Siegfried
writes : " I am convinced that grippe can be pretty nearly
prevented by keeping the mouth and throat clear and well
policed with an alkaline carbolated lotion twice or thrice
daily. Those of my friends (including myself) who have
followed this plan have escaped. I suppose you have no-
ticed the alkaline treatment of Dr. Crerar in the Lancet and
the discovery of Pfeiffer, who finds the bacillus in the mouth,
so that, theoretically, I am on the safe side." It may be
w isely added to this statement, I believe, that possibly this
precautionary measure for those who have hitherto escaped
taking influenza may be also a useful recommendation to
those already affected, toward diminishing its severity and
warding off the complications (pleuritis, pneumonia, otitis
media, affections of the eye, etc.) by destroying the viru-
lence of the influenza bacillus at the gate of entrance into
the system. In this manner may be prevented the constant
reinoculation of the body by continuous absorption of the
materies morbi — bacillus or habitat of the bacillus, as the
case may be. We recognize to-day the great advantage of
frequent local disinfection of the mouth and throat in di-
minishing the gravity of diphtheria. Why may it not also
be true of influenza and some other general acute febrile
disorders, at least somewhat analogous in type '.
In concluding this contribution, I would add that I have
not attempted to make it exhaustive, although I have quoted
several times from the work of foreign writers. My article
is essentially based upon what I myself have observed dur-
ing the past two winters, and as such I offer it for discus-
sion.
PALX,
ITS NATURE, DIAGNOSTIC SIGNIFICANCE, AND TREATMENT*
By J. LEONARD CORNING. M. D.
The relief of suffering is the distinctive prerogative of
the phvsician. It is doubtless this ability to bid defiance
to pain which, more than any other single attribute, has en-
abled medical men to maintain, in spite of the vicissitudes
of therapeutics, such a high position in the estimation of
societv. Some of the most famous lights of the profession
have in all ages been imbued with this great fact. The
neurologist, more especially, should be thoroughly conver-
sant with all matters pertaining to pain, and particularly to
the treatment of pain, for there is no single symptom which
js liable to be more frequently met with, or whose elimina-
tion will make such stringent demands upon the practical
resources of the art.
I shall offer, therefore, no apology for the following ob-
servations on the nature and treatment of pain, which, I
trust, may prove of benefit to the physician in solving many
of the practical problems of his calling.
Physiology. — The first question which naturally suggests
itself is, How do painful impressions reach the higher cen-
ters of the brain, or, in other words, along what paths do
such impressions travel in their journey from the periphery
to the centers of conscious perception '.
It is much to be regretted that only a partial answer can
be given to this important question. ,
About all we know of it is soon told. In the first
* Head before the Medical Society of the State of New York at its
eighty-sixth annual meeting.
April 16, 18!»ii,J
CORNING: PAIN.
±'29
place, the transmission of painful sensations from the pe-
riphery to the spinal cord is accomplished through the
instrumentality of the sensory nerves. The course pursued
by such painful impressions through the cord is more ob-
scure. Some physiologists believe that they are transmitted
wholly through the gray substance ; others, again, assign
special importance in this connection to the sensory con-
ducting paths of the posterior columns ; while a third class of
observers believe that sensations of pain may be transmitted
both through the gray substance and the white substance
(posterior columns). The attempt to associate the lateral
columns with the conduction of sensory impressions must
be regarded as premature, to say the least, in the present
state of evidence. As regards the subsequent path pursued
by painful impressions, it may be stated that various facts
point to certain of the libers of the posterior division of the
internal capsule as those largely concerned in the transmis-
sion of such sensations to the cerebral cortex.
Identity of the Processes in Motor and Sensory JVerves. —
It has often been asked, as a matter of theoretic interest,
whether the processes accomplished in a motor nerve differ
radically from those occurring in a sensory nerve. On this
point Radcliffe, in concluding an elaborate argument, ob-
serves that " there is reason to believe that there is no essen-
tial difference between the action which issues in sensations
and the action which issues in muscular contraction." As
a corollary to this proposition, he adds that " the produc-
tion of sensation and the production of muscular contrac-
tion only differ in this : that the electrical discharge, analo-
gous to that of the torpedo, which is developed in and near
the nerve in the state of nervous action, happens to tell
upon sensorial ganglionic cells in the one case and upon
muscular fibers in the other."
Of course, to speak of the electricity evolved during the
action of a nerve as that mode of nerve force concerned in
the production of sensation or motion is a mistake. In
other respects the figure is an apt one.
It may be of interest in this connection to consider the
experiments which had led Radcliffe and others to these
conclusions. Undoubtedly the researches of Du Bois-Rey-
moud and Matteucci have had a powerful influence in shap-
ing opinion on this point. The principal experiment of Du
Bois-Reymond consists in pouring hot water upon the leg
of a frog, the nerve of the same being connected with a
galvanometer. AYhen this is done, the galvanometer shows
a cessation of the electric current — a phenomenon which is
observed almost as soon as the water touches the inteo-u-
ment. This observation, in conjunction with the well-
known fact that there is also a decrease, amounting some-
times to almost entire absence, of " natural electricity "
during the action of motor nerves, led Du Bois-Reymond
to the inference that in sensitive as well as in motor nerves
there is a loss of electricity when the nerves pass from rest
into a state of action.
Matteucci's experiment, performed upon a rabbit, con-
sisted in dissecting out the upper portion of the sciatic
i nerve and irritating it with the galvanic current. When
the current was closed the animal screamed loudly, but when
it was opened there was no sign of pain.
The resemblance of the phenomena evoked by the gal-
vanic current in sensitive nerves to those caused by the same
agent when applied to motor nerves has led to the infer-
ence that " the change in a sensory nerve when sensation
is produced by the action of voltaic electricity, and the
change in a motor nerve when muscular contraction is pro-
duced by the same means," are, as Radcliffe puts it, exact
equivalents.
Such, then, are the principal facts which have been as-
sumed to prove the identity of the processes underlying the
actions of motor and sensory nerves. While, however, the
relation of the two kinds of nerves to the galvanic current
points to the truth of this proposition, it is, of course, self-
evident that the final restdt of the action differs radically in
each kind of nerve. In the case of the motor nerve, action
results in contractions, due to the excitation of the contrac-
tile substance of the muscle ; in the case of the sensory
nerve, on the other hand, action is translated into sensation
through the instrumentality of the central ganglionic appa-
ratus in the cortex.
So much for the fundamental features of the argument.
Inductive Evidence on the Genesis of Pain. — Let us now
consider a set of facts which will help us to frame a reason-
able hypothesis concerning the nature and genesis of pain.
In the first place, it must be remembered that a sensory
nerve supplies a certain definite area of the body, and trans-
mits to the brain only such impressions as emanate from the
area. In other words, there is no physiological anastomosis,
however much the fibers may interlace or run together. To
prove this, it is only necessary to divide a sensory nerve
and irritate its distal end, when we find that no sensation is
perceived, thus demonstrating that there is no collateral
communication whatsoever. As a matter of course, irrita-
tion of the proximal or central portion of the nerve — that
part which is in connection with the nervous centers — <rives
rise to distinct sensation.
In the same way, if we divide the spinal cord of an ani-
mal transversely, so as to sever the sensory conducting
paths and irritate the nerves which join the cord below the
incision, no sensation will be perceived ; but if we stimulate
the nerves which enter the cord above the incision, we shall
have every evidence that the sensation has been perceived.
Precisely the same sort of phenomena may be observed in
human beings who, by reason of injury or disease, have suf-
fered a solution of the sensory conducting paths of the cord.
Another important fact is that an impression made upon
any point in the course of a sensory nerve may be perceived
by the mind as though it were made not only upon the
point in question, but also upon the parts to which the
fibers of the nerve are distributed. We have, therefore,
under such circumstances, precis; Iv the same effect as if
the irritation were applied to the regions supplied by the
branches of the nerve.
An explanation is thus afforded of the fact thai when
the sensibility of a part is abolished by compression or di-
vision of the nerve which supplies it, irritations of the cen-
tral portion may still give rise to sensations which are felt
as though they emanated from the parts below the point of
interruption — i. e., from the parts to which the peripheral
430
CORNING: PAIN.
[N. Y. Med. Joce.,
terminations of the nerve are distributed. Thus, when a
nerve is divided for the cure of an intractable form of neu-
ralgia, it sometimes happens that pain still persists. This
is undoubtedly due to the fact that the division of the nerve
has not been made near enough to the nervous centers to
include the entire affected portion, and hence the continued
irritation of the central portion causes pain, which, in ac-
cordance with the law under consideration, is felt as thdugh
it emanated from the peripheral parts of the nerve. An-
other illustration of the same thing is afforded by those
paralyses in which the limbs are quite insensible to such ex-
ternal stimuli as pricking, pinching, and burning, and yet
are believed by the patient to be the seat of severe pain.
Still another example of erroneously referred pains is af-
forded by persons who have suffered amputation of a limb.
When the divided nerves of the stump are inflamed, or
otherwise irritated, nothing is more common than to hear
the subject complain that he experiences pain which appears
to be located in the part of the limb w hich has been re-
moved.
Such facts as these might, on a superficial examination,
lead one to suppose that there was little or no benefit to be
anticipated from local therapeutic measures addressed to
the affected nerve itself in cases of pain. It must be re-
membered, however, that by the aid of chemicals we are in
many cases able not only to temporarily cut off the periph-
eral portion of an affected nerve from its central connec-
tions, but also to modify the abnormal condition of the
nerve itself, thus effecting an abolition of pain which is
often permanent. Pain due to rheumatic causes is com-
monly amenable to local measures, while that associated
with certain forms of well-developed neuritis offers a less
favorable field for this class of remedies.
Definitions of Pain. — Various attempts have been made
to define pain. Cicero looked upon it as a disagreeable
movement within the body, independent of the senses. Ac-
cording to others, it is a species of sensation which may
emanate from both internal and external regions of the
body, in which are distributed nerves whose office it is to
transmit to the brain all impressions which they receive.
Lauvage calls it a disagreeable perception, originating from
any lesion of the nerve fibers ; Gabius regards it as a sensa-
tion which the mind would rather not experience (!), while
Bilon is discontented with all definitions, and believes the
word pain to be so universally descriptive in itself as to en-
able one to dispense with all definitions.* More recent
authors have, nevertheless, still persisted in further attempts
to define it. Thus Valentin f perceives in pain " sensory
impressions which, on account of their too great intensity,
become disagreeable " ; Wundt \ calls it " a feeling that
accompanies all powerful or intense stimuli," while Eulen-
burg* defines it as "a gradual increase of the feeling that
accompanies every sensory process."
* JJiclionnaire des sciences medicares, vol. x, ]>. 171', Paris, 1814.
■\ Phi/sio/ot/ische Piit!ii)lof)ic dcr Ncrven, vol. i, p. 240.
^ Lehrbuch dcr Physiologie des Menschen, p. 503, 1074.
* Functionelk Nervenkrankheiien, p. 31. Vide also Diseases of the
Peripheral Cerebrospinal Nerves, by Wilhelm Heiniich Erb. Von
y.icuisscii's Ci/c/a/Mfdia, vol. xl, |l. 11.
To my mind, the views of Erb* regarding the nature of
pain are the most comprehensive and just which have been
recently expressed. "We hold," he says, "that every in-
crease of ordinary sensory stimuli is capable of producing
pain as soon as it attains a certain intensity. Every exci-
tation the intensity of which exceeds certain limits, every
molecular change of the centripetal series induced by an
abnormally strong stimulus, is perceived as pain. Very
simple experiments — as, for example, pressure or tempera-
ture gradually increased till pain is produced — show that
with very gradual increase in the strength of the stimulus
a limit is at length reached beyond which the excitory pro-
cess is accompanied by pain, yet no sharp line of demarka-
tion can be traced defining the point at which the sensation
of pressure or temperature ceases and the sensation of pain
commences. The simplest explanation accordingly seems
to be that pain is the reaction of the sensorium to a certain
degree of excitation, and we at present see no ground for
regarding pathological pain as being essentially different in
origin from that which can be produced by simple physio-
logical experiment."
We thus find a clew to the genesis not only of those
pains which originate in over-stimulation of the nerves of
common sensation, with which we are most frequently
called upon to deal, but of those, likewise, which have their
origin in an exaggerated stimulation of the nerves of special
sense. For do we not know that intense light and loud,
inharmonious noises produce sensations which are described
by those subjected to them as veritable pains ?
As regards the nature of those fine molecular perturba-
tions originating in the nerve and transmitted thence to the
sensorium — perturbations which are evidently the essential
accompaniment of pain — we are still, and doubtless are des-
tined in future to remain, entirely in the dark. Although
we are thus debarred, on account of the crudity of our
physiology, from penetrating the ultimate mystery of pain,
we are, nevertheless, enabled to adopt proper means for the
arrest of the morbid irritation in the nerve, when once es-
tablished. As the argument proceeds, we shall find that in
combating pain we are compelled to invoke the aid of a
wide range of agents; and thus it happens that chemistry,
thermodynamics, physics, and even surgery, have all ren-
dered important assistance.
Finally, we must not forget to mention a very recent
theory regarding the mechanism underlying the pains
found along the course of nerves. According to Prus,f
who is the promulgator of this theory, there are filaments
in the sheaths of nerve trunks the irritation of which gives
rise to the painful points found in neuralgic affections.
These filaments, the presence of which was made known by
caieful microscopical examination, have received the some-
what ponderous appellation of nervi nervorum peripkeri-
corum.
It is, of course, impossible at present to prophesy with
any degree of certainty what part these structures are des-
tined to play in the physiology and pathology of the future.
* Op. et he. cit.
\ Archives slaves dc Iriologie, iv, September 2, 1892. See, also,
Brain, vol. x, p. 557.
April 16, 180% |
CORNING : PAIN.
431
Perhaps autopsies conducted with a special view to our en-
lightenment on this point may afford information ; but it is
hardly to be anticipated that we shall derive much help
from experimentation.
It now remains to say something in regard to the causa-
tion of pain. It may be stated at once, in this connection,
that by far the most prolific source of the perverted sen-
sation is found in the condition of the nerve known as
neuritis. The two principal types of neuritis are simple
neuritis and multiple neuritis. Under the last-named
heading are comprised the conditions known as alcoholic
neuritis, neuritis of Leprosy, and that of beriberi; the two
last-named conditions are so rare in this country as to
merit rather a pathological than a clinical interest. Simple
neuritis and multiple neuritis, on the contrary, are exceed-
ingly important phases of the affection, since they are of
frequent occurrence, both in hospital, special, and general
practice. As its name implies, simple neuritis is simply a
local manifestation of the disease, the inflammatory process
being restricted to one or more nerve stems.
The most frequent causes of this form of neuritis are
wounds, inflammatory conditions in the vicinity of the
nerve stems, rheumatic influences culminating in thickening
of the sheath, and tumors pressing upon the nerves. Severe
compression of the nerve, caries of neighboring bones, and
bruises may also give rise to it. To sum up the whole
question of aetiology, it may be stated that the restricted
form of neuritis is more apt to be due to local than general
causes, while of multiple or general neural inflammations
the reverse is true ; for toxic agents, acting more or less ex-
tensively throughout the organism, play a prominent part in
their causation.
In multiple neuritis, as previously noted, we have to do
with a symmetrical and more or less widely disseminated
Inflammation or degeneration of the sensory or motor nerves.
As a rule, the cerebral or bulbar nerves are little or but
slightly affected.
Since Dumenil published his excellent paper in 1864 a
multitude of observers in this field have come forward;
and, indeed, hardly a year goes by without witnessing ex-
tensive additions to the literature of the subject. At the
present time the available material is quite overwhelming,
so that detailed references to it would, in a short paper of
this kind, only serve to add confusion to a subject already
sufficiently intricate.
I shall confine myself, therefore, to the most general
observations. Let me begin with a few words in reference
to the aetiology of multiple neuritis. As has already been
said, the most common causes of multiple neuritis are
toxic and infectious agents. In this category belong lead*
alcohol, illuminating gas, bisulphide of carbon, arsenic,
aniline, dinitro-benzine, phosphorus, mercury, morphine,
ergot; and among animal and endogenous poisons of
various kinds, fevers, diphtheria, tuberculosis, beriberi,
leprosy, malaria, gout, rheumatism, diabetes, and the puer-
peral condition. In addition to these, dyscrasic states un-
doubtedly play a part in the evolution of certain phases of
the disease.
Here we have the explanation of those eases of neuritis
which occur in the course of affections involving more or
less impairment of the physiological integrity of the blood-
stream— marasmus, chlorosis, and cancer.
A large proportion of cases begin acutely, a small num-
ber develop more gradually, while a third class displays
great lethargy in the evolution of the different symptoms!
Hence it is customary in some of the books to describe
an acute, a subacute, and a chronic form of the disease.
The general symptoms of multiple neuritis are about as fol-
lows : In a large proportion of cases the symptoms begin
abruptly. It is true that the patient may complain for some
days of vague feelings of malaise and weakness in the
lower limbs, but these sensations commonly excite little or no
attention, and not until more definite symptoms are added
is medical aid invoked. At this time he suffers from
vague discomfort in the head, loss of appetite, and mental
hebetude, and he may even be delirious. There may also be
considerable fever, the temperature reaching 101° or even
105°, while the pulse is correspondingly accelerated. Some-
times, however, the evolution of the symptoms, even in the
beginning, is more gradual, and it is then quite difficult to
predict what is really impending. Whatever phase these
premonitory phenomena may assume, however, they are
certain, or almost certain, to be speedily followed by symp-
toms of sensory irritation. The subject complains of
tingling, numbness, crawling sensations, and pain. These
symptoms are specially pronounced in the affected limbs,
but they evince, as may readily be imagined, a decided
predilection for the regions in the vicinity of the nerves.
While sensory irritation is apparent from the beginning,
the opposite condition of sensory paralysis is by no means
so obvious. It is true that the muscular sense may be so
impaired as to give rise to pronounced ataxia ; the tactile
nerves, too, may be more or less affected, and the trans-
mission of sensations of heat and cold, as well as those of
pain, may be considerably retarded. Still, it must be borne
in mind that when the sensations reach the central per-
ceptive mechanism they possess considerable vigor, and
are, therefore, felt with great distinctness. Complete
anaesthesia, then, is decidedl\r exceptional. The distribu-
tion of these pallesthesia? is a matter of some interest.
Sometimes they are associated with the ramifications of a
particular nerve, while at others they are distributed in
irregular islands without obvious physiological connection ;
or, finally, they may pervade the entire limb. In any event,
their presence is significant and often of the first impor-
tance in forming a correct diagnosis.
The pains, too, when taken in conjunction with the
other features of the ease, are of value in forming an opin-
ion as to the nature of the disease. Though somewhat like
those of locomotor ataxia, they differ notably in this: that
whereas in multiple neuritis the pains are readily evoked by
pressure upon the nerves, this is not usually the case in
ataxia. With the advent of these pains there is sometimes
more or less (edema, profuse diaphoresis, or swelling of the
joints; this is specially true of the epidemic variety of
neuritis. The last-named symptom has frequently caused
the case to be mistaken for acute articular rheumat ism.
Not less important than the sensory symptoms are the
4-32
CORNING: PAIN.
[N. Y. Med. Jon*.,
derangements of motility. The latter, unlike the former,
are non-irritant in type, paralysis of motion being the rule,
while spasms are rare. In the majority of cases the
paralysis begins first in one leg, speedily involves the other,
and may advance thence to one or both arms. As a rule,
the invasion is rapid, the loss of power beginning as a
simple sensation of weakness on standing or walking and
culminating in more or less complete paralysis in fifteen
or eighteen days. The distribution of the paralysis pre-
sents some points of interest. In the first place, it is a
remarkable fact that the muscles which actuate the small
joints of the hands and feet and the wrists and ankles
are much more affected than those of the elbows and
knees. Thus, in a case which I recently saw in consulta-
tion with Dr. Haines, of Newark, the patient, a man of
sixty, who was a sufferer from multiple neuritis of malarial
origin, was able to move both elbows and knees without
difficulty, while voluntary motion in the wrists and ankles
was quite impossible. Another interesting point is, that
the paralysis shows quite an irregular distribution at first,
but assumes the characteristic form when fully developed.
I emphasize this point because on seeing the case at the
commencement of the paralytic invasion one is apt to be
puzzled unless forewarned of the erratic character of the
symptoms. Such, then, is the more common course of
general neuritis — a course which, as previously intimated,
is subject to considerable variation.
Time does not, however, permit our consideration of
the erratic types of the disease.
Simple Neuritis. — The duration and course of simple
neuritis are subject to a certain degree of variation. Usu-
ally, however, the onset is quite abrupt, although a gradual
beginning is occasionally observed. Moreover, an initiatory
chill and fever occur in some cases, but the majority begin
without these warnings.
Whatever the precise mode of onset may chance to be,
the first symptom to excite the apprehension is the pain.
This pain is usually severe and is felt more or less through-
out the distribution of the affected nerve. On applying
gentle pressure along the course of the nerve, the latter is
found to be extremely sensitive ; and after the trouble has
lasted a certain amount of time, it is often possible to feel
the nerve (which has become considerably thickened
through the integument). Though the pain is more or
less persistent, it sometimes abates, but only to return again
with renewed intensity. I have under my care at this time
a patient in whom the intermittent and severe type of neuri-
tic pain is well illustrated. The patient, a lady of remark-
able intellectual gifts, was recently referred to me by Dr.
M. S. Ayers, of Fairview.
Disturbances of sensibility and motility also occur in
the simple form of neuritis, as well as in the more general
type of the affection. Tingling, numbness, and a moderate
decree of anesthesia are observed in cases of medium se-
verity, while in those characterized by more profound and
permanent changes in the nerve the amesthesia may be
intense.
The motor derangements are sometimes merely of mod-
erate extent, so that nothing more may be complained of
than slight weakness; but when the mischief is more seri-
ous, conduction is abolished, the implicated muscles are
paralyzed and atrophy more or less extensively. If an
examination be made by the aid of the electrical current at
this time, the muscles will be found to exhibit the charac-
teristic reaction of degeneration.
Finally, more or less extensive changes in the skin have
been observed in a certain number of cases. The most com-
mon are vascular and herpetic eruptions ; both the hair
and nails may be involved, the former becoming brittle and
the latter stubby.
Pathology. — When the course of the disease is acute
the pathological changes are proportionately vehement.
The affected nerve is seen to be reddened, swollen, and
thickened ; its vessels are distended and intensely hyper-
remic, to which circumstance the lividity is due ; there is a
transudation of cellular elements and fluid from the en-
gorged vessels into the interstitial tissue and nerve sheaths,
and, in short, we have a typical picture of acute inflamma-
tion. On examining the condition of the nerve fibers more
closely, by the aid of good lenses, we find that the destruct-
ive process is by no means as far advanced in some as in
others. In those which present the most marked changes
the axis cylinder is completely obliterated, the medullary
substance undergoes fatty or granular degeneration, and
the sheaths themselves are more or less completely disin-
tegrated. Finally, the disorganized remnants may be more
or less completely absorbed, and then nothing remains be-
hind but the empty sheaths. This, as previously men-
tioned, is the course of events in the more severe cases ; in
those of a milder type, however, the changes are less far-
reaching, nothing more than moderate swelling of the
sheath and granulation of the medullary substance being
discoverable.
Finally, cases which begin in a chronic manner do not
present the primary stage of engorgement of the vessels and
fluid and cellular infiltration.
It has already been noted, in the clinical portion of this
chapter, that some cases of a severer type get well without
loss of motility, provided the muscular atrophy has not
been too extensive. This fact presupposes that the regen-
erative capacity of the nerves is prodigious. Considera-
ble difference of opinion exists among pathologists as to
the manner in which this restoration of the nerve filaments
takes place. Of late, however, two theories have chiefly
claimed attention ; according to the one, new axis cylinders
are evolved and prolonged from those which have escaped
the ravages of the inflammation, while the other affirms that
the young nerve fibers are derived " from an endogenous
growth of nuclei within Schwann's sheath." Benets and
Newman are adherents of this hypothesis.
In connection with the traumatic varieties of neuritis,
the facts bearing on the regeneration of divided nerves are
most interesting ; for, from what has been learned, both
experimentally and in the clinic, it is certain that more or
less perfect union and restoration of function may be ob-
tained in nerves thus mutilated.
Oluck found, in the course of a series of experiments on
fowls, that the excision of a piece of nerve was not followed
April It!. 1892.J
VON RUCK:
CLIMATIC RESORTS FOR TUBERCULAR PATIENTS.
433
by restoration of function, but that, after simple division,
such restoration readily took place when the ends were care-
fully coaptated. This renewal of conduction was, more-
over, established with marvelous rapidity — in two instances
in twenty-four hours. As a rule, however, when the sciatic
was divided and the ends subsequently joined with sutures,
paralysis of the muscles supplied by the nerve persisted
for fifty hours. After the lapse of this interval there was
a gradual resumption of motion in the affected muscles,
more or less complete recovery taking place in about four
days.
Waller and Vaulair believe that the regeneration takes
place from the central portion of the divided nerve, and that
the peripheral end degenerates. Tizzoni, on the other hand,
holds that the degeneration affects both ends of the nerve
at the point of incision.
Eichhorst and Wagner maintain that the reorganization
takes place from the nerve fibers on both sides of the incis-
ion, the new connecting fibers being derived from the axis
cylinders.
1 Janvier has indicated the important part played by the
mechanical support of the tissues in maintaining the physio-
logical distribution of regenerated nerves.
Lastly. Paget has found that, after division of the me-
dian nerve, sensation began to appear in the regions sup-
plied by it within two weeks. Recovery was practically
complete in about four weeks. As has already been said,
the nature of the divided nerve favors cicatrization and re-
generation of the peripheral ends, and hence the frequency
and success with which the process lias been resorted to by
modern surgeons.
From the foregoing data it is evident that considerable
difference of opinion exists among pathologists regarding the
remarkable series of events which culminate in the restora-
tion of function in a nerve previously injured either by the
knife or the inroads of active inflammation. Nevertheless,
many of the phenomena observed are exceedingly suggest-
ive, and it is, moreover, highly probable that some at least
of the points in dispute will be definitely settled in the near
future.
The Treatment of Pain. — From what has already been
said regarding the causation and conduction of painful sen-
sations, it is evident that a wide range of remedies are ap-
plicable in treatment. In the first place, we may address
our endeavors to the nerve itself, and strive, by the applica-
tion of appropriate agents, to arrest the propagation of the
painful sen-ations toward the sensorium ; or we may seek
to allay the inflammatory condition in the nerve itself. This
we may do by localizing remedies in the painful districts *
by the application of ointments, by endermic medication,
or, when all else fails, by division of the affected nerve
stem.
But the mere alleviation of pain, though eminently
worthy, is by no means the ultimate end to be desired. We
should strive by every means in our power to effect a per-
* For some of the author's more noteworthy contribution? to this
field sec the Xeic York Medical Journal for December 20, 1891; the
medical Record for .March 19, 1887; and A Treatise on Headache and
Neuralffia, Ncu York, E. 15. Treat, 1888 (also subsequent editions).
manent cure. From what has been said regarding the cau-
sation of neuritis, it is clear that, in a large proportion of
cases, the solution of this problem involves nothing less
than the elimination from the system of some poisonous
influence, such as malaria, lead intoxication, or syphilis, or
the correction of some constitutional dyscrasia. Where the
cause is found in some organic disease which serves to per-
petuate the neuritic condition of the nerve, little can be
hoped for from chemical agents of any kind. Under these
circumstances we must address ourselves to surgery, that
most useful art, which has done so much for the alleviation
of human suffering. Unfortunately, as we have said, there
are many lesions of the central nervous system which are
quite inoperable. In this category belong the sclerotic and
degenerative diseases of the brain and spinal cord. The
most that we can do in such cases is to seek to render the
patient's condition tolerable by the administration of anal-
gesics and opiates. I will merely add, in conclusion, that
when these agents have lost their potency, except when given
in toxic doses, their physiological influence may be re-estab-
lished by giving them while the patient is exposed to the
influence of a condensed atmosphere, as I have recently7
shown in an article published in the Medical Record for
August 29, 1891.
The time at my disposal does not admit of an extended
reference to the philosophical questions underlying this
mode of treatment ; that has already been done in the
article above referred to. I shall therefore merely state
that this system of using compressed air in conjunction
with drugs is based upon facts which I have succeeded in
establishing by researches that fulfill the exigencies of the
most exact induction.*
From what has previously been said regarding the cau-
sation of neuritis, it is evident that anomalous conditions
of the renal secretions, or at least some of them, bear a defi-
nite causal relation to the genesis of pain. Hence it follows
that the correction of renal derangements, in so far as they
are remediable, should always be undertaken as soon as they
are detected. These observations apply with especial force
to lithaemic conditions, which are but too often entirely
overlooked.
53 West Thirty-eighth Street.
THE CHOICE OF CLIMATIC RESORTS
FOR TUBERCULAR PATIENTS.
By KARL WON RUCK, B. S., M. D.,
ASHEV'ILLE, N. C.
At the recent Congress of American Physicians and
Surgeons the discussion of this subject brought out the
statement that, in addition to meteorological reports, the
profession wanted more and other information than that fur-
nished heretofore. The desire was expressed that the physi-
cians practicing at climatic resorts should give their eliui-
* The Use of Compressed Air in Conjunction with Medicinal Solu-
tions in the Treatment of Nervous and Mental Affections, being B New
System of Cerebro spinal Therapeutics. The Medical l\< con/ of August
29, 1891.
434
VON RUCK: CLIMATIC RESORTS FOR TUBERCULAR PATIENTS. [N. Y. Med. Jouh.,
cal experience, and tell the profession what particular class
of patients derive the greatest benefit at the particular
locality, and what stages, phases, and manifestations of the
disease were most amenable to the influence of the particu-
lar climate ; the profession caring less for information upon
temperature, humidity, rainfall, and other meteorological
data, and more tor definite knowledge as to where the indi-
vidual case would find the climatic conditions under which
he would make the greatest improvement, and eventually a
recovery.
This at first thought would seem an extremely reasonable
demand, and if climatic treatment would necessarily lead to
improvement and recovery (if only the right spot were
chosen) the desired information would have come forth long
ago.
Until physicians who advise phthisical patients will take
years of time and, during a prolonged residence at each of
these resorts, make personal and exact scientific as well as
clinical observations to enable them to personally judge of
the relative merits of climatic resorts, just so long will the
profession have to depend for their information upon those
members who practice at such health stations.
A week's or a month's sojourn by a physician at a cli-
matic resort is entirely too short a time to gather the de-
sired information — indeed, the grossest errors are possible
from the impression so received by the individual — and for
practical observation of patients suffering from a tedious
disease like consumption, a much longer time would be re-
quired to make the conclusions of the observer of any value
whatever, either to himself or to the profession, and it
would take many years to so study the health resorts of the
United States.
Physicians residing at health resorts are, however, sup-
posed to have a personal interest in making their particular
locality " come out on top," and the suspicion is not allayed
with the observing reader when he notes in contributions
to medical literature comparisons between one doctor's
home-climate and that of many other places in which the
argument and evidence adduced invariably go to show that
this particular writer's climate is in every respect superior
to every other ; hence every patient should be sent there, if
the home physician would do his whole duty to his patient !
Such contributions, natural as they may be, constitute noth-
ing but an advertisement, and should be relegated to the
advertising pages of the journals in which they appear,
even there to be judged for what they are — "a means for
personal gain."
It is unfortunate, but can not be helped, that occasion-
ally even scientific men will stoop to motives entirely un-
worthy, and never so good a climate does not seem to con-
fer immunity from jealousy and selfishness.
This being the case, it is perhaps fortunate that the
profession wants less knowledge of meteorological character
and more clinical evidence, although meteorological data are
entirely indispensable to a correct appreciation of any cli-
mate, even if they can not supply all information that seems
necessary.
The late I>r. Urehmer, of the famous < Joerbersdorf Sani-
tarium lor Consumptives, in Germany, accorded such a
locality a curative influence in phthisis which could con-
clusively be shown to afford immunity from the disease to its
inhabitants.
This theory commends itself to the good judgment of
the student of phthiseotherapy, and will perhaps find more
adherence than any other as long as our knowledge remains
empirical, and particularly so inasmuch as such climates
have been found valuable from a clinical standpoint also.
In a country like the United States, where reliable vital
statistics are seldom made except in our large cities, and
where many of the health resorts have been established in
localities only recently or sparsely settled, it is difficult or
impossible to apply this test; and, from the nature of the
disease and its aetiology, it must ever be possible to show
that the larger centers of population do furnish the greatest
percentage of deaths from tuberculosis ; it being also quite
probable that a locality which can now show such a relative
immunity as, for instance, is maintained by T. M. Lloyd
{New York Medical Journal, April, 1887) and others for
Asheville, N. C, and which the vital statistics of the city,
kept now for four years past, seem to confirm, may eventu-
ally lose more or less of this favorable influence from an in-
crease of population, as we now have in the older and more
densely settled States. No one has, however, been able to
explain what particular climatic condition produces such
immunity, although many theories have been advanced.
In a recent contribution to the treatment of pulmonary
tuberculosis, read before the Tri-State Medical Society at
Chattanooga, Tenn. (The Treatment of Pulmonary Tuber-
culosis upon the Principles of Nutrition, Dietetic Gazette,
November, 1891), I stated, as my conclusions regarding the
effect of climate, that its mysterious influence disappeared if
we looked upon it as it might affect the nutritive processes
of the patients, and that a locality with much sunshine, and
with absence of extremes of temperature, of strong winds
and impurities and irritants in the air, but having a rela-
tively dry and pure atmosphere, admitting of much out-of-
door life, with sufficient elevation to favor a better circula-
tion, must of necessity be better than where the reverse was
the case, and reliable data by physicians or from other
sources from our health resorts as to these conditions were
certainly essential to the information of the profession.
If, now, residence in such a locality were all that is needed
to enhance and favor the patient's nutritive processes, the
information where this air can be found would be sufficient
to guide the responsible home physician in his selection of
a place, provided he has reliable data ; but I am sure it re-
quires no special mention that, no matter how favorable the
climate, on it alone the patient's nutrition is not apt to
thrive ; and it is equally superfluous to mention that other
conditions essential to the best nutrition of the patient may
be so indifferent, or even bad, that not only will the climatic
influence be unavailing, but in their presence the already
impaired nutrition of the individual patient must of neces-
sity seriously suffer in spite of the best climate in the
world.
This means that apart from meteorological data the pro-
fession is in want of other information, and so important
is this addition that without it the medical adviser can
April 10, 1892 J
VON BUCK: CLIMATIC RESORTS FOR TUBERCULAR PATIENTS.
435
foretell little of the result of his advice in the choice of
climate.
To the meteorological data furnished the profession I
am, perhaps, the only observer who has given attention to
ozone for a number of years, and it would be very desirable
if from other resorts similar reports were forthcoming. In
addition, we need competent air and water analysis, both
bacteriological and chemical, and I expect to continue in
giving my attention to these additional subjects. Any one
can see the importance of pure air and water, and nothing
has been done in this direction at any of the resorts. We
also need information upon the general hygienic conditions
of the various resorts.
It is well understood that the so-called " mountain
fevers " of elevated stations, said to be especially prevalent
in Colorado, are, in fact, typhoid, and I have observed in
Asheville that, as the hillside wells have been abandoned
and as the sewer system is being extended, so have the
"mountain fever" and summer diarrhoea diminished and
disappeared.
To send a patient to a climatic resort, there to be ex-
posed to the dangers of typhoid fever, would be a doubt-
ful advantage, and one for which a relatively better air can
not atone.
If at a given health resort the meteorological data ap-
pear satisfactory, the air nevertheless may be loaded with
dust, impurities, and irritants of various kinds which the
hygrometer, thermometer, and barometer do not indicate,
and which would be seriously detrimental to lung and throat
affections.
All such matters need to be known to the profession,
and the information on these subjects needs to be reliable.
The houses in which our patients live, their hygienic ap-
pointments and surroundings, their method of heating and
ventilation, the cooking of and quality of food, the care
and comforts offered, make not a little difference as to the
results a patient may ultimately show when these are highly
favorable or more or less unfavorable.
The kind of professional adviser into whose hands the
patient falls, his skill, judgment, interest, and appreciation
of the necessities of his patients, I presume make as much
difference at the climatic resorts as at home ; and I believe
that if the patient can have the best of care and surround-
ings and perfect painstaking professional management at
home, and has to do without most of these advantages at a
climatic resort, he is better advised to stay at home.
Now, as to the clinical experience wanted, I would give
the profession the following information, and it applies not
only to Asheville, N. C, but to all health resorts, and in
that respect it is fortunate that we can speak in general.
The diagnoses are imperfect enough now, and it would cer-
tainly add much to the existing perplexities if it were neces-
sary to diagnose with a view to the particular climatic resort
to he employed.
So long as physicians will await the advent of serious
symptoms and the latter stages of the disease before re-
sorting to climatic treatment, just so long will they seek in
vain for the especial climate thai can uniformly benefit such
patients.
If a patient is sent to a climatic resort, and he selects
for his residence a boarding-house that stands on a thor-
oughfare, without grounds or piazzas, so that he is sub-
jected to dust, noise, and annoyances of sundry kinds, and
he can not be out of doors except upon the streets ; if even
slight exertion causes him shortness of breath, and he must
climb two or three nights of steep stairs to his room ; if
the house is heated in the winter by stoves or fire-places
and the halls are cold ; if he is emaciated and must sleep
on a hard bed ; if he must go out of doors to water-closets
in all kinds of weather ; if he requires a judicious diet, but
follows his own inclinations, or if, in the absence of a prop-
erly selected diet, he must eat tough meat, or pork and
hominy cooked in grease ; if he must wait upon himself,
instead of having proper care and attention — then the pa-
tient has a poorer chance for improvement than if the con-
ditions mentioned are as perfect as they can be made.
If a patient falls into the hands of a physician who
advises long and tiresome walks, " to walk off " a tempera-
ture of 103°, as I know to have occurred; if he tells his
patient: "Drink all the whisky you can," and the pa-
tient upon such advice succeeds in ruining his digestive or-
gans ; if the remedies for fever given by the medical ad-
viser are drug antipyretics from one month's end to the
other, and if for cough opiates are given as regularly ; if this
physician is one who follows routine methods, makes none
or but superficial examinations, and keeps no records, or is
not impressed with the great importance of details ; if lie
does not understand or take pains in an individualizing
management of each particular patient, with a view to pre-
vent relapses and to keep the patient at his best all the
time — then the patient's chances are diminished just to the
extent that the professional management is deficient in these
and other matters.
If the patient resides at a fashionable hotel and spends
his time in the bar, billiard, card, or ball room, instead of
out of doors or in quiet rest ; if he eats mince pie, even if
it should kill him, because he likes it, as a patient once told
me he would ; if ladies seek to excel others by elaborate
toilets, and spend an hour each day in curling their hair,
surely the chances of improvement are diminished by such
trifling conduct, no matter how favorable the climate may be.
If a physician sends a patient, who is already much ex-
hausted, upon a long, tedious, and tires< ime j< turney t< > a health
resort, that patient will, as a rule, be worse for his trip, and
the conditions may then become such that the case follows
an unfavorable course to the end, in spite of any climate,
especially if on arrival the patient is left to his own discre-
tion.
The occurrence of acute inflammatory and destructive
processes is favored or, if they are present, the symptoms
are increased by overexertion and fatigue from any cause,
and may continue to progress unfavorably until, by judi-
cious treatment and management, an arrestment can he
accomplished. The climate may aid in such arrestment,
hut it can not cut short at once this stage.
If a patient is sent who has already suffered destructive
changes to a degree that large and, perhaps, suppurating
cavities exist, and if, in addition, large areas of lung are in-
436
FRENCH: A DEVICE TO PREVENT MOUTH-BREATHING DURING SLEEP. [N. Y. Med. Jour.,
volved, embarrassed or inactive, if he is already suffering of
amyloid or intestinal tubercular disease, if he is extremely
emaciated from long-continued hectic fever, he will proba-
bly die soon after his arrival, no matter where and to whom
he maybe sent; the climate and the physicians at the place
can not save him.
If a patient is sent even in the early stage with a view
of staving a few weeks or months, and while at the climatic
resort he is to have what is often called " a good time," by
attending dances and clubs, mountain excursions and other
frolics, probably he will suffer relapse, his disease extend,
and he will then be likely to return to his medical adviser
little benefited or even worse. Climate can not help it ;
it can not protect people from their follies.
If a patient is sent and his physician has led him to be-
lieve that all he needs is a change of air, that there is not
much the matter with him, that he has only a little throat
trouble, or that his lungs are a little weak, and if this pa-
tient suffers from tuberculosis in any stage, he will proba-
bly consult no physician until he relapses; if he does, and
we caution him to the required conduct and care, he does
not believe us, until more serious symptoms show that he is
growing decidedly worse. Good results under such circum-
stances are not apt to follow, and such patients frequently
return home with little or no improvement.
If a patient is sent who is well advised, both at home
and at the resort, but who lacks that essential quality of
manhood or womanhood, self-control, and who can deny
himself nothing, he is likely to do as he pleases unless placed
where he is absolutely controlled.
Unfortunately, this is to a degree the case with the ma-
jority, and the disease itself, as well as meddlesome inter-
ference and advice, favor it ; even in an institution we
have to exercise eternal vigilance to keep our patients de-
termined and steadfast. We have to coax and to beg, to
praise and commend, to scold and to threaten them into a
course of lasting proper conduct.
On the other hand, if the profession send cases in the
early stages, if they will explain to them that now every
means are required and all proper efforts must be made to
prevent the disease assuming serious proportions, if they will
explain to their patients how important an ideal conduct even
at a health resort will be, if they will tell them that there is
no royal road, but one to be traveled with the greatest care
and circumspection, that it is one beset with difficulties, only
to be overcome by watching every minute detail and under
the constant guidance of a competent, painstaking, honest
physician, and recommend their patient to such a one — if,
then, the patient is sent to one favorable climate or another,
it will depend upon him, upon the compliance with advice,
and a sufficiency of time given to a cure, whether the patient
let u ins better or worse, improved or cured.
It is the stage of the disease reached, the proper con-
duct of the patient, the proper care and advice at the resort,
and the time given, that determines the outcome of the case,
and even the best physicians at health resorts must on that
accounl leave it largely in the hands of the profession what
their efforts shall accomplish.
The home physician, knowing his case and requirements,
needs no special instruction as to the particular resort to se-
lect ; he can, after considering all the factors in a case, know
pretty well what he can expect, and, other things remaining
equal, any resort where the climatic conditions are favorable,
as indicated in the earlier part of this paper, will give him
practically the same results. Looking upon climate as a re-
medial agent, it can not be expected to furnish an excep-
tion to our experience with other remedies, and the results
derived from any of them are influenced by the conditions
and surroundings spoken of above.
The Winy ah Sanitarium, November 4, 1891.
A DEVICE TO PREVENT
MOUTH-BREATHING DURING SLEEP.
By THOMAS R. FRENCH, M. D.,
BROOKLYN.
When, from any cause, the nasal passages are greatly
diminished in size or occluded, breathing through the mouth
is, of course, a necessity ; but even after the cause has been
removed the habit of mouth-breathing not infrequently per-
sists. Again, this injurious habit is often practiced because
of relaxation of the muscles of the lower jaw during sleep.
The mouth may be closed on going to sleep, opened while
sleeping, and when consciousness arrives is found closed
again, so that many are ignorant of the fact that they ever
breathe through the mouth. Adults who present symptoms
of the practice of this habit during sleep will, as a rule, deny
its existence, but if they are questioned closely they will
usually admit that the mouth and throat are almost always
dry in the morning, and that it may be several hours before
those parts regain their normal condition.
For all cases in which the presence of the habit is known
or suspected, and also to determine the existence of sufficient
nasal capacity during sleep, it has been my custom, in the
past few years, to direct the use of strips of a material known
as " wash blonde " in
such a way that, if the
nasal passages are suf-
ficiently free, the loweT
jaw will be held in
place, and, as a conse-
quence, nasal breath-
ing enforced. With
the kind assistance of
Mr. S. V. W. Lee, re-
cently under my pro-
fessional care, this de-
vice has been much im-
proved and is serving
an excellent purpose.
The device con-
sists of a piece of
" wash blonde," a kind of " illusion," which is attached to
straps of light webbing and adjusted to the head in the
manner shown in the accompanying sketch.
The " wash blonde " is placed under the chin and the
perpendicular straps buckled together at the top of the head.
April 16, 1892.]
II OD OMAN: FRACTURE OF THE RADIUS.
437
In this way the needful support is given to the lower jaw.
The perpendicular straps are held in position on the head
by two back straps, which are looped on to them, and which
are also regulated by a buckle. The buckle at the top of
the head is padded to prevent uncomfortable pressure being
made, and the whole appliance is so light and elastic that
it is usually worn, after a trial or two, without the slightest
discomfort
The apparatus is made in two sizes, for adults and chil-
dren, and is supplied by Messrs. F. Haslam & Co., 83
Pulaski Street, Brooklyn.
FRACTURE OF THE RADIUS.
NON-UNION; OPERATION; RECOVERY.
Bt w. e. hodgman, m. d.,
/ SARATOGA, N. T.
After an interested perusal of the cases of non-union
following fracture of the leg, reported by Dr. Fred. Jenner
Hodges, of Chicago, in the Journal for October 10, 1891,
I determined to operate, and, finally, to report the follow-
ing case, not so much for the sake of reporting the opera-
tion itself as to illustrate what seems to me a somewhat
iinique cause for non-union :
On October 9, 1891, William Y., fifty-one years of age, a
strong, well-developed, and healthy man, of excellent habits,
was, while driving a team attached to a carriage, thrown out
upon the ground and dragged some distance down a hill. The
pole of the carriage had broken, plowed into the road, and
overturned the vehicle. Just how the injuries were received,
except that a wheel passed over the right ankle, he can not re-
member. To him the result of the accident was a broken right
fibula in its lower third, a transverse and comminuted fracture
■of the lower end of the radius at about the junction of its mid-
dle and lower thirds, and a very oblique fracture of the same
radius, the lower portion of which was about three inches above
the transverse fracture. These, together with a number of cuts,
scratches, and bruises on the face, limbs, and various other parts
pf the body, completed the casualties. The leg was put up in
felt splints and fracture box until the swelling had subsided,
when plaster was substituted. This was allowed to remain in
place until six weeks after the injury was received, .when, on
removal, it was found to be united and apparently all right.
The forearm, which was much swollen when first seen by me,
was dressed with two straight, flat splints, somewhat wider
than the arm. The outside splint reached from immediately
below the olecranon process to a point midway between the
wrist and the lower ends of the metacarpal bones. The anterior
splint extended from the bend of the elbow to the wrist joint.
The splints were each padded with two layers of Canton flan-
nel, having their centers elevated by a narrow ridge made by
several folds of the same material; all being held in place by
strips of rubber plaster. The splints and forearm were retained
in position in the usual manner by rubber plaster, roller band-
age, and sling. After four or five days, the swelling having con-
siderably subsided, the arm was carefully examined and the
splints reapplied. In a few days more, the swelling having en-
tirely gone out, the splints were firmly applied and not again
removed until four weeks from the date of the injury. After
the first dressing the patient suffered no pain or inconvenience
n hatever. At this time it was found that no union had taken
place at either end of the fracture. I rubbed the ends together
as well as 1 could, reapplied the splints, and left them on for
nine days. At the expiration of this time it was quite evident
that some union had taken place in the upper or oblique fract-
ure, though absolutely none in the lower or transverse fracture.
Acting now on the advice of one of the best surgeons in
northern New York, I decided to operate without further delay.
Preparations were made for a thoroughly aseptic operation, in-
cluding sterilization by boiling of all the water to be used, and
sterilization by steam of all instruments and sponges.
An incision was made directly over the center of the radius
on its dorsal aspect, commencing about an inch below the
lower fracture and extending about an inch and a half above.
On getting the bone well exposed, it was found that the ends
were not in perfect apposition. The lower end of the radius
had a piece broken almost squarely out on its ulnar side that
dipped into the bone nearly half its width, and within this notch
the lower end of the upper piece was resting, thus creating a
condition of things that, in this muscular arm, did not show any
deformity to my eye or sense of touch. The small piece that
had been broken out bad disappeared. After separating and
freshening the ends, it was found impossible to bring them to-
gether properly on account of the overlapping. The incision
was now extended up the forearm so as to completely expose
the upper fracture, when the cause of the overlapping below be-
came apparent. The upper fracture, which was very oblique,
had allowed the loose piece to slip, or be drawn directly
downward by muscular action, until its lower end rested in
the notch in the upper portion of the lower end of the radius,
thus creating another malposition of the fragments that could
not be detected until dissection had laid it bare. No nerve
or fragment of muscle was found interposed between the ends,
and if, as is now taught, the course or relation of the nutrient
artery is not to be considered, then it must have been this
slight slipping downward and the inability of the splint to
hold the pieces firmly together that in this case caused, in one
instance, delayed union, in the other non-union. For, as before
stated, there was absolutely nothing perceptible in the patient's
general condition to cause a suspicion in that line. The much-
despised chain saw was now brought into use, and it did its
work quickly, smoothly, and well. "With it a small piece was
sawed from each end, the bone drilled, and, with a doubled
piece of No. 26 silver wire, brought together firmly and accu-
rately. The oblique fracture in which union had commenced
was, of course, not disturbed. The muscles and deeper tissues
were stitched with catgut, the skin and areolar tissue with silk.
No drainage. The external wound was seven inches in length.
Iodoform, iodoform and sublimate gauze, a plain plaster splint
from wrist to elbow, with sling, completed the dressing. The
patient sat up the next day and had at no time any elevation of
temperature or pulse, or sensation of pain in the wound. Thirty-
eight days after the operation the plaster splint and other dress-
ings were removed. The bone and soft parts had firmly and
perfectly united. The muscles are now getting loose and free,
with every prospect of a strong and perfect arm. To Dr. In-
lay, Dr. Thompson, Dr. Humphrey, and Mr. Gates, student, I
am much indebted for conscientious and valuable assistance.
The Jefferson Medical College, of Philadelphia. — The board of trust-
ees, at a meeting held on April 7th, instituted a chair of clinical gynae-
cology, with a seat in the faculty, and elected to the new chair Dr. E.
E. Montgomery, who lias been for a number of years professor of gyne-
cology in the Medico-chirurgical College. They also elected the follow-
ing clinical professors : Dr. F. X. Deroum, professor of nervous dis-
eases; Dr. E. E. (iraham, professor of children's diseases; Dr. 11. Au-
gustus Wilson, prof essor of orthopaedic surgery; Dr. II. W. Stelwagon,
professor of derm.itolog\ ; and Dr. W. M L. 1'oplin, adjunct professor
of hygiene.
438
LEADING ARTICLES.
[N. Y. Med. Joub.,
THE
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by Edited by
D. Appleton & Co. Frank P. Foster, M. D
NEW YORK, SATURDAY, APRIL 16, 1892.
FATAL MALARIAL POISONING.
In the Johns Hopkins Hospital Bulletin for December, Dr.
Osier is reported, in the proceedings of the hospital society, as
giving an account of two fatal cases of paludal poisoning. Ma-
larial poisoning so seldom causes death in the latitude of Balti-
more that these carefully studied cases are full of interest.
One of them illustrated the algid type and the diagnostic value
of examination of the blood. In the other case the diagnosis
was befogged by the history of an insolation and by some pulmo-
nary symptoms, so that before the patient's death the case was
set down as one of low anomalous pneumonia. The blood w as
examined superficially and no malarial organisms were found.
The first, or algid, case was that of a sailor, thirty-four
years old, recently from Savannah, without a history of chill or
fever, but with persistent vomiting and great prostration. His
temperature on admission was 101° F., and his pulse 104. The
blood was examined at once, and, as was expected, Laveran's
organisms were found in large numbers. Six or eight intra-
corpuscular forms could be seen in the field of the one-twelfth
immersion, the majority of which were without pigmentation.
They underwent rapid changes of outline. An unusual propor-
tion of the leucocytes showed pigment granules. Half-drachm
doses of quinine were given every six hours; when vomiting
was excessive the quinine was given subcutaneously. The
treatment seemed to have the effect of diminishing the number
of plasraodial corpuscles, but the patient died after being six
days in the hospital.
The second, or supposed pneumonic, case, was that of a
man, apparently in vigorous health, who had been employed as
a berry-picker in July. He died at the end of a fortnight. The
necropsy showed no pneumonia, although there were pulmo-
nary congestion and oedema. The post-mortem diagnosis was
that of malarial fever with malarial parasites in the blood and
in the spleen. The microscopical examination was made by
Dr. Welch, who noted that blood from the finger showed in
small numbers malarial organisms — namely, spots of the shape
and size of the red blood-corpuscles with pigmented plasmodia;
free round pigment corpuscles, varying in size from that of
blood plates to twice that size; and pigmented crescents, the
pigment being in a ring in the middle. He found in one speci-
men of splenic pulp two free and active flagella. A few pig-
mented corpuscles were found in the capillaries of the brain.
The case last reported was the earlier of the two by a year
or two; and, while Dr. Osier does not so state, he leaves the
reader to infer that bis experience with that case was a means
to the almost immediate recognition of the malarial poisoning
in the case of the young sailor.
MEDICAL MISSIONARY WORK IN EAST CENTRAL AFRICA.
Fko.yi a publication issued by the Universities' Mission to
Central Africa we learn something concerning the line of work
performed in connection with the hospital at Zanzibar. That
institution, manned and supported largely by men of the uni-
versiiies of Oxford and Cambridge, is little more than a dis-
pensary at present, with one small ward near by. The corner-
stone for a large hospital, situated close to the old Slave
Market, in the capital of Zanzibar, was laid on May 12, 1891.
Already the walls are rising — rapidly for that part of the world
— and another year will see there a regularly equipped hospital,
with trained nurses 'from England. The^cost will not be less
than $10,000, providing two wards for the natives and some
private accommodations for Europeans who fall ill with the
tropical fever. These latter require prompt and special atten-
tion ; many lives are lost by delay in seeking treatment. The
location of the hospital is especially suitable for such relief,
since its site is regarded as the most salubrious part of the
town.
The paragraph relating to the small-pox epidemic of 1887
will be interesting reading to all who {have not lost faith in
Jenifer's great discovery. The ravages of small-pox among the
native Africans, when it is not tempered by vaccination, are
extreme and almost beyond the range of descriptive language.
A LARGE FOREIGN BODY TOLERATED IN JHE
CONJUNCTIVAL SAC.
De. F. M. Cnisoi.M, of Baltimore, 'reports, in the Maryland
Medical Journal for March 2(ith, a case illustrative of the re-
markable tolerance of the conjunctiva of a large foreign body,
provided that the substance jgains entrance to the retrotarsal
fold of the upper lid. His patient, a little girl of nine years,
gave a history of having been struck on the right eye about
four months before coming under his charge. The nature of
the blow was not understood, and the results were apparently
transient and not marked by painful symptoms. A mild as-
tringent lotion was all that was used to allay a certain amount
of conjunctival irritation. But a prominence of the upper lid
was noticed, and a little later a dark object made its appear-
ance at the inner canthus of the eye. On examination, there
came into view a piece of round twig seven eighths of an inch
long by an eighth of an inch in diameter. This had been tinder
the lid nearly four months, in about the same position, until the
child probably, while rubbing her eye, caused the piece of
wood to appear at the canthus. Before this change of position,
mere eversion of the lid would not have exposed the foreign
body, since its situation was in the cul-de-sac, behind the tarsal]
cartilage. The length of time this visitor was detained was as
remarkable as the slight degree of annoyance caused by it.
The palpebral conjunctiva showed a certain amount of conges-
tion, but the appearance of the eyeball was normal.
Foreign bodies, such as bits of wood, seeds of considerable
size, and beads of different kinds, when they become lodged be-
hind the upper tarsal fold, sometimes escape the attention of the
April Hi, 1802. J
MIXOR PARA GRAPHS. —ITEMS.
439
general practitioner, and the conjunctival irritation is treated
as a conjunctivitis from cold or external violence ; but ordi-
narily their presence is indicated by a painless swelling or ele-
vation looking externally very much like a tarsal tumor. On
palpation, however, the fingers recognize that there is a free-
dom of motion, as of a foreign body under the integument, that
does not belong to a tumor of the lids.
MINOR PA It A G RAP IIS.
CHLOROFORM IX THE TREATMENT OF TYPHOID FEVER.
According to the Lancet, Dr. P. Werner has treated 130
oases of typhoid fever with a one-per-cent. solution of chloro-
form, the employment of which was suggested by Behring's
observations of the germicidal action of chloroform upon the
bacillus Werner gave a tablespoonful of the solution every
hour or every two hours during the height of the disease and
for some days after the temperature became normal. In all
cases in which, this treatment was adopted before the tenth day
great improvement was manifested; the tongue did not become
brown, diarrhoea and tympanites gradually disappeared, there
was no lendency to bed sores, and relapse was very rare. His
observations agreed with those of Steppe, who used the drug in
1890 in this disease. Possibly we may have in this a desirable
substitute for the so-called Brand treatment, of which Osier
says in his recent work : " To transfer a patient from a warm
bed to a tub at 70° F., and to keep him there "twenty minutes or
longer in spite of his piteous entreaties, does seem harsh treat-
ment, and the subsequent shivering and blueness look distress-
ing. A majority of our patients complain of it bitterly, and in
private practice it is scarcely feasible."
CATHETERISM OF THE BILIARY PASSAGES.
In the February number of the Revue de chirurgie Dr. Ter-
rier and Dr. Dally conclude an exhaustive article on catheter-
ism of the biliary ducts in conjunction with cholecystotomy or
in the treatment of the case after the performance of that op-
eration. They think that this procedure is easier in pathological
cases, especially those in which the passages are dilated in con-
sequence of retention of bile, than it would be in experimental
trials on the cadaver. In many cases it would be found difficult
on account of curvatures of the cystic duct, or of the persist-
ence of the valves, or of the cystic duct opening on the lateral
wall of the gall-bladder. In some cases the difficulties will be
insurmountable, while in others the exploration will be found
quite easy. To formulate rules for this sort of catheterism is
impossible ; one can only be guided by one's anatomical knowl-
edge. Forced catheterism, even with the finger placed under
the liver in the abdomen, seems to be dangerous under all cir-
cumstances. Our information is as yet not sufficient to enable
us to appreciate the value of catheterisme d demeure. The in-
struments employed should always be sterilized.
THE SURGEON-GENERAL OF THE NAVY.
The President has wisely settled the question of the succes-
sion to Surgeon-General Brown by re-appointing him. Dr.
Brown had just completed his four years' tenure of office, and
only about thirteen months remain before the time of his retire-
ment will arrive. It is understood that nearly all the other can-
didates for the appointment made their applications with the
proviso that they were not in the field if I>r. Brown's re-ap-
pointment was to be considered. Surgeon John 0. Boyd will
be appointed assistant to Dr. Brown, to take the place of Medi-
cal Inspector William K. Van Iieypen, who will join the San
Francisco in a few weeks as fleet surgeon of the Pacific station.
A PRESCRIPTION' FOR YOUNG PHYSICIANS.
According to the British Medical Journal, a distinguished
Vienna professor gives the following prescription to all young
physicians who call to take leave of him before embarking on
their professional career : R Veritatis, humanitatis, fidelitatis,
aa infinitum. Misce. Ft. elixir vitas. Signa : To be used con-
stantly throughout life. It is easy, perhaps, for most men to
start with a good stock of this spiritual elixir, but the difficulty
is to find an apothecary who can dispense the prescription when
the supply has run out.
ETHER-DRINKING IN RUSSIA.
This vice, says the British Medical Journal, has spread so
rapidly in Russia that the Government has prohibited the free
sale of ether and certain of its compounds. Such legislation
has proved to be efficacious in diminishing the vice in Ireland.
ITEMS, ETC.
Infectious Diseases in New York.— We are indebted to the Sanitary
Bureau of the Health Department for the following statement of cases
and deaths reported during the week ending April 12, 1892 :
DISEASES.
Typhus Fever
Typhoid fever
Scarlet fever
Cerebro-spinal meningiti
Measles
Diphtheria
Small-pox
< 'iises.
3
1
11
3
258
23
6
3
460
25
137
24
26
Deaths.
The Circle of Willis, we learn by a letter from Dr. Frank A. Mc-
Guire, is a society that has recently been organized in New York for
the purpose of diffusing social ideas among the medical profession, to
the exclusion of " shop." The society has twenty members, and is re-
ceiving accessions monthly. It will be seen that it is analogous to the
Austin Flint Society, of Baltimore, mentioned by us recently.
Gowers on the Nervous System. — We learn that a German edition
of the second revision has just been published in Bonn, also that an
Italian translation is nearly ready.
The Hospital Graduates' Club. — The fifty-ninth stated meeting will
be held at the "Arena," No. 41 West Thirty-first Street, on Thursday
evening, the 28th inst. Dr. Norris is announced to read a paper on The
Internal Administration of Ozone in the Treatment of Phthisis.
The Middleton Goldsmith Lecture. — The trustees of the Middleton
Goldsmith fund have invited Dr. Francis P. Kinnicutt to deliver the
lecture this year, on Friday, May 6th.
Change of Address. — Dr. Charles N. Cox, to No. 168 Halsey Street,
Brooklyn.
Army Intelligence. — Official List of Changes in the Stations and
Duties of Officers serving in the Medical Department, United State*
Army, from March 27 to April 9, 1892:
Wood, Marshall W., Captain and Assistant Surgeon. The leave of ab-
sence granted is extended one month.
Macaulky, C. N. B., Captain and Assistant Surgeon, will report for
temporary duty at V. S. Millitary Academy, West Point, X. Y.,
during the absence of Captain Hkmiv S. KlLBOURNE, Assistant Sur-
geon, as member of the Army Medical Hoard, Xew York city, X. Y.,
and on return of that officer will rejoin his proper station.
Meriwether, Frank T., First Lieutenant and Assistant Surgeon, Or-
dered for temporary duty at Madison Barracks, New York, during
440
ITEMS.— OBITUARIES.— LETTERS TO THE EDITOR.
[N. Y. Med. Joue.,
the absence of Captain Hknky S. Turrill, Assistant Surgeon, as
member of Army Medical Board, New York city, and on return of
that officer will rejoin station.
Hoff, John Van R., Major and Surgeon. Ordered to St. Louis, Mo., to
represent the Medical Department of the Army at the meeting of
the Association of Surgeons of the National Guard, to be held in
that city April 19 to 21, 1892.
Winter, Francis A., First Lieutenant and Assistant Surgeon (recently
appointed), will proceed from St. Louis, Mo., to Jefferson Bar-
racks, Mo., and report to the commanding officer of that station
for duty.
The suspension of the operation of Par. 2, S. O. 13, January 16th, A.
G. 0., relating to Appel, Aaron H., Captain, and Cabell, Julian
M., First Lieutenant and Assistant Surgeon, is removed.
Gardner, Edwin F., Captain and Assistant Surgeon, is granted leave of
absence for one month on surgeon's certificate of disability.
Suter, William N., First Lieutenant and Assistant Surgeon. Resig-
nation has been accepted by the President, to take effect July 28,
1892.
Ireland, Mkrritte W., First Lieutenant and Assistant Surgeon. Or-
dered to Fort Yates, North Dakota, for temporary duty during the
absence of Captain Alonzo R. Chapin, Assistant Surgeon, on sick
leave.
Hartsuff, Albert, Major and Surgeon. Granted leave of absence for
six months, to take effect on or about July 10, 1892, with permis-
sion to go beyond the sea and to apply for an extension of two
months.
Bradley, Alfred E., First Lieutenant and Assistant Surgeon. Ordered
to Columbus Barracks, Ohio, for temporary duty at that station dur-
ing the illness of Captain Augustus A. De Soffre, Assistant Sur-
geon.
Purviance, William E., First Lieutenant and Assistant Surgeon (re-
cently appointed), will proceed from Rossville, 111., to Fort Riley,
Kansas, and report for duty at that station.
Naval Intelligence. — Official Lbst of Changes in the Medical Corps
of the United States Navy for the tv<<> weeks ending April 9, 1892 :
Lewis, D. 0., Surgeon. Detached from the Naval Hospital, Washing-
ton, and ordered to the Naval Hospital, Mare Island, California.
Berryhill, T. H., Passed Assistant Surgeon. Detached from the
U. S. Steamer Pensacola and ordered to the U. S. Steamer Ranger.
Barntm, Merrill W., commissioned an Assistant Surgeon in the Navy
from March 15, 1892.
Farwell, W. G., Surgeon. Granted leave of absence for six months,
with permission to leave the United States.
Woods, George W., Medical Inspector. Detached from the U. S.
Steamer Pensacola, and ordered to the Hospital at Mare Island,
California.
Bates, N. L., Medical Director. Detached from the Naval Hospital,
Mare Island, California, and ordered home.
Brown, J. Mills. Reappointed Chief of Bureau and Surgeon-
General.
Boyd, J. 0. Detailed as Assistant to the Bureau of Medicine and Sur-
gery.
Barni m, M. W., Assistant Surgeon. Ordered to the Naval Hospital,
Washington, D. C.
Smith, Howard, Surgeon. Granted leave of absence for six months,
with permission to leave the United States.
McCullough, Champ Carter. Commissioned an Assistant Surgeon.
Society Meetings for the Coming Week:
Monday, April 18th: New York County Medical Association; New
York Academy of Medicine (Section in Ophthalmology and Otology) ;
Hartford, Conn., Medical Society ; Chicago Medical Society.
Tuesday, April 19th : Association of Military Surgeons of the National
Guard of the United States (first day — St. Louis); Medical Society
of the State of California (first day— San Francisco); New York
Academy of Medicine (Section in General Medicine) ; New York
Obstetrical Society (private) ; Medical Societies of the Counties of
Kings and Westchester, N. Y. ; Ogdensburgli, N. Y., Medical Asso-
ciation; Passaic, N. J., County Medical Society (annual) ; Baltimore
Academy of Medicine.
Wednesday, April 20th : Association of Military Surgeons of the Na-
tional Guard of the United States (second day); Medical Association
of Montana (first day — Butte); Mississippi State Medical Associa-
tion (first day — Natchez) ; Medical Society of the State of Cali-
fornia (second day) ; Medical Association of Georgia (first day —
Columbus) ; New York Academy of Medicine (Sec tion in Public
Health and Hygiene); Harlem Medical Association of the City of
New York ; Northwestern Medical and Surgical Society of New York
(private) ; Medico-legal Society (New York) ; Philadelphia County
Medical Society ; Windham, Conn., County Medical Society (annual
— Plainfield) ; Middlesex, Mass., South District Medical Society (an-
nual— Waltham).
Thursday, April 21st : Association of Military Surgeons of the National
Guard of the United States (third day); Mississippi State Medical
Association (second day) ; Medical Association of Montana (second
day); Medical Society of the State of California (third day); Medi-
cal Association of Georgia (second day) ; New York Academy of
Medicine ; Brooklyn Surgical Society ; New Bedford, Mass., Society
for Medical Improvement (private) ; Tolland, Conn., County Medical
Society (annual).
Friday, April 22d: Mississippi State Medical Association (third day);
Medical Association of Georgia (third day); Yorkville Medical Asso-
ciation (private) ; New York Society of German Physicians ; New
York Clinical Society (private) ; Philadelphia Clinical Society ; Phila-
delphia Laryngological Society.
Saturday, April 23d : New York Medical and Surgical Society (pri-
vate) ; Worcester, Mass., North District Medical Society (annual —
Fitehburg).
(Obituaries.
EDWARD WIGHT CLARKE, M. D., OF ENGLEWOOD, N. J.
The death of this very promising young practitioner took
place on Monday, the 11th inst., after an illness of less than a
week's duration. Dr. Clarke was horn in Manchester, New
Hampshire, on the 20th of October, 1862. In 1883 he received
the degree of bachelor of arts from Columbia College, after
which he took a special course in the same institution, and took
the degree of master of arts in 1884. In 1887 he received his
medical degree from the College of Physicians and Surgeons,
taking the third Harsen prize. He then served the full term on
the house staff of one of the surgical divisions of the New York
Hospital. During his service in the hospital he showed much
originality in treatment. Among other things, he devised a
method of treating fracture of the patella by means of a subcu-
taneous suture. He was one of the founders of the Association
of the Alumni of the New York Hospital. Since leaving that
institution he had practiced in Englewood. The cause of his
deatli was septicaemia occurring in the course of scarlet fever.
He leaves a widow, a daughter of Dr. Banks, of Englewood,
and two children.
fetters to % debitor.
AN OPENING FOR MEDICAL LADIES IN INDIA.
Ill North Eighth Avenue, Mount Vernon, N. Y., April 2, 1892.
To the Editor of the New York Medical Journal:
Sir: You had the kindness to insert in one of the January
numbers of your journal a notice of the need of a fully quali-
April 16, 1892.]
PROCEEDINGS OF SOCIETIES.
441
fled physician to take the supervision of a medical mission in
Ceylon. We received many responses to that appeal, and are
happy to say that a suitahle candidate has been found and is
now under appointment for that work.
We have been requested to make another appeal for two
fully qualified lady doctors for medical work in India, under the
Zenana Bible and Medical Missionary Society of London, whose
honorary missionaries we are.
There are 139,000,000 women in India, including 21,000,000
widows, 79,000 being children under nine years of age. Thou-
sands of women and girls die annually whose lives might have
been saved by proper medical assistance. There is only one
missionary for every 250,000 of the population.
The Zenana Bible and Medical Mission, which was founded
in 1852, is unsectarian and works in co-operation with different
missionary societies in India. Its object is to give medical re-
lief to the women of India and make known to them the gospel
of Christ. The agencies it employs are as follows : Fully quali-
fied lady doctors, lady missionaries, native Christian assistants,
Bible women, day schools for girls, training schools, village mis-
sions, also hospitals and dispensaries, the attendances last year
at which were over 22,000.
The society's work has nearly trebled during the past ten
years. Appeals for more missionaries are constantly received,
to which the committee are ready to respond as soon as suitable
candidates can be found. The age of the medical ladies who
apply should not exceed thirty years. The salary allowed is
about $050 to $750 per annum, with extras, such as outfit, pas-
sage, rent of house, traveling, etc. The ladies must be earnest
Christians, thoroughly unsectarian in their sympathies, and ready
and willing to work with all evangelical churches and with all
workers who love our Lord Jesus Christ in sincerity and truth.
It is the custom of this society to place two medical ladies at a
station, furnishing them with a hospital, dispen-aries, medicines,
and a suitable staff of trained native assistants. Its medical
missionaries thus enjoy advantages which are not always af-
forded to the medical missionaries of other societies. We shall
be glad to give further information about the work of this so-
ciety to any one really contemplating offering herself for this
work. We are also desirous of having an interview with such,
and shall be glad to see any one at the address given above at
any time during the last week in April or the first week in May.
Any one desiring to apply should do so forthwith, as we wish
to secure these candidates before we return to England, which
we shall probably do in May. Sincerely,
Mart and Makgaret W. Leitch,
for seven years missionaries in Ceylon.
flroeecbings of Societies.
SOCIETY OF THE ALUMNI OF BELLEVUE HOSPITAL.
Meeting of October 7, 1891.
The President, Dr. Egbert Le Fhvre, in the Chair.
An Extreme Case of Congenital Lateral Curvature.—
Dr. R. II. Sayke presented a remarkable example of congenital
lateral curvature of the spine in a girl fourteen years of aire
At the time of her birtli it had been noticed that she had a
short, catching respiration, and a few hours later a careful ex-
amination had Showed that there was a marked lateral curva-
ture of the spine with rotation of the ribs on the left side. At
the age of six years she had had pneumonia, followed by an ab-
scess, which had opened through the right thoracic wall. From
its coming so closely upon the attack of pneumonia, it had been
probable that this abscess had communicated with the pleura,,
and although it had undoubtedly aggravated the condition of the
spine, it could not be said to have originated it, as this condition
had long antedated the pneumonia. The child had received no
systematic treatment up to the time of her first coming to the
speaker, four days ago. Examination at that time had showed
a large V-shaped gap in the ribs over the liver, which was prob-
ably not due to the absence of any ribs, but to a fracture of the
costal cartilages in utero. This condition probably accounted
for the extraordinary amount of malformation, which was great-
er, the speaker thought, than that of any congenital case on rec-
ord. Her height was found to be four feet six inches and three
quarters During the past four days she had been stretched
daily by means of the well-known Sayre suspension apparatus,
and had gained each day about an eighth of an inch in height.
He desired to call particular attention to this fact, for, while it
was easy to understand how such suspension might cause a very
temporary increase in stature, it was very surprising that this
gain in height could be retained. A good deal of doubt had been
expressed by various writers as to the possibility of increasing
the height in this way, but he would remind his hearers of one
or two similar cases which he had already presented to the so-
ciety, in which such a result had been actually obtained, and
where the measurements had been taken by others as well as by
himself.
Dr. L. W. Hubbard had seen iD his service at the New York
Orthopredic Dispensary two or three cases of quite marked lat-
eral curvature with rotation and bulging of the ribs, in very
young children, and the parents of these children had stated
that the deformity had been first noticed either at the birth, or
within a few days thereafter. The case just presented seemed
to him to have originated from a congenital absence of the ribs,
or else from a separation of the ribs at the sternal ends, thereby
allowing the pressure of the uterine walls to crowd together the
ribs, and so give rise to the deformity. Undoubtedly this had
been steadily increasing as a result of a lack of support on that
side. Suspension and proper support would undoubtedly in-
crease the height, but he hardly thought it would exert any very
appreciable effect upon the deformity itself.
Dr. Sayre said that there had already been some reduc-
tion of the deformity, as was shown by the fact that garments
which could be buttoned around the chest a few days ago
could not be readily so fastened. He thought, therefore, he
was justified in looking for a considerable improvement in the
deformity.
Dr. Sayre also presented a young girl having some disability
of one hand, the exact nature of which he did not fully under-
stand, lie presented her with a view of eliciting suggestions as
to the aetiology and treatment. A year or so ago, she said she
had been cut across the right wrist by a long, straight knife, ami
so severe had been the injury that the bones had been plainly
visible in the wound. An effort had been made to unite the
extensor tendons, as well as the lips of the wound, by sutures.
She stated that about four mouths later it had become neces-
sary to break up some adhesions, and that, after this had been
done the motion of the hand had been better. Electricity and
massage had been employed for some time and had been of some
service. She had been treated for a while at the orthopaedic
dispensary, hut had become discouraged and had abandoned
treatment. He had seen her for the first time that afternoon.
The hand became blue and cold on slight exposure, and a hasty
examination had showed a total paralysis ot the digital flexors
and extensors, tor they were not under the control ol the will.
442
l'.ooK NOTICES.
[N. Y. Med. Jour.,
and did not give any reaction with a strong faradaic current. A
galvanic battery had not been at hand at the time this first ex-
amination was made. The interossei and the opponens muscles
of the middle finger and thumb had appeared to be normal, as
were also the flexors and extensors of the carpus. There had also
been great rigidity of the knuckles, which projected into the palm
just as they did in certain nervous disorders. The situation of
the wound had not been such as to explain the condition by sup
posintt that there had been an injury of a nerve, and, as the knife
was said not to be curved, it could not be supposed that the
flexor tendons in the palm had been severed, and that the at-
tending surgeon had overlooked them when suturing the other
tendons.
Dr. Hubbard said that he had seen the case at the orthopie-
dic dispensary when the patient had first applied for treatment,
and she had then mentioned certain points in the history which
had not been given in the foregoing recital. The arm had been
kept on a splint for a number of months after the injury, and
then, after breaking up the adhesions, it had been again confined
on a splint for about seven months. There had been considera-
ble inflammatory reaction and some suppuration. He had felt
quite sure that there had been some muscular control, and that
at the time he had seen her the muscles had reacted to elec-
tricity. The action of the muscles above the carpus had been
shown when the patient's fingers had been flexed. At first the
fingers had been quite stiff and the circulation very poor, but
under electricity and massage there had been a very noticeable
improvement up to a certain point, and then it had been so slow
that the patient ceased to attend regularly at the dispensary.
He thought that the condition present was entirely due to the
crippling of the tendons by inflammatory adhesions.
Dr. Irving 8. Haynes fully concurred in this view.
Dr. Sayke replied that lie did not doubt that much of the
disability was due to the crippling of the tendons by adhesions,
but this did not explain the reason for the flexors not acting
upon the terminal joints of the fingers, and what little resist-
ance there was to the flexion of these joints seemed to be due
to the action of the interossei and lumbricals rather than to ad-
hesions.
Vicious Union following Pott's Fracture; Operative
Treatment: Exhibition of a Case.— Dr. Irving S. Haynes
read a paper on this subject. (See page 423.)
Dr. L, W. Hotchkiss had seen during the past winter a case
of Pott's fracture with bad union, treated in Bellevue Hospital
according to the plan described in the paper, a simple osteotomy
being done through the shaft of the fibula above the external
malleolus. The result had been all that could be desired. He
recalled seeing Dr. McBurney operate about six years ago in
Bellevue Hospital upon a case in which both bones had been
fractured. The case had been treated for some time after the
injury by means of two lateral wooden splints without any at-
tention being paid to the flexion of the foot. As a result of this
the foot had become extended and abducted and the patient had
walked on the ball of the foot while the ankle joint had been
stiff and painful. The patient had accordingly sought relief in
the hospital and the deformity had been perfectly reduced by
an osteotomy on both bones. There were not in the hospital
plaster casts representing the condition present before and after
the operation.
Dr. Hubbard had seen a number of these cases where, years
after the operation, the disability had been extreme. Consider-
able relief had been afforded by a mechanical support consist-
ing of a stout ankle-piece passing underneath the shoe, with a
large pad to support the inside of the foot, and the usual bars
passing up on either side of the leg. In the patient just pre-
sented there was evidently a shortening of the tendo Achillis,
and when the patient stood with the feet flat on the floor there
was a tendency to outward deviation. He was of the opinion
that a gradual shortening of the tendon would take place, and
would ultimately lead to a deformity similar to, but not so great
as, the original one. This might be prevented by flexing the
ankle by a suitable traction apparatus. If this were not done,
after a number of years the internal ligament would probably
yield, and there would not only be deformity and disability of
the foot, but the patient would in all probability suffer, as he
had seen others do, from cramps about the ankle and tarsus,
and, later on, even running up the leg.
Dr. Sayre could not see the reason for the tendon contract-
ing in the manner described, as the mere fact of the patient
walking and attending to his daily occupation meant that the
tendon would be frequently stretched, and hence the condition
of the foot should improve instead of developing into an equi-
nus. It would no doubt be wise to stretch the gastrocnemius
muscle, and break up some of the adhesions still remaining in
front of the ankle. He had seen many of these cases which had
been originally treated as a simple sprain by rest in bed and the
use of fomentations, and the large number of such cases would
seem to indicate that the medical profession at large was in-
clined to overlook slight Pott's fracture. This was especially
true where such fractures occurred in fat old ladies, whose
abundant adipose tissue made it difficult to detect the exact
nature of the injury to the bones.
Dr. Hubbard explained that he did not mean that the de-
formity would result in an equiuus, but that where there was
imperfect flexion of the foot, the continued use of it in this
position would, after many years, result in an equino-valgus
and a crowding together of the small bones of the foot. Such
cases occurred without any previous injury.
Dr. Sayre said that he was well aware that a short tendo-
Achillis often gave rise to valgus and a breaking down of the
arch of the foot, for Nature intended that the ankle joint should
be bent to an angle of about 120° with the tibia, and when this
degree of flexion could not be obtained the person must move
forward by bending the medio-tarsal joint. Under these cir-
cumstances he was very apt to stretch the plantar fascia and
break down the arch of the foot, thus giving rise to a valgus.
He did not believe, however, that the tendo Achillis kept on
shortening all this time.
Dr. Haynes said that he only desired to emphasize one point
touched upon in the discussion — viz.. the importance of treating
a sprain as if it were a fracture. The reason for this was obvi-
ous, as one phase of a Pott's fracture was a rupture of the in-
ternal lateral ligament, and if union orcurred with this ligament
elongated, the state of the ankle would be worse than if the
original injury had been a fracture. Hence every sprain of
the ankle should be treated with a pi aster-of- Paris dressing;
it would certainly get well more quickly than by any other
method.
^liook Notices.
Hospitals and Asylums of the World ; their Origin, History,
Construction, Administration, Management, Legislation, etc.
By Henry C. Burdett, formerly Secretary and General
Superintendent of the Queen's Hospital, Birmingham,
etc. London: J. & A. Churchill, 1891. Vols. 1 and II.
Pp. xvi-701 ; x-348.
To those interested in hospital construction the name of this
author is well and favorably known, and the scope of the pres-
April 16, 1892.1
BOOK NOTICES.
443
ent work will he appreciated by everybody when it is learned
that the author has been engaged for the pasts twelve years in
preparing and completing the material for publication — material
that, represents the experience of twenty-five years as a hospital
official in various capacities and as a visitor to the chief institu-
tions in most European countries, to those in several of the Brit-
ish colonies, and to those in the United States. It has been his
aim to enable everybody interested to gain a more general and
accurate knowledge of a work that must tend materially to "di-
minish suffering and to increase the comfort of those members
of the community who are least able, or wholly unable, to make
provision for themselves"; and this may, in part, be accom-
plished by intercommunication and co-operation among all ad-
ministrative officers of asylums and hospitals throughout the
world.
The first volume is devoted to a history of asylums and of
their administration, and begins with the early history of insan-
ity. Attention is called to the fact that Aretaeus, of Cappadocia,
and Paulus ^Egineta, almost six hundred years later, insisted
upon the rational treatment of violent maniacs and the employ-
ment of only the kindest and simplest restraint. But their teach-
ing went unheeded or was forgotten in what Maxime du Camp
called the period of " engulfment," and less than a century ago
Pinel succeeded in awakening public and professional conscience
to a realization of public responsibility' for the insane. The au-
thor finds that at Metz in the year 1100, and at Dantzicin 1320,
there were asylums for the insane, thus disproving Desmaison's
contention that the establishment of the Valencia asylum marked
an epoch in the treatment of these Unfortunates.
From a consideration of the period of brutal suppression, ill-
treatment, and cruelty to the insane, and of the early history of
lunacy and asylum treatment in the British colonies and abroad,
the author passes to the present condition of lunatic asylums,
and gives an encyclopaedic resume, of those institutions in vari-
ous parts of the world.
As Americans our pride may be touched by such a passage
as this: "Were it not for the lavish expenditure in sanitary mat-
ters and the introduction of all the latest scientific appliances
for minimizing labor and risk, it would almost appear that luna-
tics in America were still regarded as a class to be confined first,
and perhaps cured afterward, rather than as unfortunate beings
for whose curative treatment these enormous buildings have
been designed." And : " So common, indeed, is it [overcrowd-
ing] that it may almost be said to be the rule, whereas in other
parts of the world it is certainly the exception." The justifica-
tion of the former criticism may be found, in this State at least,
in the Annual Report of the State Commission in Lunacy for
1890, and our acquaintance with other communities permits us
to say that. New York is not alone in the matter. Mr. Burdett
is aware that the responsibility fortius condition of affairs does
not rest entirely upon the medical profession ; and if more in-
telligence and less political jobbery were infused into the ex-
penditure of the appropriations for the construction of insane
asylums, the overcrowding at least might often be obviated,
and it. would be impossible to say, as has been said of the St.
Louis Insane Asylum, that the money expended in the general
construction of the institution would, if placed at interest, pay
for the board and lodging of all the inmates at the best hotel in
the city.
Regarding his criticism on the prevalent use of methods of
restraint in most of our institutions, we must cry peccavi, and
await the day when appropriations will be sufficiently generous
to enable asylums to have that quota of skilled attendants that
will enable them to dispense with what is yet often necessary
in order to prevent the patients from harming themselves or
others. This want, we believe, is oftener the Jons et origo of
the restraint employed than any lack of sympathy, intelligence,
or progressiveness on the part of our superintendents of
asylums.
The generous commendation the author bestows on what-
ever is commendable in American institutions shows that his
criticisms are made in a spirit of fairness and not from a cap-
tiousness that we are often accustomed to from our English
brothers.
The second volume treats of asylum construction, with plans
and a bibliography. It would not be possible to do it justice in
the space of a review, but we would commend it for careful
perusal to all persons and boards interested in this subject.
Transactions of the American Association of Obstetricians and
Gynecologists. Vol. IV, for the year 1891. Philadelphia:
William J. Dornan.
Tins volume is quite abreast of those that have preceded it
in scientific interest and value. To say that this association is
composed largely of progressive men is only to state a well-
known fact. They are to be congratulated upon the excellent
character of the work that they are doing year by year and on
the success they are having in presenting subjects for discussion
that are of vital interest to gynaecologists everywhere.
Abdominal Surgery. By J. Gkeig Smith, M. A., F. R. S. E.,
Surgeon to the Bristol Royal Infirmary ; Lecturer on Surgery,
Bristol Medical School; Late Examiner in Surgery, Uni-
versity of Aberdeen; Fellow of the Royal Medical and
Chirurgical Society of London; Honorary Fellow of the
American Society of Obstetricians and Gynaecologists, etc.
Fourth edition. Philadelphia: P. Blakiston, Son, & Co.,
1891.
The fact that a fourth edition of this work has been called
for within four years of the date of its first publication must be
gratifying to the author. More than that, it is an evidence that
the work is one of no ordinary value. Such a work was im-
peratively demanded by the marvelous extension of abdominal
surgery within the past decade, and it is difficult to see how the
demand could have been better satisfied. It is but just to say
however, that there are some marks of haste in the preparation
of this latest edition which might have been obviated had the
requirements for its appearance been less urgent.
We have been unable to discover any reference to the use
and value of the Trendelenburg posture, which is now recog-
nized as one of the most valuable adjuncts in the performance
of abdominal operations. On page 216 Leopold is said to have
lost four out of eighty patients after vaginal hysterectomy, and,
a little further on, "Sanger, Leopold. Olshausen, and a few
others are said to have had results nearly as brilliant."
On page 220 we observe that the author, in classifying can-
cer of the uterus, clings to the old division of scirrhus and en-
cephaloid, which may well become obsolete. Why not say hard
and soft cancer where the distinction is purely a clinical one?
The use of clamps in preference to ligatures in vaginal hyster
ectomy is still advocated (p. 233), though it is admitted that
there are disadvantages with the former and advantages with
the latter. We are quite in accord with the positive statement
of opinion, based upon experience, that in vaginal bysterectonvj
it is perfectly proper to leave the vaginal and peritoneal wounds
open. Of course there are exceptions in which such a plan
would not be the most desirable.
Upon the subject of ectopic gestation Tait's record is quoted
only to 1887. It must not be forgotten that much of the most
valuable work in this field by Tait, Price, and others has been
done since that date, and this oversight should not have hap-
444
BOOK NO TIOES.—NE W INVENTIONS. — MISC 'EL LA NY.
|N. Y. Med. Jodk.,
pened in dealing with a matter of so great importance. Another
oversight occurs in connection with the chapter upon appendi-
citis It is true that McBurney's name is mentioned in connec-
tion with the disease, but it was deserving of far more extended
notice, in view of the great value of the work that has been
done by that distinguished surgeon in this field. We doubt not
that proper appreciation will be extended in a subsequent edi-
tion, for there is no lac* f fairness in the entire volume wher-
ever it is apparent that good work has come to the author's
notice.
There is no difficulty in recognizing the fact that the author
is a man of positive convictions, and, while opinions are not ad-
vanced with unbecoming dogmatism, he has no hesitation in
offering guiding statements, and we believe that, in the main,
they will be found safe and trustworthy.
BOOKS, ETC., RECEIVED.
Bacteriological Diagnosis : Tabular Aids for Use in Practical Work.
By James Eisenberg, Ph. D., M. D., Vienna. Translated and augmented,
with the Permission of the Author, from the Second German Edition,
by Norval H. Pierce, M. D., Surgeon to the Outdoor Department of
Michael Reese Hospital, Chicago. Philadelphia and London : F. A.
Davis Co., 1892. Pp. xiv-3 to 184. [Price, $1.50.]
Outlines of Zoology. By J. Arthur Thomson, M. A., F. R. S. E.,
Lecturer on Zoology in the School of Medicine, Edinburgh, etc. With
Thirty-two Full-page Illustrations. New York : D. Ap-
pleton & Co., 1892. Pp. xvi-641.
Transactions of the New York State Medical Asso-
ciation for the Year 1891. Volume VIII. Edited for
the Association by E. D. Ferguson, M. D.
Lectures on Tumors from a Clinical Standpoint. By
John B. Hamilton, M. D., LL. D., Professor of Surgery and
Clinical Surgery, Rush Medical College, Chicago. For
the Use of Students. Second Edition. Detroit: George S. Davis, 1892.
[The Physicians* Leisure Library.]
Aphasia due to Subdural Hamiorrhage without External Signs of
Injury ; Operation ; Recovery. By L. Bremer, M. D., and N. B. Carson,
M. D., of St. Louis. [Reprinted from the American Journal of the
Medical Sciences.]
Tobacco Insanity and Nervousness. By Dr. L. Bremer, St. Louis.
Annual Report of Surgical Operations performed by Horace Pack-
ard," M. D., Associate Professor of Surgery, Boston University School of
Medicine, for the Year 1891, with a Report of a Third Series of Ab-
dominal Operations, comprising Sixty-seven Cases.
Rupture of the Sac of an Extra-uterine Pregnancy through the Fim-
briated Extremity without tearing the Falloppian Tube. Operation ;
Recovery. By Hunter Robb, M. D., Baltimore, Md. [Reprinted from
the New York Journal of Gynaecology and Obstetrics.]
Mme. Lachapelle, Midwife. By Hunter Robb, M. D., Baltimore.
[Reprinted from the Johns Hopkins Hospital Bulletin.]
Treatment of Laryngeal Phthisis. By Robert Levy, M. D., Denver,
Col. [Reprinted from the Medical and Surgical Reporter.]
Two Cases of Trephining for Traumatic Epilepsy. By Philip Coombs
Knapp, A. M., M. D., and Abner Post, M. D., Boston. [Reprinted from
the Boston Medical and, Surgical Journal.]
Diseases of the Urinary Apparatus. Phlegmasic Affections. By
John W. S. Gouley, M. D., Surgeon to Bellevue Hospital. New York :
D. Appleton & Co., 1892. Pp. xiii to 342. [Price, $1.50.]
The .Mc 'dieal Annual and Practitioners' Index : A Work of Refer-
ence for Medical Practitioners, 1892. Tenth Year. Bristol: John
Wright & Co. Pp. lii to 66V.
Accidents from the Electric Current : A Contribution to the Study
of the Action of Currents of High Potential upon the Human Organism.
By Philip Coombs Knapp, A. M., M. D., Boston. [Reprinted from the
Hi, slmi Mi ili, ul inn! Surgical Journal. \
A Case of Tumor of the Cerebellum in which Trephining was done
for the Relief of Increased Intracranial Pressure. By Philip Coombs
Knapp, A. M., M. D., Boston. [Reprinted from the Journal of Nervous
null .]/- ///<(/ />isi list . |
Astasia-Abasia. With the Report of a Case of Paroxysmal Trepi-
dant Abasia associated with Paralysis Agitans. By Philip Coombs
Knapp, A. M., M. I)., Boston. [Reprinted f rom the Journal of Ncrrous
mi'/ Mi iilnl /Jisiast . |
The Treatment of Epilepsy ; with Special Reference to the Use of
Potassium Bromate, Magnesium Bromide, Nitroglycerin, Antifebrine,
Sulphonal, etc. By Guy Hinsdale, M. D., Philadelphia. [Reprinted
from the International Medical Magazine.]
Thirty-second Annual Report of the Medical Superintendent of the
State Asylum for Insane Criminals, Auburn, X. Y. For the Year end-
ing September 30, 1891.
Removal of Superfluous Hair by Electrolysis. By F. J. Leviseur,
M. D., New York. [Reprinted from the Medical Record.]
41c to f nbentiotts, etc
A LATERAL-CUTTING CURETTE.
By Leonard A. Dkssar, M. D.
Messrs. Reynders & Co. have made for me a curette which I find of
great service in removing adenoid tissue from the lateral walls and vault
of the pharynx, as well as from the fossa of Rosenmiiller. The instru-
ment has but one cutting edge, the other being blunt, and two of them
are required to entirely free the vault and sides or tne pharynx of adenoid
tissue. The curette is passed up into the vault close to the lateral wall
and behind the arch of the palate. As the one edge is blunt, no injury
can be done to the pharyngeal structures. A lateral sweep removes the
adenoid growths from the vault and opposite side of the pharynx. The
one curette cuts from left to right, the other from right to left.
i s c e I lit n u .
A Form of Painful Toe. — The Lancet for March 19th contains the
following article, by Dr. L. G. Guthrie :
The intense suffering caused by this complaint, and the prompt and
certain relief which may be obtained by suitable *yet simple treatment,
lead me to record my own experience of a special^form of painful toe.
Both in symptoms and pathology the complaint is identical with that to
which Dr. Auguste Pollosson, in 1889, gave the name "anterior meta-
tarsalgia." Only in the latter the metatarso phalangeal joints are af-
fected, whilst in the former the distal phalangeal joints are alone in-
volved. In order to avoid a more cumbrous designation I have called
the former affection " a form of painful toe." In either case, under the
influence of prolonged standing or walking in tight boots, the ligaments
of one or more joints, metatarso phalangeal or phalangeal only, become
strained, slight subluxation takes place, the nerves are stretched and
pressed upon by the partially dislocated bones, and the characteristic
pain is produced. The pain occurs suddenly, and with a sense of some-
thing giving way at the site of the joint affected. It is relieved by tak-
ing off the boot and gently pressing the displaced bones into proper po-
sition. The reduction is always accompanied by a sharp twinge of pain,
followed by instantaneous relief. I have only met with one case of the
major affection. It was that of a tramcar conductor, who suddenly de-
veloped the symptoms, and had suffered from them for three months
April 16, 1892.J '
MISCELLANY.
445
The pain was under the head of the third metatarsal bone, and he could
relieve it by taking off his boot, flexing his toes while pressing gently
with his linger on the site of the pain. His occupation prevented him
from carrying out this treatment as often as he desired, so I directed
him to wear a boot with a very broad sole, slightly convex on the upper
surface, so as to support the sunken head of the third metatarsal bone,
and with plenty of room across the base of all the toes. This treatment
proved thoroughly satisfactory. The following are cases of the minor but
similar affection — painful toe :
Case I. — In the autumn of 1883, after a long day on duty as hospi-
tal dresser, I walked through the wet streets to the opera. The theatre
was crowded, and I had to stand throughout the performance. Toward
the close I suddenly felt most severe shooting and burning pain in the
fourth toe of my left foot. The boring of a hot iron into the flesh might
have caused similar pain. It extended up the nerves of the outer side
of the foot and leg into the sciatic, with a numbing, sickening sensation.
I limped home, with dismal misgivings lest I had fallen a premature vic-
tim to gout ; but on taking off my boot I discovered that the last pha-
lanx of the fourth toe was overextended, while the head of the second
phalanx was slightly displaced downward. Reduction caused a sharp
twinge of pain, followed by immediate relief. From this time for many
months I was constantly liable to these attacks of pain, especially in hot,
damp days, after standing or walking for any length of time. I learned
to reduce the dislocation and obtain relief by treading heavily on the
empty part of the toe of my left boot with the heel of my right, and
then forcibly drawing the left foot back within the boot, at the same
time elevating the toes against the " uppers." Both the displacement
and the reduction were accompanied by a distinct click. This manoeuvre
became necessary with more and more frequency, and the pain increased
in severity until I had serious thoughts of having the toe amputated or
the joint resected. At last, with the happy inspiration of Mark Twain's
hero, who after twenty years' confinement opened his cell door and
walked out, I discovered an equally easy means of escape. My boot}
though quite comfortable when first put on, became too tight across the
toes as soon as the foot became at all congested. Under this condition
the last phalanges became jammed and fixed together, while the relaxed
ligaments of the second joint of the fourth toe allowed the head of the
second phalanx to drop and press painfully upon the nerves. I ordered
a boot with plenty of room for lateral expansion of the toes, and I was
at once freed from the attacks of pain which made my life a burden.
Case II. — A gentleman recently consulted me on what he believed
to be a soft corn between the fourth and little toe of the right foot.
On examination, I could find no trace of the soft corn, but infantile
paralysis had left his foot with slight talipes varus and marked pes
cavus. The great toe was hyperextended and pointed outward at an
acute angle from the metatarsal joint. The rest of the toes were
crushed together in the form of a cone ; the fourth toe was laterally
flexed and almost hidden beneath the third. The calf muscles were
wasted, and the limb was nearly three quarters of an inch shorter than
the other. To counteract the shortening, he had worn for many years
an extra three-quarter-inch heel inside his boot. The sole was not
similarly raised, so he was compelled to walk in a downward plane,
forcing his toes together at each step into his somewhat pointed and
short boot. He suffered no inconvenience from these deformities until
the beginning of the year 1891, when he acquired the habit of walking
on the outside of his foot, bearing especially on the outer side of the
little toe, in order to avoid resting his full weight on the ball of the
great toe, which was unduly prominent and tender. In July, 1891,
during a long walk, he was suddenly attacked by acute pain in the lit-
tle toe. The sensation, he said, was as if a hot fusee were placed be-
tween his toes and were burning slowly outward through the little toe.
From that time until I saw him three months later he had been con-
stantly subject to these attacks of excruciating pain, and they had so
increased in frequency and severity that he said he would have his toe
amputated at once if he could not otherwise obtain speedy relief. He
could wear a loose slipper with comfort, but on walking in a boot for
even a few yards the pain occurred. It was not relieved by taking off
the boot, but he showed me how, on gently pressing the tip of the little
toe outward, the pain instantaneously ceased, the mana>uvre being ac-
companied by an extra sharp twinge of pain. Obviously his Buffering
was due to slight inward displacement of the last phalanx of his little
toe, and consequent stretching and compression of the nerves between
the displaced bone and the adjoining toe. The treatment in this case
was not so simple as in my own, owing to the various deformities of his
foot. But, to make the story short, complete relief was obtained by. a
boot contrived on the following principles : Plenty of room was given
across the toes, the little toe being especially relieved of all pressure.
The outer side of the fore part of the sole was raised and the heel
lowered, so as to throw his weight from the outer to the inner side of
the boot, and to prevent forcing of the toes together. A graduated de-
pression was made beneath the ball of the great toe in order to avoid
walking on the downwardly displaced head of his first metatarsal bone.
Remarks. — These cases form additional links in the chain of evils
attendant on wearing boots too tight across the toes. Patients will be
probably loath to admit that a form of boot to which they have always
been accustomed, and which they have regarded as both comfortable
and elegant, can be the cause of their sudden attacks of pain. And the
latter they will readily attribute to gout or rheumatism ; for to the non-
professional public, pain in a toe means gout, and pain elsewhere in a
limb means rheumatism. Not only do the paroxysms of pain strongly
resemble those of gout, but it is possible that the strained and unnatu-
ral position into which many force their great toes may account for the
prevalence with which those parts become the primary seat of true
gout.
An Appreciative Notice of American Pharmaceutical Preparations.
— The Lancet for March 26th says :
Some years ago we had occasion to report favorably upon certain
admirable products of this firm, and recently we have had submitted to
us further interesting and new preparations, the results of the examina-
tion of which are well worthy of record. Liquid pancrobilin, as its
name indicates, contains the agents which prepare food for assimilation
in the duodenum. It is a clear, syrupy, brown fluid, slightly alkaline to
test-paper, and sweet at first to the taste and then persistently bitter.
After acidulation with sulphuric acid, ether extracted a body which
gave the well-known bile reaction with strong sulphuric acid and syrup
(Petenkofer's test). Emulsion of starch was readily liquefied, and
slowly though distinctly converted. According to other reactions, the
preparation contains glycerin and spirit. On suitable treatment, the
pancrobilin pills gave reactions confirmatory of the presence of both
constituents — ox bile and pancreatin; while from the compound pan-
crobilin pills — into the composition of which nux vomica, damiana, ex-
tract of colocynth, and quinine enter — the alkaloids of nux vomica and
quinine were successfully extracted and identified. Lacto-preparata is
described as artificially prepared human milk and sterilized, in which
the tough character of the caseine is so modified that it will no longer
coagulate into hard curds. It has probably therefore been malted or
partly digested with diastase, for under the microscope a few cells of
barley starch were recognized. On analysis, lacto-preparata gave the
following results: Moisture, 1'7 per cent.; fat, 06 percent.; mineral
matter, 5-2 per cent, (mainly phosphate of potassium) ; sugars and al-
buminoids, 92-5 per cent. Lacto-cereal food is a somewhat complex
mixture, and consists of partly digested milk powder, starch, dextrin,
malted barley, desiccated bananas, cacao butter, and manna, It is
characterized by a very agreeable flavor, and evidently contains a rich
proportion of nourishing and probably easily digestible materials. Still
more novel are the kumysgen tablets made by this firm, which, when
dissolved in water, yield a kind of efl'ervescing kumyss (koumiss). The
tablets consist of small cylinders which slowly dissolve in water with
effervescence, and by putting twelve in a bottle of water provided with
a screw stopper, an effervescent milk may be obtained. The liquid so
prepared is sweet and resembles fresh milk. The greater part of the
caseine is apparently in solution, as, on addition of acid, clots at once
separate. These preparations furnish unmistakable evidence of the desire
on the part of the manufacturers to place in the market products of a
highly scientific kind, and, this being so, we may confidently recommend
them to the notice of the profession.
The Use of Gelatin Discs in the Eye. — A paper was read before
the Philadelphia County Medical Society on March 2:id by Dr. John S.
Stewart, Ophthalmic Surgeon to the Philadelphia Lying-in Charity, in
MISCELLANY.
[N. Y. Med. Joue.,
which lie said that some excuse, perhaps, might be needed for bringing
before the society a subject which could be of practical interest to
B] ilists of one department only; but it had occurred to him that a
very brief account of one of the methods of applying medicaments to
the eye, which, in his hands at least, had proved highly satisfactory,
might be not altogether devoid of interest even to those engaged in
other lines of work. He referred to the use of medicated gelatin discs,
and would consider only the advantages of applying homatropine and
cocaine to the eye by this means. Four years ago, in the article on
Homatropine, published in the Medical News, he had called attention to
the fact of having frequently observed an irritant action exerted on the
deep structures of the eye by repeated applications of a watery solution
of hydrobromide of homatropine. At that time it had been his belief
that this irritation was the principal cause why ametropia could not be
accurately estimated in very many cases where homatropine had been
employed, and a considerable experience since in the use of watery solu-
tions of the drug had tended only to confirm this opinion. That irrita-
tion was produced in every instance by this method of practice he did
not pretend to say ; but he was convinced that in all cases where there
had been considerable and long-continued eye-strain, resulting from
efforts to overcome particularly aggravating forms of refractive error,
or where chorio-retinal irritation, due to other causes, existed, the hom-
atropine as ordinarily used very often added to the Ultra-ocular disturb-
ance, and thereby interfered with the attainment of the object for which
it was employed — viz., the accurate estimation of the refraction of the
eye.
Another objection which he had to the use of watery solutions of
this drug was that a large proportion of the effect was expended on the
nasal and pharyngeal mucous tract rather than on the eye, as intended.
There was no doubt in his mind that both the irritant effects on the
eye and the, at least, unpleasant ones on the nose and throat were di-
rectly due to the necessarily strong solutions employed — ranging, so far
as he had been able to leam, from eight to twenty-four grains to the
fluidounce — instilled in most instances a number of times within an
hour.
It was said that medicated gelatin discs for ophthalmic use were
first made in 1863 by Savory & Moore, of London; but, strangely
enough, they had never been extensively used. About five months be-
fore, he had begun to try some of those made at the suggestion of Dr.
C. A. Wood, of Chicago, by Messrs. Wyeth & Brother, of Philadelphia,
and almost ever since, when he had had occasion to use homatropine
alone or combined with cocaine for the purposes of refractive work, he
had much preferred these discs to the watery solutions formerly used
by him.
On first thought it might seem unlikely that a single disc, containing
one fiftieth of a grain each of homatropine and cocaine, could exert suf-
ficient influence on the accommodative power ; but he had, in most in-
stances at least, found as nearly complete paralysis of accommodation
as he had ever been able to obtain with 1 epeated instillations of two-
and three-per-cent. solutions of homatropine. The reason was not hard
to discover. Absorption of the drug by the tissues of the eye took
place about as rapidly as the drug itself could be liberated by the dis-
solving of the gelatin ; but when a drop of solution had been instilled, a
large proportion necessarily escaped with the tears, or, if it did not get
away so quickly, was quite likely to produce in sensitive eyes the chorio-
retinal irritation which so often interfered with obtaining the results for
which the drug was used.
Very few of his patients who had had these discs in their eyes could
detect any effect whatever in the nose or throat, and in these few in-
stances the information was obtained only by questioning the patients
on the subject.
In his practice at the present time, in all eyes suitable for the use of
homatropine and requiring its use for the purposes of refraction, he was
making use of discs containing one fiftieth of a grain each of homatro-
pine and cocaine — -cither the hydrobromide and hydrochloride respect-
ively, or the alkaloid. He had found it an advantage, but not always a
necessity, in the case of most patients under twenty-five years of age, to
insert a second disc of homatropine only (one fiftieth of a grain) into
each eye as soon as the first was entirely dissolved — usually in about
ten minutes. A small camel's-hair brush moistened served conveniently
to convey the disc to the eye, and, although it had been recommended
to place the disc against the scleral conjunctiva — in the grasp of the
lower lid — he much preferred raising the upper lid and inserting the
disc beneath it, immediately above the outer canthus, then directing the
patient to keep the lids lightly closed as in sleep, and to avoid winking
until the discs were dissolved.
It had been urged against the use of the gelatin discs that the lids
and eyes were thereby rendered very sticky and uncomfortable. His
patients had not complained of this ; but he thought the annoyance had
been escaped, in large measure at least, by strictly following his injunc-
tion about keeping the eyes closed.
As to the reputed advantage of the combination of cocaine with
homatropine, he had little to say. It was said, of course, that homatro-
pine combined with cocaine dilated the pupil and paralyzed the ac-
commodation more rapidly and effectively than homatropine alone, and
that these results were more permanent. This seemed usually to be the
case; but cocaine was used by him in these cases because of the quiet-
ing effect which it produced on most eyes, thus tending, in some meas-
ure at least, to overcome the irritant effect of the homatropine, and at
the same time to facilitate the measurement of the ametropia.
On several occasions he had used the English preparation of Savory
& Moore, of London ; but he had no hesitation in expressing a prefer-
ence for the Wyeth discs.
The Iowa State Medical Society will hold its forty-first annual
meeting at Des Moines on Wednesday, Thursday, and Friday, May 18th,
19th, and 20th, under the presidency of Dr. George F. Jenkins, of
Keokuk. The preliminary programme includes the following titles :
Section in Practice of Medicine. — Report, by Dr. Edward Horni-
brook, of Cherokee ; The Body Temperature in Health and Disease, by
Dr. Greshom H. Hill, of Independence ; Observations noted in Twd\
Cases of Congestion, by Dr. C. S. Chase, of Waterloo ; La Grippe, by
Dr. H. A. Wheeler, of Onawa ; Was it Scarlet Fever? History and
Recovery, by Dr. J. P. Savage, of Sioux City ; The Year's Progress in
Bacteriology, by Dr. J. B. Ingels, of Meriden ; The Pathology and
Bacteriology of Tuberculosis, by Dr. M. N*. Voiding, of Independence;
What is it ? Why is it ? by Dr. O. B. Harriman, of Hampton ; Tuber-
culosis, by Dr. A. L. Wright, of Carroll ; Hay Fever, by Dr. E. S. Blair,
of Correctionville ; Practice vs. Materia Medica, by Dr. H. Xewell Sill, of
Strawberry Point; My Experience in Intubation of the Larynx, by Dr.
J. W. Kime, of Fort Dodge ; Diphtheria, by Dr. C. M. Drumeler, of
Panora ; Pneumonia, by Dr. X. Agnew, of Storm Lake ; The Rational
Treatment of Inebriety, by Dr. A. W. McClure, of Mt. Pleasant ; Atro-
pine Poisoning, by Dr. J. M. Emmert, of Atlantic; Pneumonia as a
Complication of La Grippe, by Dr. A. C. Bergen, of Sioux City ; Diar-
rheal Disorders of Children, by Dr. H. E. W. Barnes, of Macksburgh;
Thrombosis and Embolism in Practice aside from Surgery, by Dr. Mila
P. Sharp, of Storm Lake; Catarrh of the Bile Ducts, by Dr. F. W.
Powers, of Reinbeck ; A Case of Pulmonary Tuberculosis, by Dr. W.
C. Bundy, of Aurelia ; Diphtheria, by Dr. Milo Avery, of Aurelia ; Anti-
pyretics in Continued Fever, by Dr. R. L. Cleaves, of Cherokee ; also
papers by Dr. C. J. Hackett, of Le Mars, Dr. P. J. Farnsworth, of
Clinton, and Dr. J. H. Divine, of Sioux Rapids.
Section in Surgery. — Report, by Dr. O. J. Fullerton, of Waterloo ;
Surgical Regeneration, by Dr. R. E. Conniff, of Sioux City ; Inte-tinal
Obstruction, by Dr. J. R. Guthrie, of Dubuque ; Orthopaedic Surgery,
by Dr. J. W. Cokenower, of Des Moines ; The Surgery of the Rectum,
by Dr. Lewis Schooler, of Des Moines ; Laparotomy, by Dr. A. J. Hob-
son, of Bristow ; Oils and Fats in Surgical Dressings, by Dr. C. M.
Hobby, of Iowa City; The Management of Compound Fracture, by Dr.
A. B. Bowen, of Maquoketa ; Resection of the Intestine, by Dr. P. M.
Jewell, of Ossian ; and a paper by Dr. T. J. Maxwell, of Keokuk.
Section in Materia Medico and Therapeutics. — Report, by Dr. J. M.
Barstow, of Council Bluffs.
Section in Obstetrics and Gynecology. — Report — The Present Status
of Obstetrics and Gynaecology, by Dr. E. II. King, of Muscatine; Uter-
ine Fibroids, by Dr. D. C. Brockman, of Marengo ; Some Diseases of the
Ovaries and Results, by Dr. J. C. Schrader, of Iowa City ; Three Cases
of Ovariotomy, with Comments, by Dr. H. L. Getz, of Marshalltown ;
The Elici t of Higher Education on the Women of To-day, by Dr. J. S.
April 16, 1892.]
MISCELLANY.
447
Braunsworth, of Muscatine; Reflections on the Present Status of Gynae-
cology, by Dr. J. H. Kersey, of Stuart; Removal of the Uterine Ap-
pendages for Epilepsy — Case, by Dr. C. E. Ruth, of Muscatine ; Uterine
Polypi, with Report of Two Cases, by Dr. T. P. Stanton, of Chariton ;
An Epitome of Obstetric Practice, by Dr. H. R. Page, of Des Moines;
and a paper by Dr. .1. A. Scroggs, of Keokuk.
Section in Ophthalmology and Otology. — Report, by Dr. J. W. Dal-
bey, of Cedar Rapids ; Corneal Ulcers, by Dr. F. E. V. Shore, of Des
Moines; Methods of Middle-Ear Inflation, by Dr. J. M. Rail, of Keokuk;
and a paper by Dr. Woods Hutchinson, of Des Moines.
Section hi State Medicine and Hygiene. — Report, by Dr. Calvin
Snook, of Fairfield ; State Care vs. County Care of the Chronic Insane,
by Dr. G. H. Hill, of Independence; Local Boards of Health, by Dr. G.
A. Spihnan, of Ottumwa ; The Nature of Immunity against Infectious
Diseases, by Dr. C. E. Stoner, of Des Moines; and a paper by Dr. C. B.
Powell, of Albia.
Section in Diseases of the Mind and Nervous System. — Report, by
Dr. P. W. Lewellen, of Clarinda ; The Influence of Mind as a Cause
and Cure of Disease, by Dr. R. Sears, of Marshalltown.
A New Use for Aluminium. — On the 8th of March letters patent
were issued to the firm of A. A. Marks, of Xew York, for artificial
limbs constructed in part of aluminium.
This metal, with its unlimited uses, seems to be peculiarly adapted
for surgical appliances, instruments, and artificial limbs; its low specific
gravity and its great comparative strength are qualities that are de-
sirable to be combined in an artificial leg or arm.
There are amputations of the lower limbs that surgeons deem de-
sirable to do, without sacrificing more of the member than the parts
involved. We refer to amputations technically termed tibio-tai sal,
tarso-metatarsal, and medio-tarsal. These amputations have always
been in disfavor with artificial-limb makers, who have almost unani-
mously decried them, and in too marly instances have persuaded the
surgeons to sacrifice much of a healthy leg merely to obtain a stump
that would better accommodate the artificial limbs that they were able
to produce.
The new artificial leg constructed of aluminium, combined with the
rubber foot, is adaptable to these amputations. The socket of aluminium
incases the stump, and, on account of the strength of the metal, the
socket does not increase the diameters of the ankle to an objectionable
degree in order to obtain the requisite strength ; the metal is cast into
the proper shape to give ease and comfort to the wearer ; the aluminium
socket is terminated by a rubber foot, which not only simulates the
natural toot, but provides a soft, springy medium to walk upon and a
resistant phalangeal ball to rise upon while walking, running, or ascend-
ing stairs.
It is obvious that by this invention the amputation can be condi-
tional upon the injury, and the artificial limb conditional upon the am-
putation. In this alone the invention of the aluminium and_ rubber leg
will prove not only a boon to the one who has suffered the amputation,
but the solution of a problem that has many times perplexed the operat-
ing surgeon, as it eliminates all the objections heretofore pressed
against amputations in the region of the tarsus. The surgeon may thus
rejoice in being able to observe the old and consistent law of amputat-
ing with the least sacrifice.
Aluminium also plays an important part in the construction of
strong and durable artificial arms. The socket of an arm made of that
metal is light and strong, and will enable the wearer to subject the arti-
ficial arm to severe uses without danger of destruction. It will not
crack from overstrain like wood, it will not become soft and limp or
foul from perspiration like leather; it is lighter than any other metal,
and is amply strong for every purpose.
The Histological Lesions produced by the Toxalbumin of Diph-
theria.—The following article, by Dr. William II. W elch and Dr. Simon
Flexuer, appeared in the Bulletin of the Johns Hopkins Hospital for
March :
In a preliminary communication presented to the Johns Hopkins
Hospital Medical Society, and published in the Hospital Bulletin, \<>.
15, August, 1891, we called attention to the histological changes in the
organs of animals which had died of experimental diphtheria, following
the inoculation of pure cultures of the Bacillus diphtheria. Since then
we have extended our investigations so as to include the study of the
lesions produced by the inoculation of the toxic products of the diph-
theria bacillus. This study virtually finishes the work we have under-
taken, and it is hoped soon to publish our results in detail. However,
in order to make our preliminary communication complete, we append
this report.
The toxic products of the diphtheria bacillus with which we have
operated were obtained by filtering through a new and sterilized Cham-
berland filter a culture of the organisms in glycerin bouillon several
weeks old. The fluid so obtained was tested by means of cover-slips
and inoculations on glyeerin-agar, and proved to be sterile.
Guinea-pigs were used for the experimental inoculations. The sterile
culture fluid was introduced subeutaneously into the tissues of the belly
wall. The method pursued will be given in connection with the case of
which the lesions are to be described. This guinea-pig received on the
1 Oth of December, 1891, 1 c. c. of the filtrate. Not having succumbed,
on December 14th it received 2 c. e. more. The animal died on January
5, 1892, the duration of life since the first inoculation having been three
weeks and five days, and since the last, three weeks and one day.
At the autopsy the vessels of the subcutaneous tissues were inject-
ed, and haemorrhage had taken place into the tissues of the axillary and
inguinal regions. The subcutaneous tissues were moist, but there was
no actual oedema present. Neither was there a visible area of localized
inflammation. There was no microscopical examination made, however.
The lymphatic glands of the axillary and inguinal regions were enlarged
and reddened ; the cervical lymph glands were swollen, and the thyreoid
gland was greatly congested.
There was a considerable excess of clear fluid in the peritoneal
cavity. Both layers of the peritonaeum were reddened, the vessels of
the visceral layer being especially injected. The spleen was enlarged
to double the average size. It was mottled, and the white follicles were
distinctly outlined against the red ground. The liver was dark in color
and contained much blood. On the surface a prominent yellowish-white
area, 2 mm. in diameter, surrounded by a zone of hyperemia, was ob-
served. Smaller dot-like points of the same color and general appear-
ance were seen elsewhere in the liver. The kidneys were congested, and
the cut surface was cloudy. The adrenal glands appeared normal, as
did the mesenteric glands.
The pleural cavity did not contain such a marked excess of fluid.
The pericardial sac, however, was distended with clear serum. Under
the epicardium were many ecchymotic spots. The lungs exhibited areas
of intense congestion, or actual haemorrhage into the tissues. The
glands of the thorax were, perhaps, swollen.
The examination of frozen sections showed the heart muscle to be
slightly fatty. The epithelium of the tubules of the kidney was ex-
tremely granular and much swollen, but not fatty. The liver was very
fatty ; the lighter areas and dots were seen to correspond to foci of
dead liver cells, whose refraction was much greater than that of the
normal cells.
Cultures were made from the blood and organs of the animal, and
they remained sterile. Cover-slips were also examined and no organ-
isms found.
The histological lesions observed in this case are identical with
those described by us in connection with the inoculation of the living
organisms. Lymphatic apparatus : In general, the changes are the
same throughout. They are found in the greatest intensity in the glands
of the axillary and inguinal regions, and less in the bronchial, cervical,
mediastinal, and mesenteric glands. Yet these are considerably affects
ed. The same fragmentation of nuclei, affecting the lymph nodes and
sinuses, is met with. These fragments exhibit the variety of form pre-
viously described by us, and they have the same affinity for coloring
agents. Much of the nuclear detritus is free, but a part is contained
within large pale cells. In the spleen there is a similar diffuse frag-
mentation of the nuclei of the spleen cells. Both the lymphoid cells
of the follicles and the larger cells of the sinuses are affected. Like
the lymphatic glands, some of the nuclear detritus is inclose 1 in large
cells. Besides the destruction of cells in the spleen there is hemor-
rhage into the organ, or an extreme degree of congestion, so that the
' tissue elements are widely separated from one another. Nuclear figures
V
448
MISCELLA NY.
[N. Y. Med. Jom.
occur in the lymph glands and spleen. In the former they arc found
among the fragmented cells.
Stained sections of the liver, especially those stained in methylene-
hlue and eosine, show the yellowish-white areas to he composed of hya-
line, necrotic liver cells. The necrotic cells stain deeply in the eosine,
and they are usually devoid of nuclei. They form, on the whole, more or
less definite foci of hyaline cells, into which leucocytes have wandered.
The largest area was '1 mm. in diameter, and the outlines of il u ric
formed by haemorrhage into the tissues, corresponding with the hyper-
semic zone spoken of above. The cells in this focus have lost their
nuclei, ami they arc intensely refractive. 51 any of the dead cells have
retained their individuality, and, indeed, their borders are more distinct
than those of the normal cells. Others, however, tend to become fused
together and to lose their individual cell outlines. Occasionally, outside
the main focus of hyaline cells, single necrotic cells occur which are
surrounded by quite normal ones. 5Ianv leucocytes have wandered into
this area of dead cells, and they are especially abundant at one place in
the focus in which the hyaline and necrotic cells are in process of dis-
integration. An exquisite nuclear fragmentation is to be observed
throughout this area.
Should the focus just described be compared to many similar foci
which occur in the livers of animals dead of inoculation with the bacilli
themselves, it will lie seen to contain more leucocytes (polynuclear)
within it. The explanation of this fact would seem to depend some-
what on the incubation time, but more on the progression or stage of
the necrotic process. Inoculation of the bacilli usually leads to death
in a very short time, often in twenty-four to forty-eight hours. In this
inoculation with the toxic products alone the incubation period ex-
ceeded three weeks. On account of this, time has been allowed for the
softening and disintegration of the dead cells, and leucocytes have been
strongly attracted to these foci.
In the kidneys, besides the condition described in the frozen sec-
tions, a slight fragmentation of the nuclei of the epithelium of the
tubules is encountered. The lungs exhibit areas of haemorrhage into
the alveoli, and in many of these there has been a desquamation of the
alveolar epithelium. Sometimes the desquamated epithelial cells are
quite normal in appearance, while at others they have fragmented
nuclei. The collections of lymphoid cells around the medium-sized and
larger bronchi show, however, more cells, the nuclei of which have suf-
fered in this way.
The blood-vessels of the tissues generally contain fewer leucocytes
in this instance than in those cases in which the bacilli were introduced
beneath the skin. By the latter method an intense local inflammatory
process is provoked, associated with the emigration of large numbers of
polynuclear leucocytes. In the former, in which the filtrate, free from
organisms, is used for inoculation, the local process is reduced to nil,
there is no emigration of leucocytes, and the disease is general from its
inception. This difference is sufficient to account for the occurrence of
leucocytes in the one case and its absence in the other.
It may be considered as established now that the toxic products and
not the bacilli themselves invade the tissues in diphtheria. This fact
would at once suggest that the general lesions (those produced at a dis-
tance from the seat of inoculation in animals, and the situation of the
local process in human beings) were the effects of the soluble poison
diffused through the body. Hence it was desirable to demonstrate
this assumption experimentally ; and it is not unimportant to know- that
the lesions in the tissues produced by the bacilli and the toxic principle
on the one hand, and the toxic principle alone on the other, are in per-
fect correspondence with each other. And, moreover, it would seem not
to be superfluous to emphasize the occurrence of definite focal lesions
in the tissues of the body, produced by a soluble poison circulating in
the blood.
Artificial Teeth from a Hygienic Point of View. — " It is common
experience among dentists," says the Lancet, " that a very large ma-
jority of artificial dentures worn are discolored and by no means devoid
of unpleasant odor. This lack of cleanliness, w hich arises sometimes
from neglect, but often from want of instruction on the part of the
dentist as to the necessary modus operandi, is a fruitful cause of inflam-
matory conditions. Debris of food mixed with saliva and mucus
accumulating on a plate rapidly undergo decomposition, with the result
of irritating the mucous membrane and producing a general inflam-
mation of the oral cavity. The oral secretions become altered and
vitiated, so as to cause dyspepsia, and caries of the remaining natural
teeth is set up, which proceeds with great rapidity, especially in
' clasp ' dentures, not from the friction, but because the inside of the
clasps most generally escape the brush. The materials used in the
construction of artificial dentures differ widely in their effect upon the
tissues with which they come in contact. A larger number of cases of
inflammation of the oral tissues occur where vulcanite is used as a basil
than with gold or other metals, and so prevalent is this inflammation m
the case of vulcanite that it has received the distinctive appellation of
' rubber sore-mouth.' Several reasons have been assigned for the
effects produced by vulcanite. Nearly all this material is colored with
mercuric sulphide (vermilion), which ingredient has been accused of
being the cause of trouble ; but an exhaustive investigation did not
substantiate this view, one particular point being that ' rubber sore-
mouth ' often occurred where black rubber was used, which contains no
vermilion. The porosity of vulcanite, especially when not sufficiently
vulcanized, renders it liable to retain deleterious material if not kept
scrupulously clean."
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THE NEW YORK MEDICAL JOURNAL, April 23, 1892.
(Original (Communications.
STATISTICS OF-
OPERATIONS UPON TUBERCULOUS HIP JOINTS.*
By CHARLES T. POORE, A. M., M. L)..
BURGEON TO ST. MART'S FREE HOSPITAL FOR CHILDREN. NEW YORK.
The following paper is based upon sixty-seven cases of
tubercular disease of the hip joint occurring- in children
from three to fifteen years of age, being all the cases oper-
ated upon from 187:i to January 1, 1892, and occurring in
hospital practice.
Sixty-live joints were excised ; in five, erasion was per-
formed ; in eight cases the trochanter major was trephined ;
and in eleven cases the central cavity of the femur was
cleaned out. In all the cases of excision the disease was
more or less pronounced, and always accompanied by ab-
scess.
It has been the rule to open all abscesses as soon as dis-
covered, and explore the joint if the disease is marked; the
parts were scraped or excised, and of late all tubercular
tissue has been removed as thoroughly as possible.
The joint was entered in fifty-one cases by the old excis-
ion over, or behind, the trochanter major and the diseased
parts were removed. In the earlier cases the upper part
of the femur was thrown out through the wound and the
parts divided with a saw. Later, the bone has been divided
in situ with a sharp osteotome and the head and neck then
removed ; the disturbance of the soft parts is much less by
the latter method.
Em- the last eighteen months I have used the flushing
gouge advocated by Mr. Barker, of London. It consists of
a Volkmann's spoon, with a perforation through the handle
and opening in the bowl of the spoon. The dotted lines in
the cut represent the perforation. The other end of the
metallic portion protrudes beyond the handle, and is pro-
vided with a button for the attachment of a long piece of
rubber tubing; it has also a binding screw for the purpose
of clamping the end of the tubing to the button. The in-
strument was copied from a cut in the British Medical
Journal, 1880, vol. i, p. 123, the only changes being the ad-
dition of the binding screw and the omission of the cut-off.
A long piece of [ndia-rubber tubing, attached to the
end of the gouge, goes to a vessel of sterilized water, in
which is dissolved some boric acid; the vessel is raised
higher than the operator, so as to give force to the current.
As the^infected tissues are scraped away by the spoon,
thev are swept out of the wound by the now of water; fur-
ther, the hot water tends to control haemorrhage. I have
found that this instrument affords a ready means to scrape
and clean out, not only joint, hut abscess cavities.
* Rend before the NTew York Surgical Society, December 24, 1891 .
In all recent cases the capsule and all infected tissues
have been removed as thoroughly as possible, the acetabu-
lum scraped, and carious bone about its rim removed. The
parts were then flushed with mercuric solution (1 to 1,000),
the wound partially closed with deep and superficial sutures,
leaving a large opening leading to its deepest portion ; this
was stuffed with iodoform gauze, and over this the usual
bichloride dressing. 1 have never seen any advantage in
closing up entirely the wound, or only leaving a small open-
ing for a drainage-tube. Whenever it has been done, sup-
puration and an accumulation of tubercular tissue in the
cavity left by the removal of bone has followed. It is dif-
ficult to get away all infected tissue, and I doubt whether
it is ever accomplished ; and a good, free exit for such ma-
terial is an advantage. I have also discarded the use of
drainage-tubes, trusting to ample openings and iodoform
gauze, and I think that my wounds have acted better since
adopting this method; at least there has been less after-
curetting than formerly. There is another point gained by
this method, and, that is, we get a good firm cicatrix above
the truncated shaft which not only binds the femur to the
pelvis, but also prevents, to some extent, the riding upward
of the shaft when any weight is borne by the limb.
In fifteen cases access was gained to the joints by an
anterior incision (Schede) made " on the outer side of the
crural nerve, a little below and half an inch internal to the
I anterior superior spine of the ilium, and passing vertically
l downward four or five inches. The internal border of the
sartorius is first exposed, then the rectus, outer border of
the ilio-psoas muscle," or the incision may be made from
the outer side and just above the anterior superior spine of
the ilium downward on to the capsule of the joint. I think
that the latter incision gives more room. The advantages
of this incision are many: it readily exposes the
joint without much disturbance of the soft parts; it
gives a better view of the capsule, bone, and sur-
rounding tissues. The joint can be cleaned out
more readily than by the lateral incision, and it is the only
method by which an erasion can be done without great dis-
placement of the head and neck.
I have adopted it in all cases except those in which there
are extensive sinuses behind and below the hip, or where
there is reason to expect profound changes in the articula-
tion. If, after gaining access to the joint by this method,
a lateral incision is demanded, it can be made without any
disadvantage to the patient. In regard to drainage after
this way of reaching the joint, if thought necessary, a rub-
ber tube can be passed out behind; but I have seldom used
one. Thorough curetting and flushing out with hot water
with partial closing of the wound and stuffing the rest w ith
iodoform gauze has, in the majority of cases, prevented an]
accumulation of matter. If the case seemed to demand In !
ter drainage I would prefer to make an ample incision be-
hind the joint and then keep it opened with iodoform gauze,
discarding the use of a drainage-tube.
In my early operations the wounds were stuffed with
>akum, then earbolized gauze w;is used :
Iressed with iodoform gauze.
balsam of I 'eru and
now all wounds
arc
450
POORE: OPERATIONS UPON TPBEIK 'PLOPS HIP JOINTS.
[N. Y. Med. Jock.,
In the early cases considerable elevation of temperature
was the rule, in the later the exception; in, the former class
considerable su ppuration always followed the operation; in
the latter it has been much less, and, in some cases, entirely
absent, depending upon the amount of disease and the thor-
oughness with which infected tissues could be removed. In
many old-standing cases a comparatively clean operation is
an impossibility, and suppuration, often profuse, must be
expected, and in this class the advantage of a large drain-
age opening is great as affording ample room for the escape
of pus and infective material.
The after-treatment is as follows : As soon as the patient
is returned to bed, extension and a long splint extending
from the axilla to the middle of the leg is applied, so as to
keep the limb at absolute rest, and these are kept on until the
wound has closed, the packing being removed and reapplied
as often as required. Considerable oozing and bloody serum
will saturate the dressings for a day after the operation, but
after that, if the case goes on well, the discharge is slight.
If at any time tubercular granulations make their appearance,
the patient should be placed under ether and the parts thor-
oughly curetted, any suspicious point being removed, either
in the bone or soft parts.
If there are abscesses in the soft parts about the dis-
eased joint, their cavities should be thoroughly curetted
with a flushing gouge and drained independently of the
joint cavity if possible.
Statistics. — In sixty-four cases only one joint was in-
volved, and in three both.
The head and neck were removed in thirty-six cases^
and in twenty-four the section was made below the trochan-
ter major. The head alone was removed in seven cases.
There were extensive bone lesions in thirty-six cases, while
in the remainder the disease was limited to the head alone.
The condition of the parts removed varied from exten-
sive infiltration and softening of the bone, with perforation
of the acetabulum, to simple caries of the head or tubercu-
lar abscess.
In fifteen cases loose bone was found in the cavity of the
acetabulum, and in seven the head of the femur was de-
tached. In five of the latter cases the operation consisted
only in the removal of the loose head and curetting the cavity.
In four cases there was pathological dislocation of the head
of the bone, or what remained of it, on to the dorsum of the
ilium, and in three of these the end of the femur was an-
kylosed in this position, dead bone being imprisoned by the
new tissue forming the bond of union between the shaft
and the pelvis.
In eleven cases the acetabulum was perforated, and in
nine intrapelvic abscesses were present. In one case the
gut and bladder were perforated by the abscess ; in one
only the gut, at what point could not be made out, but it
was probably low down, as in one well-formed faeces passed
out through the wound, while in the other water passed from
the perforated acetabulum out through the anus.
Secondary abscesses formed in quite a number of cases,
especially those in which the wound had been closed by
sutures and drainage-tubes used.
In ten rases the end of the bone had to be re-excised
after some time, and in thirty-five cases old sinuses cu-
retted on account of the appearance of tubercular granula-
tions.
Simple erasion has been performed in five cases, and by
this I mean that the joint has been opened by the anterior
incision, the capsule removed as thoroughly as possible, but
no bone operation of any magnitude done, the flushing
gouge and scissors being alone used. Of these, only two
patients have recovered without a regular excision, the re-
maining three coming to that operation.
The ultimate result in sixty-six cases is as follows. By
cure is meant that all sinuses have closed and there is no
symptom of trouble about the hip ; by relieved, that sinuses
are open :
There were thirty-two children discharged cured, twenty-
five died, three discharged relieved, two discharged not im-
proved, and four in the hospital.
Of those discharged relieved, in one the ultimate result
is unknown, one died from causes not connected with the
joint, and one, when last heard from, was evidently affect-
ed with amyloid degeneration.
Of those discharged not improved, one died shortly after
leaving the hospital, and in one the result is unknown.
Of the cause of death, fourteen died from amyloid de-
generation, one from amyloid degeneration and peritonitis,
two from general tuberculosis, one from acute nephritis,
one from septicaemia, one from heart failure, one from
coma (uraemic), three from meningitis, and one from ex-
haustion.
In three of the fatal cases the wound was soundly
healed and the children had the use of the limb some time
before their death.
In one case the knee joint on the opposite limb had to
be amputated on account of advanced disease of that articu-
lation. The time that elapsed from the time of operation
to the date of death varied from one day (the case of heart
failure) to five years, the average being seventeen and a half
months.
Of the cases of perforation of the acetabulum, seven
patients died and four recovered.
Of the two patients with perforation of the gut, one
died from heart failure soon after the operation ; the other
recovered and has had no further trouble. He has been out
of the hospital for three years, and is well.
Shortening. — There are two factors going to make up
the amount of actual shortening of the limb :
1. That dependent on the disease — atrophy and arrest-
ed growth.
•2. The amount of bone removed.
The first may amount to more than that due to the real
shortening of the femur from the removal of bone. Thus,
in a case not operated upon, the limb, after ten years, is
three inches shorter than the sound one.
Second, that due to the amount of bone removed. This
is always equal at least to the extent to which the shaft is
shortened, depending upon the point of section.
There must be some loss in the actual length of the
limb, even when the head alone is removed.
I can only find the shortening recorded in fifteen cases,
April 28, I892.|
POORE:
OPERATIONS rPON TUBERCULOUS 1I1P JOINTS
451
and at the time of discharge from the hospital it was as
follows :
In three cases it was three quarters of an inch, in five
an inch, in two an inch and a quarter, in two an inch and a
half, in one an inch and three quarters, in one two inches,
and in one four inches.
There is another factor that contributes much to the
difficulty in walking, and that is the riding upward of the
end of the femur upon the pelvis when any weight is borne
upon the limb and increases practically the shortening.
This riding upward is due to the loose connection of the
end of the femur with the pelvis. It sometimes amounts
to more than the actual shortening, as measured from the
anterior superior spine of the ilium to the malleolus, but it
varies much in different cases. I depend upon two factors —
first, when the section is made ; and, secondly, the amount of
cicatricial tissue formed about and above the truncated shaft
of the remur and its condition. If only the head of the
bone has been removed, the neck, unless it has been pulled
away by too heavy an extension weight, will be confined in
the cavity of the acetabulum by new connective tissue, and
no riding upward can take place. On the other hand, if all
the neck has been removed, and, further, if section has been
made between the trochanters, there is nothing to prevent
this displacement every time weight is thrown upon the
limb but the amount and condition of cicatricial tissue
around and above the end of the bone. For this reason I
think that the more of this kind of a buttress is formed
above the point of section, and the more compact it is, the
more useful will the limb be. Therefore no attempt should
be made to obtain immediate closure of the whole wound. It
may appear to be more brilliant surgery, but, from my own
experience, it is a detriment to the patient. There is
another practical point — namely, not to keep the end of the
bone away from the line of acetabulum by7 too powerful ex-
tension, or the cicatricial tissue formed will afford too lax
a bond of union between the end of the bone and the pelvis,
and a flail-like joint will be the result. A strong hip splint
should be worn for at least one year after a cure, in order
to prevent the new-formed tissue from being elongated.
Of the patients discharged cured, the present condition
of twenty-three is absolutely known : One is well eighteen
\ years after discharge ; one is well eleven years after dis-
charge ; two are well nine years after discharge ; one is well
■ seven years after discharge; two are well six years after
discharge^ one is well five years after discharge; one is
well four years after discharge ; one is well three years after
discharge; four are well two years after discharge ; nine
are well one year after discharge.
The amount of shortening in some of these cases has
increased, while in others there has been but little, if any,
change. One patient at the time of discharge had one inch
shortening; in eight years it has increased* to two inches and
a half; one patient at time of discharge had an inch and a
Quarter shortening, in eighteen months had an inch and
three quarters ; one patient at time of discharge had an inch
and a half shortening, at the end of six years two inches
and half shortening ; one at time of discharge had an inch
and a half, at the end of one year an inch and a half ; one
at time of discharge had an inch shortening, at the end of
five years had an inch and a half ; one at time of discharge
had an inch shortening, at the end of two years had an inch
and a half ; one at time of discharge had an inch shorten-
ing, at the end of eighteen months had an inch ; one at time
of discharge had three quarters of an inch shortening, at the
end of three years had an inch and a half ; one at time of
discharge had four inches shortening, at the end of fourteen
years had seven i indies shortening.
In the patient who at the time of discharge had four
inches shortening, at least half of this was due to atrophy
of the limb and arrest of growth. He now has seven inches
shortening. For a time he wore a high shoe and would get
along with but little difficulty, but he has discarded its use,
and now goes about with the aid of a crutch. He is able to
bear his weight on the limb and has considerable power
over it.
The usefulness of a limb after excision of the hip joint
depends chiefly upon the strength and firmness of the at-
tachment of the end of the femur to the pelvis ; the short-
ening, provided it is compensated for by a proper high
shoe, is not the main impediment to easy walking.
Among the lower classes it is often impossible to pre-
vail on the parents of these children to provide and keep in
repair a high shoe, and they go about either walking on
their toes with the foot in a position of talipes equinus, or,
if the deficiency is great, with a crutch or cane, so that the
best result of the operation is not obtained.
In those cases where much bone has been removed and
where extension has been so great that the bones have been
kept far apart, there is great danger that a Hail-like joint
will result, with no power in the limb to bear weight ; a
crutch is a necessity. On the other hand, if the parts have
been kept in good apposition — that is, the truncated end of
the femur well up — a flail-like joint is the exception. Some
of my cases, I know, use a crutch ; a few from necessity,
but with most of them it is due to the fact that they have
discarded their high shoe.
There is always some limp, a sinking down of the side of
the body on which the operation has been performed, due
often to the instability of the support. Notwithstanding
this, most of them are able to get about without discomfort.
In some cases there is no riding upward of the shaft, while
in others it is the chief cause of the difficulty in walking.
In many cases most of the normal motion of the limb can be
performed while the patient is on his back, while in others
flexion is difficult. The limb is certainly not so good as
one ankylosed at a proper angle. A successful erasion
gives as good a limb as after a cure by the expectant
method of treatment.
Cases in which the acetabulum is perforated are not
hopeless, provided good drainage is afforded, and this can
only be obtained by an excision, the section being made be-
low the trochanter major, no matter what may be the con-
dition of the head. The presence of amyloid degeneration
is not a contra-indication to excision, but rather an indica-
tion for it, provided the soft parts are not completely
riddled with abscess and the bones profoundly diseased ; in
such a case an amputation affords the best chance for sax ing
452
HOLSTER: ERUPTIONS FROM IODIDE OF POTASSIUM.
[N. Y. Med. Jouk.,
life. Disease of the pelvie bones is of grave import, and
these cases usually terminate fatally in my experience.
There are two operations connected with disease of the
lii|> joint that I wish briefly to refer to — namely, trephining
the trochanter major and neck, and cleaning of the medul-
lary cavity of the femur.
Macnamara and others, a few years ago, drew attention
to the fact that it was possible in cases of hip-joint disease
beginning in the neck to trephine the neck through the
trochanter major, and either remove the point of disease or
afford drainage to the bone, anil thus prevent the joint from
being infected.
1 have performed this operation upon eight children.
The indications are symptoms pointing to disease begi li-
ning in the bone, such as painful spasm and night cries,
tlir articulation itself not being involved.
The operation is easily performed by making an incis-
ion over the trochanter major, and then applying a three-
eighth-of-an-ineh trephine, so as to perforate the center of
the neck as far as possible without entering the joint.
This is then flushed out with mercuric solution, a small
Volkmann spoon passed in to discover if possible any soft
point, then a drainage-tube and iodoform, and, over all, the
usual dressing applied.
In four cases diseased bone was found; in the other
none. The immediate effect of the operation is always to
stop night crying and spasm, and diminish the tenderness
about the joint. The ultimate results were as follows: In
two there was no return of any disease ; the patients made
a rapid recovery and have remained well ever since. The
six other cases came to an excision, the pain after some
weeks returning and the disease following its usual course.
In the two patients discharged cured their histories were
such as to leave no doubt as to the nature of the disease —
articular osteitis. In some of the other cases I am now
satisfied that the joint was involved at the time of the opera-
tion, and that it had been delayed too long. Recently I
opened an abscess on the outer aspect of the thigh in a case
in which I had trephined the neck two months previous.
On tracing up the abscess, it was found that it had its
origin in the trephine cavity, and from it protruded tuber-
cular tissue ; with a small spoon tubercular bone was re-
moved. It is reasonable to suppose that the tubercular
foci in the bone were finding an outlet through the trephine
opening, and not into the joint. I think that my error has
been in not operating earlier. The operation is certainly
devoid of danger.
Cleaning out the Central Cavity of the Femur. — In some
cases of joint disease, after the removal of the head and
neck, the cut surface of the shaft presents a dark appear-
ance, the bone is soft and infiltrated, the periosteum is
thickened and easily detached, so that the whole shaft can
be easily forced out through the wound, leaving the peri-
osteum intact. If the medullary cavity of the femur is
reached l>y the section, it is found filled with dirty, dark-col-
ored material ; the external shell of the bone is thinned, of
a dark color, and soft. In cases where this condition exists
i lie upper portion of the wound may do well, but a sinus,
often several, will persist, through which the cut end of the
femur can be felt more or less eroded and from which the
periosteum has retracted. If the wound is opened and a
section made farther down, the same unhealthy condition
will be found, and in a short time the cvit end of the femur
will present a condition and appearance the same as before.
The wound will seldom close, and after a time amyloid de-
generation shows itself, followed by a fatal termination.
Since 1884 I have in all such cases made an opening into
the shaft of the femur on its outer aspect just above the
knee joint. Exposing the medullary cavity, a long probe,
to which is attached a piece of silk thread and to this a
long strip of iodoform gauze, is drawn through the whole
length of the cavity in the bone so as to thoroughly re-
move its contents ; it is then flushed out with bichloride
solution, iodoform dusted in, a drainage-tube inserted in
the lower opening, and the wound in the soft parts closed,
except where the drainage-tube protrudes. The result of
this operation is that all the diseased tissue is removed
from the medullary cavity of the femur, and, unless there
are other causes at work, the wounds close and recovery
follows.
In twenty-one cases this condition of the shaft of the
femur was found; in eleven, the central cavity was cleaned
out, and in ten no operation was done ; in the ten latter cases,
eight patients died and two recovered. Of the eleven pa-
tients treated as above described, two died and nine recov-
ered, one of the patients dying from heart failure twenty-
four hours after the operation; the other, three years later,
from amyloid degeneration, the femur giving no further
trouble. By recovery is meant that the excision wound
healed.
In one of the cases of recovery the whole shaft became
enlarged, but has never given any discomfort.
ERUPTIONS FROM IODIDE OF POTASSIUM,
WITH REPORT OF
A CASE OF DERMATITIS TUBEROSA I-ROM THE IODIDE *
By GEORGE D. H OLSTEN, M.D.,
ATTENDING PHYSICIAN FOR DISEASES OF THE SKIN,
BROOKLYN (E. D.) HOSPITAL DISPENSARY.
The study of eruptions produced by the ingestion of
various drugs has made rapid advances during the past few
years. Among these drugs iodide of potassium occupies a
prominent position, both on account of its frequent employ-
ment and because of its tendency to produce eruptions,
whether given in large or small doses, or for a long or short
period of time.
Iodide of potassium may produce a great variety of
eruptions, the recognition of which becomes of importance,
as the drug is employed so frequently in syphilitic as well
as other affections, and failure to distinguish between a
syphilitic or other eruption and one caused by the iodide
may be of serious consequence to the patient.
The history of a case lately under my care is as fol-
lows :
* Head before the Society of the Alumni of Charity Hospital, Marco
2, 1892.
April 23, 1892.]
IIOLSTEX: ERUPTIONS FROM IODIDE OF POTASSIUM.
453
G. H., aged sixteen months, was taken sick with symptoms
of coryza, followed by bronchitis, for which, among other reme-
dies, a saturated solution of iodide of potassium, two drops every
two hours, was ordered on April 5th. On the 8th an eruption
of small, isolated, conical-shaped, light reddish-brown papules
appeared on the face and extremities. The eruption increased
in amount and the individual lesions in
size. I first saw the case on April 23d.
During this time the general health of the
child had improved ; the coryza and
bronchitis had diappearcd, the appetite
had returned, and, except tor the erup-
tion, he was entirely well. The iodide
had been continued up to about a week
before I first saw him, and altogether less
than a drachm and a half of the drug
had been taken.
The lesions appeared on the face and
extremities, none on the body. On the
face they were on both cheeks and a few
on the forehead ; there were also a few
small spots on the sides of the neck.
Both arms and forearms from shoulders
to wrists were occupied by lesions, as were also both lower ex-
tremities from hips to ankles. The hands and feet were free.
On the legs the lesions were equally numerous on the posterior
as on the anterior surfaces, while on the thighs only the anterior
surfaces were affected, and much less than the legs, as regards
both number and size of the individual lesions. The upper ex-
tremities showed more lesions on the arms, both posteriorly and
anteriorly, while on the forearms the lesions were few.
The eruption was observed in all of its stages of develop-
ment, from a small pin-head papule to a lesion an inch in diame-
ter and half an inch in height. The eruption began as small
elevations on the skin, most of them being of nearly normal
color ; others slightly pinkish and some white. To the touch
they felt solid, and were movable with the skin, but gave the
impression of being deeply seated. There was no surrounding
erythema. Lesions beginning as vesicles or pustules were not
seen.
As the papules became larger they began to fiatten on the
top, the border became smoothly rounded, the entire lesion was
raised above the surroundingskin, and the surface was smooth and
shining; the color varied from pink to yellowish-brown. When
the lesions reached the size of a split pea the surface would become
studded here and there with minute whitish specks, more numer-
of thin white fluid exuded. The largest of these tumors was on
the outer side of the left leg (Fig. 1) and measured about an inch
and a half by an inch, and over half an inch in height. It was
oval in shape, the surface smooth and .shining, and of a dark-red
color. This was studded with a large number of these minute
pustules. Pressure over the growth did not squeeze out any
us around the periphery of the papules. These specks varied
in number, being proportionately more numerous on the larger
lesions, although there were some on which no such white specks
could be seen. On puncturing these specks a minute quantity
fluid, but on puncturing these individual specks, minute drops of
whitish fluid exuded.
Two dajs later all of the lesions, and especially the smaller
ones, had increased very much in size; some had doubled ; oth-
erwise their appearance was as before.
On the 27th of April the smooth covering of the growth on
the leg had come off, on removal of a mercurial plaster which
had been applied, and small openings discharging pus were pres-
ent; several days later this tumor presented a fungating appear-
ance, being composed of small, round, dark-colored, fleshy pro-
jections, between which pus welled up on pressure. These
fleshy projections bled easily on being touched. Several of the
other growths on tins left leg went through the same process
as this one just described, but remained smaller in size.
The accompanying photograph (Fig. 2) — taken May fith, a
month after the iodide was first given, and more than two weeks
after its cessation — shows several minute lesions on the legs
which have appeared during the past week. These, beginning
as papules, soon after formed a tiny vesicle on each of their
apices which in a day or two changed into a pustule, but the
solid character of the lesion beneath always remained evident.
The large lesions on the leg had assumed a fungoid or cauli-
flower appearance ; the papillary growths were bathed in pus,
which welled up alongside of them, and they bled easily
on pressure or handling.
A week later the larger lesions on the face had be-
come distinctly flatter, looking like patches of roughened
leather set on the skin.
The treatment used in this case was: On the lower
extremities, first a mercurial plaster, but this was soon
discontinued and the growth destroyed by repeated ap-
plications of dichloracetic acid. To the face, applications
of ichthyol in watery solution were made, using at first
a six-per-cent. solution which was subsequently increased
to thirty per cent. This was also applied to one arm. As
the lesions on the face and upper extremities were nearly
the same as regarded size, appearance, and character, the
right arm was left untreated for some time in order to
observe the natural course of the disease and for pur-
poses of comparison. In every instance the lesions treated
with ichthyol solution healed more rapidly than those not
so treated. Some of the lesions were also treated with sali-
cylic acid in ointment and also in collodion, but, while this
HOLSTER: ERUPTIONS FROM IODIDE OF POTASSIUM.
[N. Y. Med. Jodk.,
removed the horny portion of the epidermis, it had no effect
on the deeper portion of the lesions. The involution of the
smallest lesions, which were not treated, was very slow. The
action of the dichloracetic acid was not altogether satisfac-
tory; the amount of tissue destroyed was superficial, making
repeated applications necessary. As the lesions extended deep-
ly into the corium, scars were a natural sequence, but, as
they now are smooth and show no tendency to contract, that
feature offsets the superficial action of the acid.
The most usual form of eruption produced by iodide of
potassium is one resembling ordinary acne, but differing
slightly from that disease in appearing not only on the face,
shoulders, back, and chest, which are the seat of acne vul-
garis, but also on other portions of the body — the extremities
— and in the individual lesions being smaller and without
induration ; in the contents being thinner in consistence and
the tops more acuminate — differences, though very slight,
still sufficient to cause an inquiry as to whether the
iodide had been taken or not. They also resemble the
acneform eruption of bromide of potassium, but are
slightly smaller; the reddened base is generally absent,
but when it exists the pustules are more acuminate than in
bromide acne.
Vesicular and bullous eruptions are among the rarer
forms of skin lesions. The vesicles may be preceded by an
erythema, as in a case of Berenguier's (l), in which numer-
ous small discrete vesicles seated on a bright scarlet surface
had appeared suddenly.
The bullous form is more infrequent than the vesicular.
Morrow (2) has reported an interesting example seen by
him at Charity Hospital, in a man aged fifty, who had,
three days after beginning the use of the one-in-two solu-
tion of iodide of potassium, a drachm three times daily, an
erythematous condition of the face with vesico-pustules.
The drug being continued, the dermatitis increased and the
vesicles developed into bullae. Ten days later the face and
neck were bright red and swollen, and the integument was
infiltrated ; the eyelids were oedematous, preventing the eyes
from being opened, and the ears were swollen and covered
with crusts from ruptured bullae ; the forehead was thickly
studded with pustules. On the dorsal surface of the hands
and wrists there were several bullae, one on the right hand
being as large as a pigeon's egg and surrounded by smaller
ones. The mucous membranes were free.
McGuire (3) has reported a case of bullous eruption due
to iodide of ammonium. After about twenty grains of the
drug had been taken a vesicular eruption appeared on the
scalp, face, and shoulders, which disappeared in a few days
on discontinuing the medicine. Two weeks later the iodide
was again given, and after four doses — in all, five grains —
had been taken, the eruption reappeared and attained its
maximum development in ten days after the drug was
finally discontinued.
The special characteristics of this form are the develop-
ment of bulla; of varying size, commingled with vesicles and
pustules. Usually beginning as minute vesicles on an ery-
thematous surface, they increase rapidly and develop into
regularly rounded or globular bulla}, which may remain
single or coalesce with neighboring ones until they attain
an enormous size. All portions of the body have been the
seat of this bullous form.
Besides the varieties already mentioned, others have
been seen and noted, such as an erythematous form occur-
ring usually on the forearms, face, and anterior surface of
the chest, either diffused or in discrete and irregular spots,
or in circumscribed patches.
Rugg (4) reports a case in which, after four grains had
been taken every four hours for several days, large red
papules, with a shotty feel, came on the wrists and forearms,
and from this a uniform erythema, followed by free desqua-
mation, spread all over the body.
The erythematous form may subside in a short time or
become intensified and develop into a papular or urticarial
form, which may be general over the body, but is more
usual on the hypogastrium and extremities; it is said to
differ from ordinary urticaria in being brighter — of a rose-
red — and of more exaggerated development.
Taylor mentions a case in Charity Hospital in which
the urticarial eruption was confined to the face, the neck,
and the backs of the hands and wrists ; it was always re-
produced after a few fifteen-grain doses of the drug, and
vesicles usually appeared on the tops of some of the wheals
within forty-eight hours.
A purpuric or haemorrhagic form was first described by
Founder (5), who regarded it as rare, having seen only some
fifteen examples. It has also been reported by Vidal (6),
T. C. Fox (7), Stephen Mackenzie (8), and others. Mac-
kenzie's case was that of a child who died after two grains
and a half had been taken in a single dose. Silcock (9)
reports a case in which the purpura disappeared upon the
administration of arsenic, to reappear when that remedy was
discontinued. In a case of Kuess's, haemoptysis and metror-
rhagia also occurred. Morrow (10) redeveloped the purpura
four different times, thus proving its relation to the iodide.
It was reproduced within forty-eight hours by five-grain
doses of the drug.
Fournier describes this eruption as consisting of discrete,
miliary, millet-seed-sized to lentil-sized spots, usually round-
ed, more rarely oval or discoid in form. Its seats of predi-
lection are the legs, more especially the middle three fifths,
avoiding the knees and feet, and it develops more profusely
on the anterior than on the posterior surface. As many as
a hundred discrete spots may be found on each leg. These
purpuric eruptions usually appear in from one to three days
after the commencement of the administration of the drug,
and rapidly reach their height ; if the medicine is discon-
tinued, they disappear in two to three weeks.
A polymorphous form is also encountered, in which the
eruption presents at the same time papules, tubercles, and
pustules, the papules representing an early stage, the pust-
ules a later one, in the same process. Ecthymatous con-
ditions and furuncles may be evolved from hard papules.
1'ellizari (11) has reported a case in which three eruptive
forms were present at the same time. There were three
slightly elevated papules, of a strawberry-color and slightly
rough, on the left forearm near the wrist ; on the arms and
legs there were several bulla?, half an inch in diameter, sur-
rounded by a circumscribed dark-red areola, and three tu-
April '2:1, 189&]
HOLSTER: ERUPTIONS FROM IODIDE OF POTASSIUM.
455
mors larger than a nut deeply imbedded in the subcutaneous
tissue. All of these elements disappeared rapidly on dis-
continuing the iodide, the bullae leaving white scars. The
eruption was redeveloped several times by the readministra-
tion of the drug, each renewal being accompanied by fever.
G. H. Temple (12) reports a sixty-year-old man with ter-
tiary syphilis who received three times daily a grain (0-6)
of iodide of potassium, with the effect that after eight days
his hair and beard, normally white, became of a rose- red
color. At the same time his linen and the handkerchief
with which he wiped off the sweat also were dyed red. On
his leaving off the medicament, the abnormal color gradu-
ally faded away, but returned on renewal of the drug.
This variety of the iodide eruption which I present
was, I think, first described by Fisher (13) in 1859. lie
states that " a nodulo-pustular form is very rarely observed,
and occurs most frequently in scrofulous individuals, usu-
ally upon the upper half of the body."
Hutchinson (14) reports a case which he saw of a syphi-
litic man affected with very severe iodism, with the develop-
ment of a pustular eruption ending in the patient's death.
On the face, arms, legs, and body there were innumerable
purple or red, irregular elevations, raised a quarter to half
an inch above the level of the skin ; semi-fluent, fluctuant, or
firm, varying in size from that of a hazel-nut to that of a
walnut — one even measured two inches across — some with
surfaces entire, others with the summit abraded and dis-
charging a thin, yellowish, offensive stuff. They were both
single and conglomerate, and had an inflamed areola.
Tilbury Fox (15) reports two cases; the first, that of a
cachectic, feeble syphilitic, who was ordered ten grains of
iodide three times daily, which four days later was increased
to fifteen grains. The following day there appeared on the
forehead, both eyelids, and scattered here and there on the
face, scalp, and neck, small vesiculated spots similar to acne.
The drug being continued, the following day the acne pim-
ples had become large vesicles filled with a milky fluid, soon
changing into thin, inodorous pus. The medicine was
stopped, but the eruption increased in size, and some lesions
burst, and showed a base covered with florid granulations.
The second case was that of an old woman for whom a
mixture was ordered containing among other ingredients a
small quantity of arsenic and three fifths of a grain of iodide
to each dose. On the twenty-fifth day after she began taking
this medicine an eruption of pale, shotty spots was observed
over the forehead and the backs of the hands. These le-
sions increased in extent and intensity, though the medicine
was stopped. On the seventh day after the appearance of
the eruption bullae had funned, which on the eighth ap-
peared to be solid and inflamed, and were very painful to
the touch. Four days later the eruption had almost entirely
disappeared. A week later the medicine was again given,
when, after five days, the same papular eruption appeared
which developed into large, severe ecthymatous elevations
Containing dark, puriforra fluid.
Duhring (16), under the title of Circumscribed Phleg-
monous Dermatitis due to Iodide of Potassium, describes a
case in which, after the drug had been taken for several
weeks, there occurred on the patient's forehead a slightly
inflammatory annular patch, half an inch in diameter, con-
sisting of a number of pin-head-sized vesico-pustular lesions
looking like an irritated patch of ringworm. This extended
rapidly, and several similar patches occurred elsewhere
upon the face. At the end of a fortnight the original lesion
was nearly two inches in diameter, and consisted of a cir-
cumscribed and defined, irregularly rounded, elevated, firm,
inflammatory, violaceous patch. The center was depressed
and crusted, while the periphery was studded with numer-
ous deep-seated, yellowish, sebaceous-looking pustules, pre-
senting an acneform appearance. On raising the central
crust, a dark-red, shining, mamillated, or warty surface ap-
peared, and on cutting into the pustules they bled, but did
not exude their contents.
Besnier (17) has reported two cases as acne anthracoide
iodopotassique, in which the face and thorax were covered
with veritable tumors of variable volume, of a reddish, cop-
pery hue, flabby, almost fungous, and presenting punctate
depressions or vacuoles analogous to those of anthracoid
furuncle. It was impossible to express their contents, and
incision gave exit only to blood.
Dr. Taylor (18), under the title Dermatitis Tuberosa of
Iodic Origin, has reported the case of a syphilitic man in
whom the lesions produced by the drug were tumors, deep
red in color, of round or oval outline, in size from that of a.
three-cent piece to that of a quarter-dollar, pedunculated
and sessile. The tumors on the side of the forehead and
by the side of the nose were pedunculated and mushroom-
shaped ; the rest of the tumors had sharply defined vertical
margins. A thin inflammatory areola was present around
each lesion. In structure the tumors were soft, spongy,
and non-resistant, the larger ones conveying to the fingers
a sensation of bogginess and false fluctuation. On the
surface of most of the tumors were a number of minute
cribriform openings, from which a small quantity of pus
could be made, on pressure, to exude, which, drying, formed
crusts of various sizes. Each tumor reached its full devel-
opment in about a week, after which the openings disap-
peared ; the surface of the tumors now presented a uniform
warty appearance. Pigmented patches, decidedly but super-
ficially atrophied, were left. No subjective symptoms be-
yond a slight pruritic heat were complained of, and there
were no systemic disturbances present.
Hallopeau (19) mentions the case of a man, aged forty-
eight, who had an eruption on the face and upper extremities
consisting of deep-lying scars and vegetations, which had
been preceded by bulla? and vesicles. The cicatrices were
isolated and depressed, with thin centers, and occasionally
covered with crusts and vegetations; they were roundish in
outline; in size, from that of a split pea to that of a small
coin. A few were elevated above the surface. From the
patient's history a diagnosis of syphilis was made, and a
gramme of iodide a day was given. After several days
there appeared on the backs of the hands blebs w ith cloudy
contents, which dried into a crust; on other portions of tin-
body the same appearances were manifested. After the
patient had taken the iodide for fourteen days it was sus-
pended, and after three weeks' time again given, when, on
the fourth day, with intense fever, the vesicular formation
456
HOLSTEN : ERUPTIONS FROM IODIDE OF POTASSIUM.
[N. Y. Med. Joph.,
again began. A third trial resulted in the same manner.
There was therefore no longer any doubt that the eruption
was due to the drug, or that the scars and vegetations
were the sequehe of the blebs, which after drying left a scar,
and from these scars the vegetations gradually developed.
Hyde (20) has reported two cases also, under the desig-
nation of Dermatitis Tuberosa due to the Ingestion of
Iodine Compounds. The first was that of a girl, aged
eighteen, who took, three time daily, teaspoonful doses of
a solution containing a grain of iodine and a drachm of
iodide of potassium to the ounce. On the third day, at-
tended with moderate coryza, there appeared a number of
semi-solid papules on the forehead and two or three on the
dorsum of the hands. In the evening of the same day the
entire scalp and forehead were covered with small and large
lesions of the same general character, rapidly increasing in
size.
The drug was continued for nearly a month longer, with
constant aggravation of the cutaneous symptoms. Dr.
Hyde describes her appearance when he first saw her as fol-
lows :
The scalp was completely covered with closely packed
pigeon's egg-sized tubercles, the matted hairs projecting through
and between them, all smeared with a puriforro mucus mixed
with the fatty base of the salve. The forehead, temples, cheeks,
neck and back were generally and symmetrically covered with
superficially seated, small egg-sized, semi-solid, discrete and con-
fluent, oval, roundish, and irregularly shaped tubercles, of a
dull-reddish hue, some standing out to the extent of several
millimetres prominently from the general surface. Their surfaces
were usually flattish, occasionally fissured and macerated with a
mucoid secretion. Many certainly resembled large-sized secret-
ing condyloma. None were true bullae, and none when punct-
ured extruded their contents. Some had the appearance of an
irregular furrow filled with muco-pus at the summit, the gen-
eral line of this furrow corresponding to the axis of the long,
oval-shaped lesion, resembling the sausage-link tumors of my-
cosis fungoides. They were evidently masses of softish, vascu-
larized epithelium, secreting superficially a thick, grumous. mu-
coid fluid, in places commingled with pus.
There were two large, compound nodules on the flexor
aspect of the right forearm, two on the left hand, and sev-
eral on other portions of the body. Iodine was detected
chemically in the urine. The patient's general health was
excellent. The eruption promptly subsided as soon as the
drug was stopped, leaving dull-red infiltrations in patches,
covered with light and dark crusts superimposed upon a
secreting surface. Here and there slight and superficial
atrophy of the skin in patches resulted. After two weeks'
time the drug was again administered, with the result of
producing the same eruption.
The second case was that of a male infant, seven months
old, who, since the age of seven weeks, had been taking a
medicine containing, among other ingredients, a grain of
iodide of potassium in each dose. When first seen he was
covered on the scalp, face, ears, neck, and forehead with
an eruption made up of closely packed, confluent, softish,
and semi-solid tubercles, of a deep mahogany-red hue, dry
and moist in different parts, of about the size of a large
pea; roundish or oval in shape, quite commonly flattened
at the apices, often presenting a depression similar to an
umbilication, in places smeared with mucus. Some of the
lesions suggested in appearance that they had boiled-sago-
grain contents; in others, far more numerous, they were
simply closely packed, Mat-topped, deep-red tubercles of the
sort already described, looking very much like mollusca,
with semi-solid contents. They were not interspersed with
pustules or bulla?, and bore no signs of traumatism.
The pathology of iodide eruptions has been studied by
different observers. Thin (21), in examinations of a bullous
eruption, found the sebaceous glands unaffected, but the
walls of the blood-vessels of a limited area were diseased,
permitting the escape of blood, which displaced the con-
nective tissue, pierced the rete, and accumulated under the
horny layer of the epidermis. He considers that the in-
jury in its mildest form is seen in acne where limited oede-
ma with congestion of the vessels occurs ; and that in severer
grades, as in bullous and pustular eruptions, there is an
effusion of serum, with more or less of the formed elements
of the blood ; while in the worst forms, as in iodic purpura,
destruction of the walls of vessels and haemorrhage takes
place.
Vincent Harris (22) also reports a case in which he
found disease of the blood-vessels, which were numerous,
dilated, and sheathed with exudation corpuscles, the effusion
being greatest in the papillary layer, which was flattened out.
The sebaceous and sweat glands were unaffected.
On the other hand, Adamkiewicz (23) considers the
sebaceous glands the starting-point of the eruption, because
he has detected iodine in the contents of a pustule ; but,
as Duckworth (24) records a case of eruption on cicatricial
tissue, where probably glands no longer existed, and as
eruptions have also been noted on the palms, where normally
sebaceous glands do not occur, this theory can not be con-
sidered correct.
As to the causation of these eruptions : In a certain
number of cases, especially of the severe haemorrhagic and
bullous affections, grave structural changes have been found
in some of the internal organs, notably the kidney and
heart. This has led to the opinion by some observers that
deficient elimination should be held responsible for the skin
manifestations. Iodide of potassium is a diuretic by its ir-
ritant action on the glandular portion of the kidney, and the
iodide can be detected in the urine. Large doses will often
produce free diuresis where small ones fail, so that, as has
occurred on a number of occasions, an eruption was not
produced while patients took large quantities of the salt,
but, on their ceasing its ingestion or diminishing the dose,
the toxaemic effect on the skin appeared. But deficient
elimination is not present in every case, and that theory
will not explain why eruptions have occurred when only a
small quantity has been taken, or a small single dose, as
in Mackenzie's case. We are therefore compelled to fall
back on the term idiosyncrasy.
These idiosyncrasies are not manifested by the skin alone,
but other tissues may be involved, either in connection with
the cutaneous lesions or singly ; as, for instance, the con-
gestion, with excessive secretion, of various mucous mem-
branes, which is of more frequent occurrence than skin
April 23, 1892.]
HOLSTEN: ERUPTIONS FROM IODIDE OF POTASSIUM.
457
rashes, and differs in being- more transitory ; while an erup-
tion on the skin persists, and usually increases in severity,
so long as the drug is continued and even after it has been
suspended.
There is perhaps no drug respecting which idiosyncrasy
is more common, and the dose required to show this idio-
syncrasy so variable. In some only half a grain may be
necessary, while other persons may be so tolerant of its
effects as to take with impunity over an ounce a day. From
this peculiar tolerance and variability in the amount taken,
the conclusion can be drawn that it is not the amount of
iodide given to patients, but the effects produced, which
should be watched, for in some patients a small dose of a
few grains daily will achieve more good results than a large
quantity given in another case.
Hallopeau (19) has reported a case in which he regarded
the idiosyncrasy as having been developed gradually through
the long previous use of the drug.
The various cutaneous manifestations of iodide of po-
tassium are supposed to be due to the contained iodine,
but that the physiological effects of iodine and iodide of
potassium are identical has not been proved. H. C. AVood
(25) quotes Kammerer and Professor Binz as asserting that
iodides are decomposed in the tissues, and act by liberation
of the contained iodine. With these views Wood is not in
accord, holding that they have not been ptroved, an(j main-
taining, further, that the general professional opinion is
that iodine and iodide of potassium differ in their thera-
peutic action. Gaglio (26), from his studies of this subject,
concluded that the assertions of Binz were not proved.
Iodide is absorbed, and is eliminated chiefly by the
kidneys, and to a greater or less extent by all the mucous
membranes and the skin.
Ehlers (27) made seventy quantitative examinations of
the urine, and found that an average of eighty-two per cent,
of the iodide could be recovered. When symptoms of
iodism developed, the urine showed a diminished elimina-
tion of the drug, the iodism disappearing as its elimination
increased.
Professor See (28) asserts that the elimination takes
place slowly and intermittently, so that the drug when given
continuously accumulates in the system. He further states
that it can be found in the saliva after it has disappeared
from the urine. The iodine seems to be eliminated partly
as an alkaline iodide and partly in organic combination.
It has been further affirmed that the iodide of ammo-
nium stands first in its irritating property and the iodide of
potassium next, and that the sodium salt is the least irri-
tating of all. That the large number of cases reported are
in connection with the potassium salt is probably due to the
fact that this is employed far more frequently than the
two others. In Duffey's (29) case iodide of potassium
twice developed an eruption; the sodium salt was then em-
ployed, in doses of ten grains three times daily for eight
days, without producing any eruption. The ammonium sail
was then given in two ten-grain doses, and within twelve
hours the eruption manifested itself.
Ringer (:S<>) reports a ease in which thirty grains a day of
the iodide of potassium after five days developed a pustular
eruption ; this disappeared in a few days after stopping the
drug. The ammonium salt was then tried, but, after the
second dose of ten grains, redeveloped the eruption. The
iodide of sodium was then substituted in the same doses
and continued for four days, but without bringing out the
eruption, which, however, promptly reappeared after a sin-
gle dose of the iodide of ammonium.
Lesser (31) reports a case of erythema nodosum which
came on in two days after the internal use of the iodide of
potassium. The use of the sodium salt was followed by
the eruption in a less severe form. The treatment, after
being changed to the subcutaneous use of the potassium
salt, was not followed by any eruption.
Bibliography.
1. Berenguier. Des eruptions provoquees par Vingestion de.
medicaments, Paris, 1874.
2. Morrow. Jour, of Cutan. and Ven. Diseases, April, 1886
3. McGuire, J. C. Jour, of Cutan. and Gen.-ur. Dis., May
1888.
4. Rugg, B. A. Lancet, June, 1879, p. '869.
5. Fournier, A. Revue mens, de med., 1877, p. 653.
6. Vidal. Jour, of Cutan. and Ven. Dis., 1866, p. 81.
7. Fox, T. C. Brit. Med. Jour., 1879, p. 813.
8. Mackenzie, Stephen. Med. Times and Gas., February and
May, 1879.
9. Silcock. Med. Times and Gaz., Oct. 31, 1885.
10. Morrow, P. A. Drug Eruptions, New York, 1887.
11. Pellizari. Archives of Derm., July, 1881, p. 264.
12. Temple, G. H. Brit. Med. Jour., August, 1891.
13. Fischer. Wiener med. Woch., 1859, p. 470.
14. Hutchinson, J. Report of the Medical and Surgical
Registrars of the London Hospitals for 1875. Again reported
in Archives of Surgery (English), July, 1889, with two colored
plates.
15. Fox, Tilbury. Clin. Soc. Trans., vol. xl, 1878, p. 40, with
colored plate.
16. Duhring, L. A. Med. and Surg. Rep., Dec. 13, 1879, p.
516.
17. Besnier, E. Annales de derm, et de syph., 1882, p. 168.
18. Taylor, R. W. N. Y. Med. Jour., Nov. 3, 1888.
19. Hallopeau. Annales de derm, et de syph., May, 1888.
20. Hyde, J. N. Med. News. Oct. 13, 1888, p. 411.
21. Thin. Med. and Chirurg. Trans., 1879. p. 189.
22. Harris, Vincent. Trans, of the Path. Soc., 1879, p . 476
23. Adanikiewicz. Charite Annalen, 1876, vol. hi, p. 381.
24. Duckworth. Trans, of the Path. Soc, 1879.
25. Wood, H. C. Therapeutics ; its Principles and Prac-
tice, seventh edition.
26. Gaglio. Lo Sperimentale, July, 1887.
27. Ehlers. Hospitals Tidende, 1889, No. 1.
28. S6e. Lond. Med. Rec, vol. i, p. 757.
29. Duffey. Dublin Jour, of Med. Sci., April, 1S80, p. 273.
30. Ringer. Practitioner. London, 1872, p. 129.
31. Lesser. Deutsch. med. Woch., 1888, No. 14.
3lo Lafavette Avenue.
Cocaine Fatalities. — "At a recent meeting of the Societc de Chiiur-
gie of Paris, a letter from Professor Germain See was read in which lie
stated that he had collected particulars of two hundred and sixtv acci-
dents with hypodermic injections of cocaine, of which twenty-one termi-
nated fatally. The professor considers the drug to lie dangerous, and
pronounces himself opposed to its employment.'' — Druggists Circular
and Chemical Gazette,
458
KWNEAR: ASTHMA.
|N. Y. Meu. Joce.,
ASTHMA :
ITS PURELY NERVOUS ORIGIN AND
AN EFFICIENT TREATMENT.
By B. O. KINNEAR, M. D.
Any chronic disease which interferes with the entrance
of oxygen into the air cells and proves an obstruction to
the natural aeration of the blood is a cause not only of dis-
tress to the patient from his inability to respire freely, but
every function of the body becomes slowly and steadily dis-
eased. This may not be shown for some time in asthma,
for the attacks are at first transient, and for a long period the
system seems to recover its full vigor between the seizures.
Nevertheless, after a lapse of years, changes in nutrition
take place throughout the whole body. Constipation is
apt to follow, more or less emphysema results, the heart
is weakened, and the right ventricle hypertrophied from the
unusual effort required during the spasmodic arrest of
normal inspiration.
The digestion is disordered. The nervous system de-
teriorates. There is more or less constant discharge of
mucus from the lungs ; the muscular system is enfeebled,
and nearly all the processes of nutrition, secretion, and ex-
cretion are vitiated. The bronchial mucous membrane is
thickened or hypertrophied.
Asthma is one of the most painful and distressing dis-
eases known, yet in itself comparatively rarely proves fatal ;
yet there is evidently no doubt, from the general impair-
ment of health, that it paves the way for other disorders to
invade and assault the already debilitated citadel. These
new assailants are noted as the cause of death, whereas had
not asthma been present the patient might have recovered.
My intent is to present the treatment of asthma and its
complications by the use of cold over the spine, as well as
to give an explanation of why cold over this region will in
many cases restore to full health, and in others repair the
diseased condition inducing the spasmodic onslaught, and
reinvigorate the whole body to such a degree as to consti-
tute almost a new life ; or to revivify the vital powers to
such an extent that life becomes once more "worth liv-
ing," and not a perpetual struggle for breath, as it prac-
tically ultimates in in a large number of unfavorably pro-
gressive cases.
Dr. Alfred L. Loomis, on page 59 of his Text-book of
Practical Medicine, says : "The spasmodic contractions of
the bronchial tubes may be regarded as due to a neurosis,
which depends upon the existence of a peculiar diathesis.
Some muscular spasm or contraction of the circular mus-
cular fibers of these tubes is the essential element of the
asthmatic paroxysm, and the consequent narrowing of the
tubes is a necessary mechanical result."
Ross, in his Diseases of the Xervous System, page 522,
declares: " The symptoms are mainly caused by spasmodic
contraction of the muscular tissue of the bronchial tubes.
" The asthmatic paroxysm may be excited by direct irri-
tation of the trunk of the vagus; in other cases it is caused
by a reflex irritation of the sensory nerves of the lungs
themselves, or of those of remote organs, such as the stom-
ach, the intestines, or uterus.
" An attack sometimes results from central irritation,
and it is then generally associated with hysteria."
Flint, in his Practice of Medicine, remarks, page 216:
" It is a neuropathic affection, tonic spasm of the bron-
chial muscular fibers being induced by a morbid excitation
through the nervous system.
" The exciting causes of the paroxysms doubtless exert
their effect through the excito-motory or reflex function of
the nervous system.
" Asthma is always nervous."
lie also states on page 218: "Mental emotions some-
times act as an exciting cause of the attacks."
And every physician of middle age is aware that severe
shock may give rise to asthma in persons who had previ-
ously been quite free from the disease. A noticeable
symptom given by nearly all authors as preceding the at-
tacks is a much increased flow of limpid urine, which occurs
frequently in nervous people not subject to asthma.
Ranney, in his Lectures on Nervous Diseases, page 723,
informs us that " spasmodic asthma may be benefited by
galvanism of the neck.
" Its beneficial effects are probably due to changes in-
duced in the vagi."
The evidence that this disease is of nervous origin, af-
fecting the circular bronchial muscles, might be greatly
multiplied both from authoritative writings and from the
records of individual observation; but enough testimony
has been adduced to prove that the direct factor giving
rise to the asthmatic paroxysms is the narrowing of the
smaller bronchial tubes, so that oxygen can not enter the
air cells and be absorbed into the circulation, such closure
beinir due to contraction of the muscular fibers around the
bronchi.
It therefore clearly appears that if a reasonable hypothe-
sis can be presented demonstrating why these small muscles
contract, " by a morbid excitation through the nervous sys-
tem " the profession will approach nearer than hitherto to
a knowledge of the originating cause of asthmatic spasms,
and will thus be so much closer to an appropriate and ef-
fective treatment.
Gray, in his Anat&my, gives us the information that
" anterior and posterior branches from the pneumogastric
follow all the ramifications of the bronchi." This fact goes
to prove that some of the "central cells" of the pneumo-
gastric are the active cause in effecting contraction of these
tubes — first, because a nerve separated from its center loses
its function ; second, when the center is hyperactive, this
activ ity is declared at its terminal end, as illustrated and
confirmed constantly by reflex action, and, as the writer
believes, from central action also, in nervous people,
demonstrated in motor nerves by twitching of muscles in
various parts of the body, and particularly in chorea. The
next question that confronts us is: What condition of these
central nervous cells will give rise to contraction of the
bronchial tubes '. The reply naturally is : An increased ac-
tivity of the cells, an irritation of them, an overflow of
nervous force from them to the bronchial muscles. What
can induce this abnormal overflow \ What power irritates
the cells to so energetic an action, with such distressing
April 23, 1892.]
KINNEAR: ASTHMA.
459
results ? It seems to me that the only reasonable and
natural explanation lies in the fact of an abnormal circula-
tion of the blood within the group of cells of the pnenmo-
Brastric issuing nerves to the ramifications of the bronchi.
A condition of dilated blood-vessels, with a hyperactive
circulation through the center, would allow of increased
nutrition of the cells and a greater impulsion from them than
is natural in health ; therefore a stimulation of their func-
tion, and more forcible nervous currents sped to the muscles
about the bronchi, with a resulting contraction and narrow-
ing of the tubes; and, as an outcome, the attack of asthma.
If this hypothesis is true, then any remedy or remedies
which will contract the dilated blood-vessels in these cen-
ters, either directly or by withdrawal of the excess of blood
from them, thus allowing of arterial closure to normal cali-
ber, will most quickly relieve the acute seizure, and, if the
blood can be prevented from returning in undue quantity
to the center, hinder the recurrence of this painful and dis-
tressing disease. That just such an effect may be induced
I have now proved in a number of people suffering, many
of them for years, from asthma.
My own belief is that there are two varieties of nerve
involved in the production of the disease. They are the
motor, already spoken of, and the accompanying trophic or
nutritive nerve, which latter terminates in the cells of the
lungs and the cells of the bronchial mucous membrane. It
is now very generally recognized that every motor nerve has
a second function — viz., that of regulating nutrition to all
cells in the area over which the motor is distributed, so
that nothing new is advanced by this statement ; but a sat-
isfactory explanation is thereby added to the pathological
effects produced upon the bronchial mucous membrane in
many cases. The effect here referred to is the congestion
and thickening of that membrane in many chronic cases,
this very turgescence adding a further obstruction to the
entrance of air into the air cells ; as well as from the hyper-
ajsthesia of the mucous membrane induced, causing, when
irritated by smoke, dust, ipecac, odors of various kinds,
sudden colds, etc., a reflex spasm of the tubes through the
sensory nerves. These trophic nerves appear, therefore, to
arise in the same group of pneumogastric cells as the
motor. The accompanying cut, used in ray article read
before the Hay Fever Association, in Bethlehem, N. H., in
1890, and produced in their report of 1890 as one of four
illustrations of the nervous centers involved in that disease,
demonstrates very clearly the hypothesis advanced. The
centre, B, shows a group of pneumogastric cells distribut-
ing nerves to the bronchial mucous membrane, X, X, X, X,
causing, when the center is hypenemic, tumidity of the
raucous membrane of the tubes.
The central group of cells, C, the nerves of which ter-
minate on the muscular stria' surrounding the tubes Y, Y, Y ',
when hypenemic, gives rise to contraction of the muscles
and the closure of the tubes.
The expansions, O, represent the air cells.
By excluding, then, the excess of blood from these re-
spective centers, their function is brought to the normal ;
consequently the muscles about the bronchi expand, and
the swelling of the mucous membrane subsides.
This result is attained by ice applied over the spine in
such a way that, the circulation being naturally distributed
over the body, the congestion of the centers is at once less-
ened in the acute attack ; and, by an expert application of
the same remedy, used for weeks in some cases and for
a much longer time in others, the blood is kept away in ex-
cess from the centers, the weakened coats of the arterioles
within them recover their normal, or almost normal, con-
tractility, and either great relief or a cure is obtained.
But this is not all the good which may be assured by
the use of this remedy.
If there are cold extremities, as is frequently the case in
asthmatics, they are warmed and strengthened also by the
increased nutrition due to a larger supply of blood.
If there is indigestion, the condition may be much bene-
fited through a more active circulation induced in the gas-
tric glands, the pancreas, and liver, resulting in a largei
supply of digestive fluids. The secretions throughout the
intestines are increased for the same reason, and peristaltic
action renewed by reinvigoration of the muscles around
the intestines, and constipation relieved, if present, to a
great extent, in some cases wholly. These results are due
to the fact, proved now by hundreds of eases, that ice over
the spine dilates the arteries throughout, the body, distrib-
uting the blood to organs and tissues where there has been
an insullicient supply.
The excessive secretion from the bronchial tubes, a very
distressing factor in chronic forms of the disease, is largely
diminished also by ice over the spine.
460
KINNEAR:
ASTHMA.
[N. Y. Med. Jodh.,
By the relief to the contraction of the tubes and the
subsidence of tumidity of the bronchial mucous membrane,
the hypersensibility of the whole tract is lessened, so that
reflex spasms are much less liable to take place.
Reflex spasms also, from indigestion and impacted rec-
tum, disappear as well by the relief given to these condi-
tions.
It is most astonishing and delightful to witness the
change from deficient to healthy action in various organs,
as well as a return to normal nutrition and strength through-
out the whole body, under the expert use of cold over the
spinal nervous centers, due in large measure to the distri-
bution of a sufficient circulation to parts of the economy
where it has been less than normal, and, oppositely, the ab-
straction of blood from other portions of the same where
circulation has been excessive.
Many people who have lost weight rapidly regain it,
and stouter persons lose flabbiness and become solid to the
touch, with a great addition to the physical strength.
While the writer is convinced of the truth of the hypothe-
sis set forth, he does not expect to convince his medical
confreres of the same by an essay, yet, from the results ob-
tained in the following cases, he hopes to induce those who
have time for study to investigate Dr. Chapman's system
for themselves in reference to the treatment of asthma,
and, in fact, in reference to the general treatment of dis-
ease, which the author of this paper has found of immense
service to himself, as well as to patients suffering from a
variety of complaints.
I hold, with Dr. Chapman, that the health of the body
is regulated and controlled by the combined normal action
of five sets of nerves — viz., the sensory, the motor, the
trophic, the sympathetic or vaso-motor, and the nervous
supply to glandular organs, which latter may be accounted
as a division of trophic nerves, as they have to do with se-
cretion and excretion.
And, finally, that a limited or excessive amount of blood
circulating within their centers constitutes not only disease
in the centers, but through that abnormal condition disease
is invariably demonstrated at the termination of their nerves.
The application of ice over the spine is always soothing
and agreeable when necessary, but particularly to those
people who are always chilly and nervous. It relieves the
surcharged nervous centers of their blood in such cases, and
warms and nourishes the whole body.
Case I. — Mrs. , of Boston, Mass., sixty years of age ;
treated in 1882. She had been a sufferer from asthma for six-
teen years, the disease increasing in intensity year by year until
at the time of examination she was confined to her bed three or
four days out of each week, with dreadful distress during the
whole attack. She had become emaciated to such a degree that
the husband of the patient remarked to me : ''Doctor, my wife
is but a bag of bones now, and you will freeze her to death by
applying ice over her spine." He, however, decided to try the
remedy. The appetite was very poor, and she suffered greatly
from indigestion. The whole body was cold to the touch, but
the legs and arms especially so. The pulse was rapid and weak,
the bowels were constipated, and the patient was exceedingly
nervous. Ice was applied in a full-length bag, extending from
the fourth cervical to the third lumbar vertebra, and used four
hours a day, an hour at a time. The patient was wheezing at
the time of the first application, which discomfort was relieved
during the first hour, and the patient's nerves were much
soothed as well.
The progress upward was most rapid and well pronounced
from the outset of treatment. Some attention was given to the
digestion, and a few laxative cholagogue pills were used during
the first few weeks. Her appetite speedily improved, and she
gained very fast in weight. The body and extremities became
permanently warm. The general physical weakness disappeared
wholly. Natural action of the bowels gradually recurred. The
pulse beat much more strongly and regularly. The general
nervous hyperesthesia departed and the paroxysms of asthma
grew less violent and frequeDt, while their duration was short-
ened to scarcely an hour at a time after three months' treat-
ment. She used to say : "Doctor, directly I find the attack
coming on I apply the ice and it is at once checked, passing
rapidly away." This patient was practically well in six weeks,
and during the rest of her life remained almost wholly free
from the disease and its distressing results. She died some
four years afterward from another disease.
I should consider that the emaciation, weakness, dys-
pepsia, constipation, etc., relieved also by the treatment,
had been wholly caused in this patient by the severe and
protracted asthmatic paroxysms, interrupting free oxygena-
tion of the blood, therefore vitiating its quality and so
hindering normal nutrition throughout the body. Secre-
tion and excretion could not be sustained naturally. This
result illustrates the rapid benefit which is obtained by the
treatment in a case of uncomplicated asthma in a person
of originally strong constitution.
Case II is that of a boy of about twelve years of age,
treated in the Catskills during August of 1885. He was the
son of the man in charge of a New York fishing club, and in-
herited the disease from his father, a man of about forty-five
years of age. The father had been afflicted with asthma since
early boyhood, and was of an exceedingly nervous tempera-
ment. The boy seemed well and full of life and spirits, but
suffered with nocturnal attacks frequently for several successive
nights, lasting from about midnight until daylight. He used a
ten-inch ice-bag between the shoulders, from about the first
dorsal vertebra downward, twice a day and for three quarters of
an hour at a time for a few days. Afterward once a day was
found sufficient to check the attacks and lengthen the periods
between them. He used the bag by my advice for several
months. I heard of him again in 1887 as quite well. When
the bag was applied the first time his attack was relieved and
he was sound asleep in fifteen minutes. This case is particularly
interesting as being one of hereditary asthma.
Case III. — Mrs. D., sixty-six years of age. living in Boston,
had been troubled with asthma for many years, particularly in
damp weather. For several years has had chronic bronchitis.
The heart is weak, the digestion poor, the circulation feeble, and
there is a tendency to constipation. A son of hers, a physi-
cian, died of consumption. He was a very large man, and until
attacked looked the picture of health. This patient was much
benefited by the use of ice over the spine from the second
dorsal to the third lumbar vertebra. The spasmodic seizures
were much relieved in duration, frequency, and intensity. The
large amount of watery mucus usually coughed up daily greatly
lessened and the appetite and general strength improved. She
used the treatment for more than a year under my care, at
times remaining quite free from the disease for weeks together,
a most unusual experience; but she had to use the bag steadily
April 23, 1892.]
CARR: THE NATURE OF INFLAMMATION'S.
461
three or tour times a week to retain the improvement. She
then removed to Concord, N. 11., since which date I have heard
nothing from her. The results achieved appear to the writer
satisfactory when her age is considered.
Case IV is that of a shop girl, naturally delicate, and over-
worked during the two preceding years. She had a large num-
ber of fainting spells, a weak heart, a poor digestion, was ex-
ceedingly nervous, and was troubled with constipation and dys-
menorrhea. She also had frequent headaches. The treatment
had to. be used witli great care in this case, as the patient was
so thoroughly exhausted, and it was necessary to her support
that her work should be continued. The use of the ice was com-
bined with tonics and laxatives, and she gradually improved in
all respects, and at the termination of eighteen months was as
well as she probably ever could be. The asthma had quite gone;
her nervous condition was much improved. The bowels only
needed occasional assistance. Menstruation was normal, her
circulation was good, and she was enabled to perform her daily
work without great fatigue. Her headaches were less frequent
and her sleep refreshing.
Case V was that of the brother of an old professional friend,
lie was forty-three years old. Had suffered from asthma many
years. When examined he was in a pitiable condition. He had
not been free from the asthma for three months, was greatly
emaciated, and had a constant cough night and day, which would
continue hour after hour, and had almost completely prostrated
him. He was suffering from night sweats, with some slight rise
of temperature. There was no consolidation of the apex of
either lung. There was a good deal of frothy and mucous expec-
toration. His appetite was capricious and small. His bowels
were constipated, and his legs, arms, feet, and hands cold. The
whole external surface of the body had a bluish tinge. Ice was
used night and morning for an hour and a half over the last
eight dorsal and first three lumbar vertebras. In three weeks'
time he recovered almost full strength, with a great increase of
weight, a good appetite, and the only trace of asthma left was a
slight wheezing on over-exertion. Against my own judgment
he persuaded me to let him take a journey and do some impor-
tant business requiring fatiguing exertion. Almost immediately
after his return he was attacked most violently with all his
former symptoms, and rapidly retrograded to his former condi-
tion. The treatment was carefully continued for some time, but
without good effect. I discontinued the use of the bag, feeling
that his vitality was at too low an ebb to afford him benefit.
He died some months afterward.
My impression is that, could the patient have continued
to rest after making his remarkable gain for some months,
he might have fully recovered ; but, having a wife and chil-
dren dependent upon him, he felt that as soon as he had
gained he must use his strength, and in consequence re-
lapsed.
There is no doubt that a fruitful source of the spas-
modic seizures of asthma is bodily exertion, and an uneasy
mental condition another.
Case VI— Mr. F. G. L., fifty years old, examined in July,
1888. Has had asthma for forty-four years. The disease has
increased in violence, particularly during the past two years.
Has not now been free from asthmatic breathing for six months.
There are frequent and exceedingly violent nocturnal spasms of
the disease. The only relief to be obtained of late at these times
has been given by injections of morphine, one third of a grain,
atropine, one one-hundredth of a grain, often twice in the night.
The patient is learning to depend on opium for relief. He suf-
fers with great mental depression. The apex of the head espe-
cially is abnormally hot. The digestion is not so good as for-
merly. The bowels constantly tend to a more severe constipation*
The legs and feet are a good deal cooler than the upper body,
but very much colder during the nocturnal attacks. For two
months at Bar Harbor this gentleman required constant atten-
tion. The first improvement noted was a better circulation in
the lower body, while the ice-bag, when applied over the dorso-
lumbar region, soothed the patient, frequently checked the at-
tacks, and enabled him to do without morphine. His appe-
tite and digestion began to improve. The head became much
cooler and the spirits improved. After his return to Boston the
general strength increased, and during the past two years he lias
never had to resort to morphine. The spasmodic attacks have
been infrequent and much less violent. He has continued the
treatment at intervals, and while he will probably never fully
recover from the disease, he is much stronger than for several
years previous to treatment, unless he be subject to great and
long-continued bodily fatigue, mental strain, or exposure to cold
or damp.
I believe not only that the attacks may be held in abey-
ance, but that they will lessen in number and severity with in-
creasing age. The arterioles in the pneumogastric center will
never probably, after forty-four years' dilatation, contract to
the normal ; but, by a sufficient use of the treatment to keep
the circulation throughout the body properly distributed,
thereby both withdrawing excess of blood from the centers
as well as nourishing and strengthening the whole physical
framework, comparative freedom from the nocturnal attacks
may be assured, and a state of health secured. In one of
my cases of hay fever treated during the season of 1891 the
asthma concurrent with the nasal trouble in this patient was
wholly relieved.
46 West Seventeenth Street, New York.
THE NATURE OF INFLAMMATIONS
IN THE LIGHT OF RECENT DISCOVERIES.
By W. P. CARR, M. D.,
PROFESSOR OF VISCERAL ANATOMY AND DEMONSTRATOR OF ANATOMY
IN THE MEDICAL DEPARTMENT OF COLUMBIA UNIVERSITY, WASHINGTON, D. C.
So much of the mystery connected with this subject
has been cleared away by the investigation of recent ob-
servers that we are now in a position to drop much of the
old mysterious technology in regard to inflammation and
to explain its varieties and phenomena as clearlv and ration-
ally as we can explain any biological process.
Before beginning to discuss the subject in a connected
manner, I will make the following propositions, which I
consider either as axioms or as propositions proved, and
acknowledged as proved, by the majority of the profession.
I. All inflammations are, strictly speaking, local, as we
know of no disease in which all the l issues of the body are
inflamed. Even if specific fevers be regarded as inflamma-
tion, or fermentation, of the blood, having in addition in
many instances lesions of solid organs or tissues, we must
remember that the blood is only one of the many tissues of
the body, and luematitis is as much a local affection as
peritonitis.
II. The cll'ccts of local inflammations mav become gen-
eral in at least three ways. First, by the action upon the
462
GARR: THE NATURE
01 INFLAMMATIONS.
[N. Y. Meu. J<h;h.,
nervous system of septic poisons absorbed into tbe blood.
Secondly, by direct injury or irritation to the nerves in the
inflamed area, causing shock, pain, loss of sleep, and reflex
disturbances of the general nervous system. Thirdly,
through the drain of suppuration.
III. Every cell in the body is directly or indirectly
under control, more or less complete, of the nervous system.
This includes the blood cells, which are controlled indirectly
by the vaso-motor nerves.
l\r. The following phenomena of acute inflammation
have been actually observed- — viz., a dilatation of the capil-
laries of the part, a slowing of the current, accumulation of
leucocytes around the periphery of the vessels, complete
occlusion of the vessels in places by the leucocytes, stasis,
clearing of the lumen of the vessels by the passage into the
tissues of these aggregated cells, escape of plasma into the
tissues, transformation of escaped cells into connective-
tissue cells, and, in septic inflammations, the presence of
bacteria in the interior of escaped white blood-cells, some-
times showing evidence of degeneration or digestion by the
cell.
V. The escape of leucocytes from the blood-vessels and
their transformation into connective tissue also take place
normally and in normal tissues.
VI. The escape of plasma also takes place normally for
the purpose of bathing and nourishing the cells of the body,
and is returned to the blood-vessels by means of the
lymphatic circulation.
VII. The plasma that escapes in inflammation serves as
a culture medium for the escaped round cells, and' exerts a
germicidal action upon bacteria.
VIII. This escape of blood elements,- which is the es-
sential feature of inflammation, is therefore only an exag-
geration of a normal process.
IX. Aseptic inflammation can be caused only by de-
struction or irritation of tissue by mechanical or chemical
means, or by heat, cold, or electricity, under conditions that
prevent the access of bacteria. But any aseptic inflamma-
tion may quickly become septic by access of germs to the
tissues.
X. Aseptic inflammation is only a process of repair, and
consists essentially of a replacing of destroyed tissue by
connective tissue formed from the colorless blood-cells.
Aseptic inflammation of a low degree may be indefinitely
prolonged by the circulation in the blood of some toxic
•substance, purely chemical, which continues by its presence
to irritate or destroy tissue. Otherwise, aseptic inflamma-
tions either become septic or result in repair, or what we
term resolution. This repair may be delayed by lowered
vitality of the tissues, and in case of bone injury by lack of
bone-forming material in the blood plasma.
If we consider these propositions proved, as I think we
must, then we may give a more definite explanation of
aseptic inflammation than has yet been done.
Take, for instance, a contusion with subcutaneous
laceration of tissue. The injured afferent nerves carry an
impulse to the vaso-motor centers (we need not now con-
sider where these are situated), and through the vaso-motor
nerves the capillaries are dilated. This dilatation causes a
slowing of the blood current, and either opens pre-existing
stomata in the capillary walls, or causes a relaxation and
separation of the single layer of cells forming these walls,
so that plasma begins to flow out through these openings.
Many of the openings become choked by the colorless cor-
puscles that come lazily floating in the periphery of the
slow blood-current and are swept into the openings or
stomata by the outgoing plasma. Other leucocytes catch
against these, and the vessel becomes entirely occluded in
places. Stasis results. But the cells finally pass out by
amoeboid movement or are forced out by the blood
pressure, the lumen of the vessel is re-established, and the
current begins again. The cells after their escape wander
about for a time by their inherent power of amoeboid
movement, nourished by the plasma that accompanies them,
and which continues to pass out of the vessels and be ab-
sorbed by the lymphatics ; but, finally, they become fixed,
shoot out processes, and are thus transformed into connect-
ive tissue. It is possible that these ("ells may proliferate
after their escape, and that there may also be proliferation
of the older connective-tissue cells, but I regard this as im-
probable. The new connective tissue is laid down around
capillary loops that shoot out from the blood-vessels just as
they have been seen to do in the developing chick, and thus
the destroyed tissue is replaced. Such cells as were killed
in the original injury break down and form a mass of debris
that is carried off by the lymphatics or absorbed by leuco-
cytes as food. This debris has been called pus ; but it is
not what we commonly understand by pus, and should not
be so called. The amount can not exceed the amount of
tissue originally killed, and if the tissues remain aseptic, it
is always completely absorbed. Not only so ; this absorp-
tion must precede the connective-tissue formation, and the
amount of new connective tissue usually corresponds to the
amount of tissue destroyed. Sometimes, however, when
there is more irritation of nerve terminals than destruction
of tissue, the- new connective-tissue formation may be ex-
cessive. Particularly is this the case when the nerve irri-
tation is increased by some form of chemical toxajmia, in-
testinal toxaemia, lithiasis, etc.
Aseptic inflammation, however, almost invariably termi-
nates in rapid resolution, and leaves little trace behind.
But any inflammation may become septic. And undoubt-
edly in open wounds this result is usually brought about by
contact with some substance containing germs upon its sur-
face. Barely germs are deposited in the wound from the
air or from particles of dust floating in the air. Still more
rarely, we must believe, with all the evidence before us, true
auto-infection takes place from germs floating in the blood
of the individual. We can readily understand how this
occurs in those diseases where pathogenic organisms are in
the circulation, and it is more than probable that even in
the blood of apparently healthy individuals some of the
milder kinds of pathogenic germs may occasionally be
found. Such germs are not vigorous and are not able to
harm active cells, but, when brought in contact with injured
cells and dead debris, may multiply, become vigorous, and
cause serious results. They may cause suppuration, or may
seriouslv interfere with the healing of the wound without
HE NEW YORK MEDICAL JOURNAL, APRIL 30, 1892.
( ASK III.
a
Anril B3, 1892.]
CARE: THE NATURE OF INFLAMMATIONS.
403
causing suppuration, especially if the tissues are already
weakened by .malnutrition or toxaemia. Pyogenic bacteria
may also gairi access to subcutaneous lesions through micro-
scopic abrasions of the cuticle, or, as recently pointed out
by Dr. Welch, of Baltimore, from the deeper layers of the
epiderm itself. Dr. Welch, in a paper read before the Con-
gress of American Physicians and Surgeons, recently an-
nounced the discovery of a germ, very much like the Staphy-
lococcus pyogenes a/bus, almost invariably present in the
deeper layers of the epiderm, not amenable to washing or
superficial disinfection, and capable of producing pus under
favorable conditions, lie regards it as the usual cause of
stitch abscess. He has also made the following interesting
observations : Healing by first intention is not proof that
no organisms were present, as he has found germs in the
serum from such wounds. They were never abundant,
however, nor of a virulent kind. He also finds that the
power of a germ depends largely upon the amount of poi-
son it carries with it, and that if germs are freed from the
culture medium, rich in poison, in which they have been
developing, they are much less active. He also finds the
blood serum to have antiseptic properties, and that some
tissues are much more resisting to germs than others in the
•same animal.
Thus the peritonaeum was able to dispose of twenty times
as much of a certain culture fluid, containing pyogenic bac-
teria, as was required to cause suppuration in the eye of the
same animal.
We must conclude, therefore, that the tissues of the
body are able to kill and dispose of a certain variable num-
ber of most kinds of bacteria, and that this power is modi-
fied by at least six factors — viz. :
1. The kind of tissue. 2. The condition of the tissue
as to vigor of its cells and antiseptic properties of its blood
plasma. 3. The kind of germ. 4. The number of germs.
5. The condition of the germ, both as to vigor in multiply-
ing and producing poison, and as to whether or not it is
accompanied by a quantity of its poison, and thus armed
and enabled to destroy at once a number of cells in its im-
mediate vicinity, and thus gain time for reproduction.
Therefore, when germs gain access to an area of inflam-
mation, we are confronted by a very complex problem.
If a limited number of germs be present, if they are not
too vigorous in producing poison, and if this poison is not
of too virulent a kind, they are eaten by the white blood-
cells that come pouring from the vessels, or are killed by
the blood serum, and find their way into the leucocytes by
chemotaxis; and the result is the same whether we call it
phagocytosis or chemotaxis. The germs are destroyed and
resolution and repair take place, as in aseptic inflamma-
tions.
But in other cases the germs are too powerful. They
kill the cells by the excretion of poison, and this may take
place after the germ has got inside the cell. Should this
state of affairs occur in the deeper tissues, those cells in the
center of the inflamed area are killed, and can not, of
course, form connective tissue ; but those around the pe-
riphery make their usual change into connective tissue, and
thus wall up the pus and germs, forming an abscess. Here,
shut up with their own excretions, the germs may, after a
longer or shorter time, die, and the fluid in the sac become
absorbed, leaving a cheesy mass that may remain indefi-
nitely. More or less of the poison, however, passes by os-
mosis or is forced by pressure through the abscess wall, is
absorbed into the lymphatics, poured into the blood, and
gives rise to systemic symptoms by its action on the nerve
centers.
In other cases the inner layers of the sac are killed by
the virulence of the poison, and form fresh pabulum for
the imprisoned germs, while fresh layers of cells are con-
tinually deposited on the outside. Thus the abscess grows
until some surface is reached upon which it may burst.
In such cases as this we have practically an aseptic in-
flammation, around and outside the abscess wall, caused and
maintained by the chemical poison transuded or forced
through the wall from the active p°ison factory within,
while the wall checks the movements of the germs and pre-
vents a general and rapid spread of the inflammation.
After the abscess breaks, if not into some cavity, the *
larger portion of the germs and the poison are extruded
and usually the cavity- soon closes, largely by contraction of
its walls, partly by formation of connective tissue, which is
now produced more rapidly than it is destroyed. But
should the abscess break into a cavity, such as the perito-
naeum, the germs, finding themselves in new pabulum, and
already armed with a large amount of poison, increase rap-
idly and overwhelm the system by the rapid production of
their deadly excretion. Unless this is promptly removed,
there is but the faint hope for the patient that the germ
may succumb to the combined action of its own poison and
the antiseptic serum, before the organism attacked.
That this fortunate termination may ensue is probable,
in some instances, when even the peritonaeum is invaded by
pyogenic organisms. It must be due to the fact that the
germ, when weakened by the antiseptic serum, is even more
susceptible to its own poison than the patient ; that recovery-
takes place from typhoid fever and other specific diseases.
Otherwise the germs would continue to increase ad infini-
tum, or, at least, until the death of the patient. It is well
known that many germs are readily killed by their own ex-
cretions. Those that produce lactic acid are readily killed
by lactic acid ; those that produce substances like carbolic
acid are readily killed by carbolic acid.
But we may have a form of septic inflammation where
the germs are so active and where their poison is so vio-
lent that the cells are killed too quickly, and the inflam-
mation extends too rapidly, for any limiting wall to be
formed. Such inflammation is produced by the erysipelas
germ when once it has become lodged under the skin in the
cellular tissue. Here, again> our only hope is that the germ
may succumb first to the combined power of its own poi-
son and the antiseptic action of the lymph or that it may
at least become so enfeebled as to die without leaving
progeny.
Diffuse suppuration may also be produced bv slow and
comparatively mild germs when the tissues of the body are
much enfeebled by malnutrition, haemorrhage, shock, etc.,
or by the action of a poison — such, for instance, as the ah-
464
DANIELS: HYGIENIC CLOTHING.
[N. Y. Med. Joob.,
sorption of ptomaines from the intestine. Here the inflam-
mation fails to be limited because the cells of the body are
too feeble to act promptly, and, perhaps, because the blood
plasma has lost its antiseptic properties.
On the surface of a tissue, or in open wounds, the pro-
cess is modified by the fact that the germs and their poison
arc free to flow away from the body with the pus, and, as
there is no pressure, there is little absorption of poison.
Hence it takes a large area of superficial inflammation to
produce systemic symptoms, and, as the absorption is slight,
the destruction of cells is less active than the process of re-
pair. Consequently, unless we have to deal with germs of
unusual virulence, such as those that produce hospital gan-
grene ; or, unless the tissues of the body are so feeble as to
allow of phagedenic ulceration, the destroyed tissue is en-
tirely replaced by connective tissue, and we have what we
call healing by second intention. In those exceptional cases,
however, the destruction will continue to spread until the
germs are destroyed by caustics or other means.
Thus we see that every form of acute inflammation is a
conservative process ; and not only so, that it is only an ex-
cessive activity or exaggeration of the normal functions of
living tissue.
We see that it consists essentially in all cases of a war-
fare of the blood elements upon bacteria and a replacing of
destroyed tissue by round cells from the blood. Why, then,
may we not define inflammation as an unusual activity and
concentration of blood elements in a tissue for the purpose of
repairing injury or repelling noxa? ?
And this definition need not be limited to acute inflam-
mations. For, although there is some difference of opinion
about chronic inflammations, particularly the scleroses, as
to whether connective tissue is formed first, or whether de-
struction of cells takes place first, we must regard them as
conservative. We must admit that they consist in a forma-
tion of connective tissue or glia, either for the purpose of
replacing destroyed cells or for the purpose of walling out
and limiting the action of a poison or irritant, a noxious sub-
stance.
Understanding thus the nature of inflammation, and be-
ing able to explain all its varieties, we are surely in a better
position to prevent the dangerous forms — to prevent, in fact,
all forms except the aseptic, and to guard against the dan-
ger of auto-infection and of operating upon tissue enfeebled
by the absorption of ptomaines from the intestine.
HYGIENIC CLOTHING*
By FRANK H. DANIELS, A. M., M. D.,
VISITING PHYSICIAN TO THE MANHATTAN HOSPITAL.
At the present day scientific clothing enters so largely
into the modern economy that it is important for us medi-
cal men to look back occasionally and review the progress
which has been made in this department. Not as tailors,
to l>c sure, lor with the a'sthetic side of this question I will
* Head before the Harvard Medical Society of New York City, Janu-
ary 9, 1892.
not weary you. But as hygienists it is necessary for us not
only to be abreast of the times, but also to understand
thoroughly what is required of good clothing, and how that
requirement can best be filled. The outer clothing may in-
deed adorn ; the inner must be made on scientific princi-
ples, and the latter is of the greatest importance.
An ideal clothing is one which does not interfere with
the functional activity of the skin, while it at the same time
protects it against sudden changes of temperature. The
normal skin is an excretory as well as a secretory organ,
excreting a small quantity of salts, a little carbonic acid,
and a large quantity of water in the form of perspiration,
both sensible and insensible. The total amount excreted
by the skin is, as you know, large, and has been estimated
by Sequin as eleven grains in a minute, or more than two
pounds in the twenty-four hours.
The quantity of carbonic acid thrown off by the skin
of a healthy man in twenty-foui hours is about one hun-
dred and fifty grains; this quantity is, however, increased
by a rise of temperature or by exercise. The quantity of
oxygen consumed is about the same ; but the thickness of
the human epidermis affords a great obstruction to any
diffusion between the gases in the blood of the cutaneous
capillaries and the external air.
According to Foster, the proportion of the insensible to
the sensible perspiration will depend on the rapidity of the
secretion in reference to the dryness, temperature, and
amount of movement of the surrounding atmosphere. Thus,
supposing the rate of secretion to remain constant, the drier
and hotter the air, and the more rapidly the strata of air
in contact with the body are renewed, the greater is the
amount of sensible perspiration which is by evaporation
converted into the insensible condition ; and, conversely,
when the air is cool, moist, and stagnant, a large amount
of the total perspiration may remain on the skin as sensible
sweat.
This excretory activity, or, as we shall call it, the func-
tional activity of the skin, is usually dependent upon vas-
cular dilatation. When the excretions of the skin are di-
minished, the cutaneous blood-vessels are usually found con-
tracted ; and vice versa, when these vessels are dilated, the
excretions become increased in quantity. And by this con-
traction and dilatation of the cutaneous blood-vessels, with
the accompanying variation in the quantity of perspiration,
the temperature of the body is largely regulated. It is
found that the excretory organs of the human body will do
each other's work to a certain extent, and that, if the skin
is not acting normally, its excretions are taken care of by
the other excretory organs — viz., lungs, kidneys, and bow-
els. The balance of health is, however, under these cir-
cumstances, disturbed, and such vicarious action will not he
long tolerated.
It will be seen from the above how important is a nor-
mal cutaneous function, and how far-reaching is any dis-
turbance of its proper activity. It may be stated as facts,
firstly, that, excluding contagious diseases, all acute forms
of disease may be avoided if the skin is acting properly;
secondly, all chronic diseases may be held in check by
keeping up the functional activity of the skin. Whenever
April 23, 1892. J
DANIELS: HYGIENIC CLOTHING.
465
a patient, suffering from chronic disease of any internal or-
gan, seeks our advice, we always do everything in our power
to keep the skin in an active condition ; and we find that,
when the latter gives out, our treatment is of little avail.
The function of the skin being threefold (an excretor
of gases, an excretor of fluids, and a heat regulator), a per-
fect clothing must answer a threefold requirement, and we
will now investigate the properties of fabrics in general use
with regard to their porosity, hygroscopic qualities, and
heat-conducting qualities.
Linen, silk, cotton, and wool are the only materials we
shall consider, as they are the only ones which are now, or
ever have been, used to any extent in clothing.
No kind of clothing fabric yields warmth ; it can only
preserve the natural warmth of the body, and prevent its
radiation or conduction, and this it does well or badly ac-
cording as it is a bad or good conductor of heat.
Count Kumford was the first to experiment in this direc-
tion, and he proceeded as follows : Several thermometers
with long stems were wound about with a certain weight of
the different materials to be tested, and, after being plunged
into boiling water, and allowed to cool to a certain point,
were then placed in a freezing mixture. The time required
for the different thermometers to reach certain points was
then noted, and in this way he was able to determine which
material protected the bulb of the thermometer best from
the surrounding medium, or, in other words, which was the
best non-conductor of heat.
These experiments show that raw silk, as spun by the
worm, is the best non-conductor, and that raw wool is
the next best, followed by silk thread, spun wool, cotton,
and linen. Raw silk can not be used, so that wool stands
at the head of our list, and raw wool stands to spun wool as
a non-conductor as eleven to nine — i. e,, it is over twenty
per cent, better.
Parkes's experiments have shown that the hygroscopic
properties of wool, as compared with cotton or linen (and
these two stand about the same in this respect), are twice
as great when weight is compared with weight, and four
times as great when surfaces are compared. Perfectly dry
wool can absorb fifty per cent, by weight of water, and re-
tain from twelve to eighteen per cent.
The function of perspiration, as well as of heat regula-
tion, takes place best when the fabric next the skin is a
thoroughly porous one ; and Pettenkofer's experiments
have shown that, if heavy flannel be taken as allowing one
hundred parts of air to pass through, linen will allow sixty
and silk only fourteen parts to pass through.
The Medical Record for January 15, 1887, said : " There
is no doubt that wool stands at the head of the materials
out of which clothing is made. Its virtues depend upon its
being a poor conductor of heat, its porosity allowing the
passage of the exhalations from the skin, its power of ab-
sorbing moisture, and giving it up slowly and gradually."
Nearly a century ago Count Rumford said that woolen
clothes greatly promoted insensible perspiration, owing to the
strong attraction which subsisted between wool and water v
vapor which was continually issuing from the human body.
"It is evidently not due to the warmth of the covering; for
the same degree of warmth produced by more clothing of a
different kind does not produce the same effect. It is a
mistaken notion that it is too warm a clothing for summer.
I have worn it in the hottest climates, and in all seasons of
the year, and never found the least inconvenience from it.
It is the warm bath of a perspiration confined by a linen
shirt, wet with sweat, which renders the summer heats of
tropical climates so insupportable ; but flannel promotes
perspiration, and favors its evaporation ; and evaporation,
as is well known, produces positive cold."
It will be seen from what has already been said that
wool answers each one of the requirements of a perfect
clothing material in the highest degree ; and it only re-
mains for us to determine how wool shall be used so as to
take the greatest advantage of its properties. Until re-
cently the only woolen fabric we have been acquainted
with practically has been flannel, where the wool is flrst
spun and then woven more or less tightly into a fabric. By
this means the value of all the properties which make
wool pre-eminent as a clothing fabric is diminished ; and
laboratory experiments made with wool as it comes from
the sheep do not agree with those made on flannel — i. e.,
spun and woven wool. In order to preserve the absorptive
property of wool in the highest degree, the fibers must be
arranged with their points against the skin, and not longi-
tudinally, as in a woven fabric. This idea has already been
recognized and taken advantage of by the originator of the
Jaros hygienic underwear, and I pass around for your in-
spection a few garments made from this material. It is, as
you will see, unspun wool caught into the mesh of a loosely
knitted cotton back in such a manner as to preserve unim-
paired all the properties which make wool valuable as a
clothing fabric. Let me briefly recapitulate the qualities de-
manded of a clothing fabric, and then tell me if this fabric
does not answer these requirements in the most admirable
manner. It should be hygroscopic, porous, and so loosely
woven as to include more or less air in its meshes. For, as
has been pointed out above, less heat is lost by radiation if
the body is surrounded by a layer of air heated to the body
temperature or thereabout. Krieger has already called our
attention to the fact that the outer framework of a fabric is
but secondary in importance of action as a covering or cloth-
ing material when the material next the body has the impor-
tant qualities just mentioned as being possessed by the Jaros
hygienic underwear. I have here a sample of the latest
production of the Jaros Company, which may be said to be
the most perfect clothing fabric made. The framework or
back of this is silk, rendering the fabric still lighter. The
arrangement of the wool is such that, by capillary attrac-
tion, perspiration is absorbed, and carried to the silk or
cotton back, whence it is evaporated into the surrounding
atmosphere; and this attraction is so great that the hack
may be thoroughly saturated, while the wool next the skin
is perfectly dry. When our clothing is damp from perspi-
ration, or from any other cause, our bodies lose just as
much heat as the moisture in the clothing is capable of ab-
sorbing. The importance of always having dry material
next to our skin is evident ; and the material which w ill re-
tain the least moisture is the best. Woolen fiber is found
466
LEA DING ARTK 'L ES,
[N. Y. Med. Jouk.,
to answer this purpose more nearly than any other. The
Jaros materia] is highly porous, allowing free ventilation ;
at the same time a large amount of air can he caught, and
rendered to a certain extent immovable, thus preventing too
rapid hiss of lieat by radiation. Von Ziemssen, in vol. xviii
of his Encyclopaedia, says : " A material of loose texture con-
fining much air in its interstices is warmer than the same
amount of clothing material closely woven. Wool or cotton
carded and spread out in the shape of a wadding and held
will make a warmer garment than the same quantity spun
and woven and similarly covered. This applies with force
to underclothing." This fabric does not shrink ; for cot-
ton, the material of which the framework is made, never
does to any extent.
While citing perfection attained in clothing materials,
we are confronted by the Jaeger material, or stockinet, a
loosely-knitted flannel made of pure wool, and comparing
most favorably with the pure knitted woolen garments of
the old established and renowned manufacturers, Cart-
wright & Warner, of England. Carefully selected wool
is, no doubt, the great claim for this fabric, which is well
as far as it goes. In the Jaros material, on the contrary,
we find a practical accomplishment of scientific theories,
the caprice of no one scientist having been followed out,
and, in contradistinction to "systems," in which the profes-
sional world finds nothing- new, we have a simple, practical,
scientific material.
It is only recently that I have had my attention drawn
to this Jaros wear, and have had an opportunity of testing
it ; and I must confess that nothing has given me such per-
sonal satisfaction and comfort. I have gone out into the
cold from a small, overheated tenement-house room after
performing a difficult and tedious obstetrical operation, with
my white shirt saturated with perspiration, and have felt
no trace of chill. And I have found on reaching home
that, although my white shirt and the cotton back of my
Jaros wear were wet, the wool next the skin was perfectly
dry, as well as the skin itself. x\nd this winter, for the first
time in years, I have had no nasal catarrh, from which I
usually suffer every autumn and winter ; and I attribute my
escape so far solely to my Jaros underwear. And, in this
connection, let me say that Dr. O. B. Douglas, in a dis-
cussion before the Post-graduate Clinical Society, on the
treatment of nose and throat diseases, expressed himself
equally pleased with this wear.
Underwear of this description is of inestimable value to
those whose occupation compels them to go from place to
place where the temperature is continually changing; for,
no matter how high or how low the temperature of the
surrounding air is, the skin is perfectly protected against
any sudden change.
I do not wish to be understood as detracting in the
least from I 'rofessor Jaeger's due deserts ; for he is entitled
to great credit for what he has done in insisting upon the
value of wool as a material to be worn next the skin. But
he is simply re-echoing what Count Kuinford said a century
ago, which I have already quoted to you this evening. lie
has founded no new system ; he simply insists that pure
fine wool is better than the mixtures we have been using.
THE
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by Edited by
D. Appleton & Co. FuANii P. Foster, M. D.
NEW YORK, SATURDAY, APRIL 23, 1892.
CRANIECTOMY IN MICROCEPHALY.
In a recent paper on microcephaly M. Lannelongue strongly
affirms the belief that the condition is due to a maldevelopment
of the brain, and that the changes in the cranium are second-
ary, thus agreeing with Broca and others. Although the pri-
mary defect may not be in the cranial bones, there is abundant
evidence in many cases that the brain is exposed to ahnormal
pressure. Believing this to be true, Horsley, as reported in the
British Medical Journal for September 12, 1891, decided to
operate upon a patient under his care. The child was three
years old, usually restless, and never happy when quiet. lie had
an idiotic expression, and often made fretful noises, and placed
his bands to his head, as if in pain. He was unable to swallow
unless the food was pushed well hack into his throat. His mus-
cular development was excellent. The head was decidedly mi-
crocephalic, but symmetrical. The pupils were unequal.
An operation having been determined upon, an incision
through the scalp, to the left of the median line, was made, ex-
tending from the frontal eminence backward. The flap was
turned back and a strip of periosteum removed, half an inch
broad and four inches long, tapering at the points. The under-
lying bone was removed along the same lines. The dura mater
was exposed and bulged slightly. Healing of the wound wa8
perfect. Undoubted improvement was soon noticed in the
child's intelligence and general behavior, and the result was
distinctly in favor of the opinion expressed by Lannelongue.
In Mr. Horsley's second case the result was less favorable.
At the time of operation the child was seven years old. At its
birth, which had occurred at the seventh month of gestation,
there had been no fontanelles. From the eighth month it had
heen subject to convulsions. Its intelligence was slight and it
was unable to speak. It was restless, often passionate, and de-
cidedly idiotic in appearance. The head was of fair size, but
the frontal region was very small.
In the operation a portion of bone was removed similar in
shape to that in the first operation. A transverse incision was
also made along the coronal suture as far as the pterion, and a
narrow strip of bone removed. This was done with a view of
relieving the speech center. During the operation the pulse
became quick and irregular and the respiration was accelerated.
These symptoms continued, hyperpyrexia developed, and the
patient died.
From his own experience and from the collation of pub-
lished cases Mr. Horsley is convinced that the operation should
be performed in all cases, as the condition is otherwise hopeless
and interference has evidently secured notable improvement in
some instances.
April 23, 1892.]
LEADING ARTICLES.— MINOR PARAGRAPHS.
407
CAN THE PERIOD OF DESQUAMATION IX SCARLET FEVEE
BE SHORTENED?
It is the general belief that particles of cuticle cast off (lur-
ing the period of desquamation are active sources of infection.
It has been alleged that the free use of antiseptic gargles and
mouth -washes, together with the removal of epidermic scales
as rapidly as they are formed, will destroy all contagion. It is
the custom of many physicians to have the body bathed daily
with warm water and anointed with oil or carbolized vaseline.
A three-per-cent. ointment of carbolic acid, to which a little
thymol is added, is said to make an admirable preparation for
this purpose. This undoubtedly reduces to a great degree the
risk of infection to others. That it materially shortens the
period of desquamation is doubtful, though it is said that it
tends to avert the sequelaa.
Jamieson, who has written much upon the subject, in an
article in the Lancet for December 12th, proposes resorcin as
an agent that will actually accelerate desquamation. Its power
to cause the outer layers of the epidermis to separate without
injury to the deeper parts is well known. Used in the form of
an ointment, it has not been found to have this result in scarlet
fever, but in combination with soap it is said to be very active.
Salicylic acid must be added to render this soap stable. Tn this
form resorcin seems to shorten the desquamative period de-
cidedly. The soap should be used with warm water, and after
it has been thoroughly washed away with clear water the body
should be anointed with some simple oil.
MINOR PA It A G HAP IIS.
LEPROSY IN MINNESOTA.
We would call the attention of those health authorities
whose notions of leprosy are apparently contemporary with
those of the first century of the Christian era to an article in
the Lancet for March 26th, that has been indorsed by the well-
known secretary of the State Board of Health of Minnesota,
Dr. Hewitt, aDd by that excellent sanitarian. Dr. Henry B. Ba-
ker, of the Michigan State Board of Health. The article in
question is by Dr. Gronvakl, of Minnesota, and describes the
experience of tint State during the past forty years with the
lepers among its Scandinavian population. It is stated that all
leprous persons are registered and kept under observation, and
all suspicious persons are visited by inspectors of the State
board. The only thing that the board requires is for the affect-
Id person to have his own bed and utensils. And yet, with so
little interference with the freedom of the individual, there are
but eighteen cases of leprosy in the State; in none of the de-
scendants of lepers has there been any sign of the disease dis-
covered; no leper has been born in Minnesota; and so no
ground has existed for the exhibition of officious zeal in declar-
ing a patient to be an outcast and treating him as such.
A NEW METHOD OF RNTERORRHAPHY.
In the British Medical Journal for April 2d Mr. F. Bow re-
man Jessett reports a new method of enterorrhaphy with de-
calcified-bone tubes. The latter are of cylindrical form, one
end daring so that its diameter is double that of the opposite
end, and the length of the two tubes is two inches and a halt*.
He designates the tubes as male and female, the former con-
sisting of two parts: a cylindrical portion fastening into the
proximal end of the intestines, and a sliding cylinder or spur
that enters the female tube. In the flaring end four holes are
drilled, through which pass two long threads of chromicized
gut, armed with needles at each end. The intestine is excised
y
and the male tube is inserted into the proximal end of the in-
testine as far as the flange, the spur projecting beyond the di-
vided end; the threads are passed through all the coats from
within outward and held by clamp forceps, while the female
tube is in like manner introduced into the distal end. The spur
of the male tube is now passed into the female tube, the cor-
responding threads are tied, and the proximal end of the intes-
tine is steadied with the left thumb and finger, while with the
right thumb and finger the distal end is slipped over the proxi-
mal for a quarter or half an inch. With four quilt chromicized
gut sutures the intestine is sewed and the operation completed.
While this operation seems simple, the necessity of having pre-
pared tubes of different sizes on hand presents the same objec-
tion that has been urged against Senn's plates.
INDURATION OF THE STERNO-CLEIDO-MASTOID MUSCLE
IN THE NEW-BORN.
Dr. Clarendon Rutherford, professor of descriptive anato-
my in the College of Physicians and Surgeons, of Chicago, has
sent us an account of another case in which this condition was
observed, and under circumstances similar to those recently re-
ported. It occurred in May, 1890, in a first child, the head and
shoulders of which were large. The induration was on the
l ight side and extended from the clavicle upward about two
inches. The muscle was somewhat tender on manipulation.
The face was slightly turned to the left side and the head drawn
toward the right shoulder. The swelling was first noticed dur-
ing the fourth week after delivery, which was instrumental.
The umbilical cord was around the neck, and the traction on the
head and shoulder might have done the damage. The indura-
tion disappeared in about four weeks, after the use of an oint-
ment of sodium iodide, potassium iodide, and vaseline. The
child did not grow until after the disappearance of the swelling.
There were no glandular enlargements.
M ETALLOTHERAPY IN A CASE OF HYSTERIA.
Is the Gazette dea hopitaux civils et militaires for April 2d,
Dr. Moricourt giv es a minute history of a case of hysteria major
in which, after long-continued treatment of various sorts, the
patient was hypnotized and, metalloscopy being practiced,
found to respond to aluminium and especially to gold. Gold
coins were accordingly employed, applied to the forearms, and
slow but complete recovery took place. On examination after
the lapse of more than a year from the time of discontinuing
treatment, the patient, a girl of nineteen, was found still quite
free from hysterical symptoms, except that she could not help
laughing whenever a funeral procession passed.
T11F. INFLUENCE OF PURPURA II.K.MORRIIAOICA ON
MENSTRUATION AND PREGNANCY.
In the concluding part of volume xxxiii of the Transactions
of the Ohxtetrical Society of London, for the year 1891, we find,
a carefully prepared article by Dr. John Phillips dealing that
rare occurrence, purpura hemorrhagica as a complication of the
generative functions in women. Dr. Phillips thinks the follow-
ing conclusions justifiable: 1. That the prognosis in cases of
4fi8
MINOR PARAGRAPHS.— ITEMS.
[N. Y. Med. Jotje.,
pregnancy complicated by this disease is extremely grave, the
large majority proving very rapidly fatal. 2. Death may be due
to post-partum haemorrhage or to some constitutional condition,
allied to septicaemia, of the nature of which we are so far igno-
rant. 3. That abortion or premature labor inevitably takes place,
but at variable periods, owing either to the serious general dis-
turbance, or to haemorrhage into the placenta. 4. That the or-
dinary purple rash may be modified somewhat, first appearing
as a bright red stain, darkening in a few hours' time. 5. That
apparently, so far as has been observed, the disease is not, as a
rule, transmitted to the foetus ; but that it may be classed as one
of the causes of foetal mortality in tttero.
THE yETIOLOGY OF PUERPERAL ECLAMPSIA.
In the Comptes rendu* hebdomadaires des seances de la Societe
de biologic for March 25th M. Combemale and M. Bue, of the
clinical laboratory of the Lille faculty of medicine, give brief
accounts of four cases of puerperal eclampsia in which they
found the Staphylococcia pyogenes aureus or the Staphylococcus
pyogenes albas, especially the latter, in the hlood, either during
or immediately atter labor, and succeeded in cultivating it. The
authors do not draw the positive conclusion from these few facts
that the micro-organism is the cause of the.convulsions, but they
intimate that that is probable.
THE CITY BOARD OF HEALTH.
Certain resignations of officers are announced as having
recently being made "by request," and it is intimated that the
requests were made on account of the officers' political affilia-
tions being distasteful to the powers that be. In another in-
stance an excellent officer, a physician of high attainments and
of long experience in the board's employ, is said to have been
made to change places with his deputy. We hope it will be
shown that the newspapers are wrong in attributing these
changes to political motives, or at least that the medical mem-
bers of the board of commissioners protested against them.
ITEMS, ETC.
The American Paediatric Society will hold its fourth annual meet-
ing in Boston on the 2d, 3d, and 4th of May, in the Boston Medical
Library Association Building, No. 19 Boylston Place. The preliminary
programme gives the following titles : The president's annual address,
by Dr. William Osier, of Baltimore; Experiments as to the Value of
Nascent Ozone in Certain Forms of Diseases of Children, with Demon-
stration of an Efficient Generator, by Dr. Augustus Caille, of New York ;
Manifestations of la Grippe in Children, by Dr. C. Warrington Earle, of
Chicago ; An Epidemic of Alopecia in a School of Girls, by Dr. C. P.
Putnam, of Boston ; a discussion on The Relation of Rheumatism and
Chorea by Dr. C. W. Townsend, of Boston, Dr. M. Allen Starr, of New
York, and Dr. Samuel S. Adams, of Washington ; The Nomenclature of
Diseases of the Mouth, by Dr. T. M. Rotch, of Boston ; Report of the
Committee on Nomenclature of Stomatitis ; Pseudo-diphtheritic Pro-
cesses, by Dr. W. D. Booker, of Baltimore ; The Treatment of Diph-
theria by Sublimations of Mercury, by Dr. Dillon Brown, of New York;
Typhoid Fever in Children under Two Years, by Dr. W. P. Northrup, of
New York ; Typhoid Fever in Children, by Dr. C. Warrington Earle, of
Chicago ; Typhoid Fever in Infancy, by Dr. W. S. Christopher, of Chi-
cago ; Acute Emphysema in Children, with Report of Cases, by Dr. F.
Forchheimer, of Cincinnati; Pre-tubercular Amemia, by Dr. 13. K. Rach-
ford, of Newport, Ky. ; Prevention versus Medication in the .Manage-
ment of the Diseases of Children, by Dr. I. N. Love, of St. Louis ; Syphi-
litic Broncho-stenosis, by Dr. A. Seibert, of New York; A Simple Method
for Clinical Examinations of Breast Milk, by Dr. L. Emmett Holt, of
New York ; Sacro-coccygeal Tumor in a Child Three Weeks Old ; Op-
eration ; Recovery, by Dr. F. Huber, of New York ; Two Tracheal and
Bronchial Casts, by Dr. F. Huber, of New York; A Case of Death from
Laryngismus Stridulus in Incipient Rhachitis, by Dr. Samuel S. Adams,
of Washington ; and The Value of Milk Laboratories for the Advance,
ment of our Knowledge of Artificial Feeding, by Dr. T. M. Rotch, of
Boston.
The Presbyterian Hospital. — Appointments on the medical staff
have recently been made as follows : Dr. Frederick E. Lange, con-
sulting surgeon ; Dr. Francis P. Kinnicutt, Dr. William P. Northrup,
and Dr. Walter B. James, visiting physicians ; and the following-named
gentlemen as consultants in special departments : Dr. T. Gaillard
Thomas in gynaecology, Dr. M. Allen Starr in neurology, Dr. Francke
H. Bosworth in laryngology, Dr. Charles Stedman Bull in ophthal-
mology, Dr. Albert H. Buck in otology, Dr. Newton M. Shaffer in ortho-
paedies, and Dr. George Thomas Jackson in dermatology.
The Grant Monument and the Medical Profession. — A meeting of
" representative physicians and surgeons of New York city " was held
at the Holland House on Wednesday afternoon, for the purpose of se-
curing the co-operation of physicians in the work of providing for the
construction of General Grant's tomb.
The Brooklyn Surgical Society. — At the meeting of Thursday even-
ing, the 21st inst., the special order of business was a paper by Dr.
George Wackerhagen.
The Societe de biologie. — At the meeting of March 20th Professor
Chauveau was elected president for- the term of five years, as the suc-
cessor of Professor Brown-Sequard.
Army Intelligence. — Official List of Change's in the Stations and
Duties of Officers serving in the Medical Department, United States
Army, from April 10 to April 16, 1892:
Wells, George M., First Lieutenant and Assistant Surgeon, is relieved
from duty at San Carlos, Arizona, and ordered to report in person
to the commanding officer, Fort Grant, Arizona, for duty at that
station.
Glennan, James D., First Lieutenant and Assistant Surgeon, is relieved
from duty at Camp Oklahoma, and ordered to Fort Sill, Oklahoma
Territory, for duty at that station, relieving Captain Francis J. Ives,
Assistant Surgeon, who, on being so relieved, will report in person to
the commanding officer at Fort Sheridan, Illinois, for duty at that
post. S. 0. 86, A. G. 0., April 12, 1892.
Chapix, Aloxzo R., Captain and Assistant Surgeon, is granted leave of
absence for three months on surgeon's certificate of disability.
Gorgas, William G, Captain and Assistant Surgeon, is granted leave
of absence for two months, to take effect on or about May 1, 1892,
with permission to apply for an extension of one month.
Arthur, William H, Captain and Assistant Surgeon, is relieved from
duty at Fort Grant, Arizona, and ordered to Vancouver Barracks,
Washington, for duty as Post Surgeon at that station, relieving
Captain Louis Brechemin, Assistant Surgeon. Captain Brechemin,
upon being relieved by Captain Arthur, will return to his proper
station, Presidio of San Francisco, Cal.
Naval Intelligence.— Official List o f Changes in the Medical Corps
of the United States Navy for the week ending April 1G, 1892 :
Dixon, W. S., Surgeon. Ordered to the Smithsonian Institution.
Society Meetings for the Coming Week :
Monday, April 25th : Medical Society of the County of New York ;
Boston Society for Medical Improvement ; Lawrence, Mass., Medi-
cal Club (private) ; Cambridge, Mass., Society for Medical Improve-
ment ; Baltimore Medical Association.
Tuesday, April 26th: Louisiana State Medical Society (first day — New
Orleans) ; Medical and Chirnrgieal Faculty of Maryland (first day
— Baltimore); Texas State Medical Association (first day — Tyler);
New York Academy of Medicine (Section in Laryngology and Rhi-
nology); New York Dennatological Society (private); Buffalo Ob-
stetrical Society ; Medical Society of the County of Putnam (quar-
terly), N. Y. ; Boston Society of Medical Sciences (private); Hunter-
April 23, 1892.]
REPORTS ON THE PROGRESS OF MEDICINE.
469
don, N. J., County Medical Society (Flemington) ; Litchfield, Conn.,
County Medical Society (semi-annual).
Wednesday, April 27th: Louisiana State Medical Society (second day);
Medical and Chirurgical Faculty of Maryland (second day) ; Texas
State Medical Association (second day); New York Surgical Society;
New York Pathological Society ; Metropolitan Medical Society (pri-
vate); American Microscopical Society of the City of New York;
Medical Society of the County of Albany , Auburn, N. Y.j City
Medical Association ; Philadelphia County Medical Society ; Glouces-
ter, N. J., County Medical Society (quarterly); Middlesex, Mass.,
North District Medical Society (Lowell).
THURSDAY, April 28th: South Carolina Medical Association (first day —
Georgetown) ; Medical and Chirurgical Faculty of Maryland (third
day) ; Louisiana State Medical Society (third day) ; Texas State
Medical Association (third day); New York Academy of Medicine
(Section in Obstetrics and Gynaecology); New York Orthopaedic
Society; Hospital Graduates' Club (New York); Brooklyn Patho-
logical Society ; Roxbury, Mass., Society for Medical Improvement
(private — annual) ; Hartford, Conn., County Medical Association
(annual); Pathological Society of Philadelphia.
Friday, April 20th : South Carolina Medical Association (second day).
Saturday, April 30th : South Carolina Medical Association (third
day).
Answers to Correspondents :
No. S80. — The Asclepiad is published quarterly by Messrs. Long-
mans, Green, & Co., of Paternoster Row, London, and sold for two shil-
lings and sixpence a number. The American agents are Messrs. P.
Blakiston, Son, & Co., Philadelphia, and Messrs. Cupples, Upham, & Co.,
Boston.
ileports on the progress of |Ucbtrine.
CUTANEOUS AND VENEREAL DISEASES.
By SOPHIE KUPFER, M. D.
The Treatment of Eczema hy Thilanine is the subject of a paper
by Dr. Saalfeld (Therap. Mvnatsheft, November, 1891). Thilanine is
obtained by the action of sulphur upon lanolin, and contains three per
cent, of sulphur. It is a yellowish-brown ointment, having the consist-
pace of lanolin. It is of value in superficial inflammations of the skin,
and is advantageously substituted for the inert ointments, as it is more
energetic in action. The author has used it in several cases of eczema,
and has never found it to produce any irritation, while it has always
yielded excellent results. In other cutaneous affections — such as herpes
zoster, sycosis vulgaris, and a case of chrysarobin dermatitis — he has
likewise obtained excellent results from its use.
Nitrate of Silver for Weeping Eczema. — Dr. Leven (Therap. Gaz.,
Feb. 15, 1892, p. 114) recommends the use of a one-per-cent. solu-
tion of nitrate of silver in obstinate cases of weeping eczema. Several
applications are to be made during the day, the part to be covered with
a bismuth ointment in the intervals.
Eczema of the Face and Scalp in the Infant is treated by Dr.
Baumel (Nouv. Montpel. med., Jan. 2, 1892, p. 19) in the following man-
ner : The hair is cut off and a hood of oil-silk is worn during the
night. This hood favors perspiration, and the secretions soften and loosen
the crusts. Simple poultices will accomplish the same object. The
crusts are then very simply detached by washing with soap and water
in the morning. The following ointment is then applied twice daily :
R, Vaseline, r j ; iodoform, gr. xv to 3 j, according to the age of the
patient. He gives internally a teaspoonful of the syrup of horse-radish
root twice daily, and regulates the nursing and diet.
Exfoliative Dermatitis. — Dr. Stephen Mackenzie (Lancet, Jan. -J,
1892, p. 27) describes a cuticular glove, obtained from the hand of a
patient fifty years of age. He had shed the skin of his hands at regu-
lar intervals twice during the year. The exfoliation was preceded by-
redness and pain in the parts, and an eruption of red spots.
The Contagiousness of Leprosy is the subject of an article by Dr.
Thin (Lancet, Jan. 16, 1892, p. 134). He investigates the origin of
leprosy in the town of Parcent, Spain, which, now a leper colony, was
free from the disease in 18S0. At that time a leper settled in Par-
cent and became intimate with another man, a native of the town.
They ate and drank from the same dishes and occupied the same bed.
Within a year the latter had contracted the disease, and from this
nucleus leprosy spread, until, at the date of observation, sixty cases of
the disease had occurred, and forty-five persons died. The intimates of
the person mentioned were the first to be affected, while those who
shunned his society remained free from the disease. The disease like-
wise spread to a neighboring town. Dr. Thin also relates the case of a
healthy infant who contracted the disease from a wet-nurse, and who in
turn infected his brother.
Amygdalitis and Cutaneous Eruptions. — The connection between
these affections is the subject of a paper by M. Le Gendre, in L 'Union
med. (Jan. 21, 1892). He notes a case of amygdalitis in a woman, aged
thirty-three years, in the course of which several successive eruptions
of purpura and papular erythema appeared. They ended when the
amygdalitis disappeared. The patient had mild fever, fugitive pains in
the joints, and marked debility. He reports three other cases, in the
first of which an erythema multiforme appeared on the fourth day of a
follicular amygdalitis; in the second, a month had elapsed before the
appearance of articular pains and purpura, the patient having been
in a very debilitated condition in the interim. The third case was
that of an attack of amygdalitis that appeared between two eruptions
of erythema polymorphum. M. Le Gendre urges the investigation by
bacteriologists of the connecting link between tonsillar and cutaneous
manifestations.
A Case of Traumatic Pemphigus is recorded by Dr. Phillippi
(Mbnatsheft fur prakt. Dermat., i, 1892, 42). The patient, a woman of
thirty-one years, complained of severe pains in the feet and legs, more
pronounced after she had been standing or walking for any length of
time. An eruption of vesicles then appeared upon the dorsal surface
of both feet and on the lower third of the leg. A large serpiginous
blister was found when she presented herself for examination, and sev-
eral pigmented spots, of about the size of a quarter of a dollar, where
a crop of blisters had been.
Pyrogallic Acid in Psoriasis. — Dr. Grellety (Gaz. med. de Paris,
Feb. 6, 1892) gives the following formula for the local treatment of
psoriasis: R Salicylic and pyrogallic acids, aa 3 jss. ; alcohol and ether,
q. s. to dissolve ; collodion, J ijss- This preparation has no toxic
properties.
Antisepsis in Skin Diseases. — In an article in the Rev. gen. de clin.
et de ther. Dr. Arnozan lays down the following general rules for the
treatment of diseases of the skin : The general indications are : To ob-
tain cutaneous and intestinal antisepsis ; to relieve itching ; to remove
the thick scales in certain diseases ; to relieve the congestion or to
stimulate cutaneous circulation; to apply certain specifics for destruc-
tion of irreparable lesions; to use for this end internal or external
medicaments, not very numerous in all ; and to prescribe diet and heat
cures. As for antiseptics, in simple cases, in which no special action is
required, he recommends boric acid. Its action, he assert-, is sufficiently
antiseptic, and, though it is not very energetic, it is neither irritant nor
toxic. To produce scaling of the skin he uses salicylic acid or tincture
of iodine. In syphilitic ulcerations, mercury, and in tubercular, iodo-
form are used.
Hydrotherapy and Nerve Remedies in Dermatoneuroses. — M. Jac-
quet (Rev. gin. de clin. et de therap., No. 8, 1892), after applying the
usual remedies in a case of lichen planus, had recourse to hydrotherapy
with a very good result. He had, during a month and a half, treated
the patient with baths, Fowler's solution, etc., with no result. He then
ordered a daily douche of a temperature of 9,")° P., to be followed by a
short cold douche. In a few days a great change took place. The itch-
ing was stopped, and the eruption began to disappear during the third
week of treatment. The treatment lasted six weeks, when the patient
was completely restored. Five months later a relapse occurred, which
subsided rapidly upon employing the douches. The action was, in his
opinion, that of regulating the nervous system, and thus relieving the
severest symptom of the disease — viz., the pruritus. M. Jacquet calls
470
REPORTS ON THE PROGRESS OF MEDICINE.
[X. Y. Med. Joue.,
attention to the nerve remedies which are very efficacious in itching
affections. Antipyririe and the bromides are of great value.
Syphilidiform Erythema is, according to M. Founder (Rev. gin. de
clin. el de t/ierap., No. 8, 1892), a disease which is often confounded with
true syphilis. It develops in children between the ages of three and
eight months, and may appear suddenly in a child whose health has
been good, but who suffers (in most cases) from diarrhoea. The site it
occupies is the genital region and the internal surface of the thighs,
in particular the cutaneous folds. It begins as a papulo-vesicle,
which resembles closely ;i vaccine papule. The vesicles may be isolated
or in groups, but they gradually coalesce and form one large lesion. In
the second stage the center becomes depressed, the vesicle ruptures, and
the surface is eroded and, when not properly treated, simulates a moist
papule. Generally, the affection remains a purely local one, though in
some cases the glands become involved. Usually a second crop ap-
pears at the end of several days, passing through the same succession
as the preceding one. When treated, it lasts at least a week be-
fore cicatrization occurs. When neglected, its course is long. The
treatment should be only local — cleanliness, washing with boric-acid
solution, and dressing with bismuth, zinc oxide, salol, or iodoform.
The diagnosis is of the utmost importance, as it is very undesirable to
institute mercurial treatment in non-syphilitic children, particularly
when diarrhoea is present. A careful family history should be obtained,
and if the parents are healthy, the diagnosis is easy to make. If ac-
quired syphilis is suspected, a. very careful examination will reveal
the initial lesion. When no previous history can be obtained, other
signs of syphilis must be looked for. Deformities, coryza, mucous
patches in the mouth, all may aid in the diagnosis.
Cod-liver Oil in Lupus Vulgaris. — A woman, thirty-three years of
age, had a patch of lupus vulgaris on the left cheek, which was cured
by the scraping method. The right cheek then became similarly af-
fected. Iodoform was used, but with no success (Rev. gen. dc clin.
el de therap., No. 3, 1892). M. Zilgien then applied the following
dressing. He dipped a baud of iodoform gauze into cod-liver oil and
alternated this dressing daily with simple iodoform powder. Wherever
the oil was applied, rapid cicatrization took place.
A Hare Form of Skin Disease is described by Dr. Kenwood in the
Lancet (Jan. 9, 1892). It is an aberrant form of urticaria, occurring as
the consequence of a severe body chill. No concomitant derangement
of the digestive or reproductive organs was found, though there was an
accentuation of the color and acidity of the urine. When seventeen to
eighteen years old, the patient first noticed the occurrence of swellings
whenever she had a chill. Otherwise she was in excellent health and
of a slightly florid complexion. The eruption consisted of wheals, six
inches in diameter, appearing three days after the chill, when the other
effects were somewhat spent. They occurred upon any part of the body.
The lips and eyelids, particularly the lower eyelids, were frequently at-
tacked. The pharynx was involved upon one occasion. The area to be
affected first assumed a slight blush, sometimes bright like erythema,
but more generally of a duskier hue. A faint tingling pain manifested
itself at this time. When rubbed, the center rose, became relatively
blanched, and then the lesion spread rapidly by an indefinite border
until it reached the limit of its extension. It now appeared as a pale
swelling, surrounded by a faint red line. The tingling sensation, which
was always slight, was greater in the stage preceding the swelling, and
diminished gradually, disappearing when the wheal reached its maxi-
mum. At this stage there was no subjective sensation of any kind,
unless the wheal was rubbed or pressed. The duration was two days in
bad attacks, but the lesions had come and gone in as many hours.
They left no trace. Sometimes, early in the attack, friction over an
Apparently normal area produced wheals. The feature of special in-
terest in the case was that some of the swellings had assumed the
character of a condition described as acute circumscribed cutaneous
(edema. There were present in most attacks three or four (edematous
tumefactions of the skin and subjacent tissue, firm and knobby in con-
sistence, with ill-delined borders, and slightly paler in hue than the sur-
rounding skin. The] pitted very slightly upon pressure. Their favorite
site was the skin over the deltoid muscle of the arm, and that over the
buttocks. In a recent attack, swelling of the tongue was caused by one
of them. They were never less than two inches and a half in diame-
ter, and were generally of an oval shape. Their similarity to the whales
was shown by th?ir changes of development, the rapidity of their ap-
pcarance and disappearance, and the common cause producing both.
There was at first a blushing area, then a rapid swelling, growing paler
as it increased in size, and finally the surrounding zone of skin became
slightly redder in color. There was no defined border, and subjective
sensations were not present.
The author, considering the various features of the case, concludes
that it is a hybrid of the following three conditions: (1) Common acute
urticaria, (2) urticaria gigans, (3) acute circumscribed oedema. As the
patient was of a somewhat rheumatic constitution, the treatment insti-
tuted was with a combination of salicylate of sodium and iodide of
potassium.
Heat in the Treatment of Syphilis. — Dr. Aussass (Jour, des mid.
<-nt. el syph., January, 1892) presented before a society a young man,
seventeen years of age, who had become infected from a wet-nurse.
From the age of fifteen years on he had had a persistent headache,
which yielded neither to mercury nor to large doses of iodide of potas-
sium. Residence in a warm climate improved him a little. The doctor
then ordered daily hot baths in combination with mercurial friction,
and obtained a brilliant result in a very short time. The benefit was due,
in his opinion, to the more rapid elimination of the mercury under the
influence of the hot baths, and to an increased receptivity of the body
for the remedy.
Primary Chancre of the Cheek. — A case is reported by Dr. Shield
(Lancet, Jan. 30, 1892) occurring in a widow, thirty-four years of
age. No history of infection could be obtained. All that was known
was that the sore had existed for two months. It was a dusky-col-
ored swelling, of the size of a florin, and situated in the center of the
left cheek. The edges were sharply defined and there was neither
ulceration nor discharge. The submaxillary glands were enlarged, and
the skin was covered with a dusky syphilide. Mercurial treatment was
instituted, and under it the rash had faded and the chancre had become
reduced in size.
Succinimide of Mercury for Injections. — In the Arch, fin- Derm,
und Syph. (January, 1892), Professor de Amicis gives a formula for
the hypodermic injection of mercury, which he has used with great suc-
cess. He injects a one-per-cent. aqueous solution of succinimide of mer-
cury, to which he adds a one-per-cent. solution of cocaine. It yields good
results in both secondary and tertiary lesions. Its activity is as great as
that of the bichloride, and it produces much less pain and irritation.
The Modern Treatment of Syphilis. — Dr. Finger (Med.-chirttrg,.
Ctilbl., Feb. 5, 1892) advocates the use of baths in the pustular and
ulcerated forms of the disease. He considers the absorption of mer-
cury in considerable quantity as the first advantage of this method, its
local action upon the lesions themselves the second. He dissolves two
and a half to eight drachms of bichloride of mercury in about fifteen
ounces of water, and adds the whole to a bath having a temperature of
78° to 80" F. This temperature should be maintained by the addition
of hot water. The patient remains in the bath from half an hour to
two hours. It is taken daily and is to be followed by an hour's rest in
bed. If the lesions are only upon one limb, an arm or foot bath will be
sufficient. For this a drachm and a half to three drachms of the bi-
chloride should be used.
For children the author advises a mode of treatment rarely em-
ployed— viz., the application of mercurial plasters. The back, chest,
arms, and legs are surrounded in definite rotation with the plasters,
which are left in situ for several days until they fall off spontaneously.
Treating of the hypodermic method, he calls attention to the superior-
ity of the intramuscular method over the subcutaneous injections of
insoluble salts. He warns against the danger of cumulative action in
these cases. The mercurialism can not be met excepting by surgical
means involving an incision over the site of injection, and removal of
the injected material. He advocates the use of a one-per-cent. solution
of corrosive sublimate plus a twenty-per-cent. solution of common salt
as the best preparation for injection. A solution composed of socoiodate
of mercury, fifteen grains; potassium iodide, twenty-five grains; dis-
tilled water, two drachms and a half, is the most energetic, according
to him, and is sufficient, being injected five to six times at intervals of
a week, to accomplish ii complete cure.
April 23, 18&2,]
MISCELLANY.
471
Aristol for Venereal Ulcers is recommended by Dr. Giintz (Merno-
rab., Jan. 23, 1892) as a substitute for iodoform. He considers iodo-
form the best remedy, but recognizes the objection to its odor. Aris-
tol should not be remedy in the form of an ointment, but should lie
applied directly to the wound. It is insoluble in water, but forms a
tough brown pap with olive oil, which is, however, difficult of applica-
tion. The undissolved powder itself is inert. Therefore the ulcer
should be strewed with the powder, and a drop of olive oil be allowed
to fall slowly from a glass rod upon it. Without waiting for the solu-
tion to be effected, the ulcer is promptly covered with some fine im-
permeable tissue, under which the solution takes place slowly. No
cotton or charpie should be applied to the ulcer. If the secretions are
very profuse, or if the ulcer is in an unfavorable location, this dress-
ing must be secured by means of court-plaster. The application
should be renewed twice daily, after careful removal of that previously
applied. Its advantages are that it is painless, odorless, and non-irri-
tating, and that there are no inconveniences attaching to its use. Pain-
fid ulcers become painless, and previously bedridden patients become
able to go about after its use. If, however, as is the case in corroding
or torpid ulcers, the healing tendency is not sufficiently rapid, recourse
to iodoform must be had.
Although aristol is not curative in soft chancres, nevertheless,
where it is substituted for iodoform, there is no danger that the lesions
will assume a more serious character. This happens frequently when
mercurial ointments are used. In hard chancres its action is better.
But it is of especial value in secondary lesions, in ulcerating gummata,
in tubercular syphilides, etc. Although, if continued long enough, this
treatment will effect a cure, nevertheless it is hastened by the internal
administration of antisyphilitics.
Ointments.— Dr. Wende (Buff. Med. and Surg. Jour., January, 1802)
lays down the following essentials for a good ointment basis :
1. Proper Consilience. — It must be soft, smooth, and pliable, readily
admitting of a uniform application.
2. Homogeneity. — It must be perfectly homogeneous, free from grit-
tiness and irritating bodies.
3. Durability. — It must not show a tendency to change its physical
and chemical peculiarities on exposure or long keeping.
4. Miseibility. — It must be capable of easily receiving the ingre-
dients to be coml lined or incorporated.
5. Power o f Imbibition. — It must be capable of absorbing liquids,
especially water.
6. Limitations of Temperature. — It must have a melting-point some-
what higher than the temperature of the body. It must not liquefy.
7. Inability to produce Irritation. — It must be perfectly bland and
neutral in reaction.
Syphilis and Heredity. — Dr. Molfese (77 Progrcsso medico, Jan. 20,
1892) cites the case of a young man, twenty-three years of age, who
contracted syphilis and was treated with protiodide of mercury and
calomel. Intense headache, evening fever, and profuse night-sweats
ensued after a short period. Inguinal, cervical, and submaxillary
adenitis was present. There were mucous patches on the sides of the
tongue, on the pillars of the fauces, on the soft palate, and at the angles
of the mouth, and a maculo-papular syphilide covered the body. The
bichloride of mercury was then injected, and marked improvement was
noted after the tenth injection. Disappearance of the headache, fever,
and eruption marked the improvement, but the mucous patches per-
sisted, breaking out anew in another place when they disappeared from
a previous one. During two years of observation it was found that, if
for any period, however short, there was an interruption of the injec-
tions, the submaxillary and inguinal glands became swollen and painful.
Not fully two years after the date of infection the patient married
a healthy woman, who, ten months later, gave birth to a healthy child.
The patient had, immediately preceding marriage, subjected himself to
a treatment of eighty injections. Neither mother nor child showed any
evidence of syphilis. The woman, becoming pregnant for the sec I
time, aborted at five months, and two months later again conceived, and
aborted at three months. After the first abortion glandular enlarge-
ment was found; she lost Hesh, and had rheumatoid pains. Two
months after the second abortion she again conceived, and was deliv-
ered at term of a healthy child. The w in underwent no treatment,
with the exception of taking a few ounces of iodide of potassium.
The husband received fifteen hypodermic injections, but this was when
the pregnancy had already advanced to six months. Dr. Molfese con-
cludes, therefore, that the mother was infected, not from the husband,
but from the first foetus ; and that a syphilitic father who has borne to
him one healthy child can not count upon immunity from the disease
for other offspring.
HI i s c c 1 1 a n n .
Hippocrates was the theme of a " bibliographical demonstration " in
the Library of the Faculty of Physicians and Surgeons of Glasgow, on
November 23, 1891, by Dr. James Finlayson, the honorary librarian.
Written out from memory, it appears in the April number of the Glas-
f/u, r Mcdiod Journal. The greater portion of it is as follows:
Value of Historical Studies. — In resuming our " bibliographical dem-
onstrations " to-night, I wish to take the present opportunity of saying
that I have long desired to try this method of directing the attention of
some of our students or young graduates to the history of medicine. I
believe that the history of our art is not only full of interest to us as stu-
dents, but that it is of great importance to us as practitioners. To those,
especially, who have only recently entered on practice, it seems to me that
some know ledge of the history of medicine affords the only means of sup-
plying the place of personal experience, in judging of the ever changing
phases of our art. The history of various revolutions in theories and in
practice, and the indications thus afforded of the lines on which steady
and substantial progress has been made since the earliest times, or, on
the other hand, of the pitfalls into which our predecessors have been
entrapped, seem to me the only way of securing for the inexperienced
any sense of " perspective " in looking at new facts and new ideas as
they arise.
But the history of medicine seems never to have been much of a
success in the schools of Scotland ; even when taught, as it has been in
Edinburgh, by a man of the greatest eminence and ability, the success
is reported to have been dubious, or at least slight. In England, so far
as I know, the results have not been much better, although the re-
quirements of the Royal College of Physicians of London in the exami-
nation for its membership have kept the subject more alive there than
here.
Method of Bibliographical Demonstrations. — I have for a long time
thought that this subject, like most of our medical subjects, should be ap-
proached— if approached at all in the form of lectures — by the practical
methods we now adopt in other departments. My own personal experience
was that I only began to feel the reality underlying such names as Hip-
pocrates, Galen, Avicenna, Bonetus, or Morgagui, when I was led, during
my connection with the medical library in Manchester, to handle the works
of the giants of the past. When thus made to realize the substantial
character of their contributions, an occasional dip into their writings, if
even only to read their title pages, the headings of their chapters, or a
short passage on some subject having a special interest at the moment,
gave me, from that time, a sense of a certain personal acquaintanceship
with the writers, very different from the mere shadowy idea previously
gathered from seeing or hearing their names in a book or a lecture.
Alter such a glimpse, one sometimes felt impelled, and certainly more
prepared, to gather up from historical or biographical works more de-
tailed information as to the lives and doctrines of those who had lei!
their mark for all time.
In charge of a valuable medical library in this great medical center,
I have often thought of trying how far the method of " bibliographical
demonstrations" could be made available in stimulating interest and
laying the foundations for future study ; but the pressure- of practical
work, of a varied but always of a more urgent kind, has hitherto pre
vented me from undertaking the experiment. Nearly two years ago
I obtained permission from the Council of the Faculty to give demon-
strations in the Library to any members of the profession I might think
of inviting, but I was only able to make a beginning this winter. The
472
MISCELLANY.
[N. Y. Med. Jock.,
slight preliminary experiments already made this month seemed so en-
couraging that I have now ventured, at this third meeting, to enter
upon a demonstration of the Hippocratic writings.
Our meeting here is small, but, in my view, that is one of the condi-
tions of success in this plan. We wish the numbers to be such that
you can all sit around the table on which the books are placed, see
them when demonstrated, and look at them quietly for yourselves after
the demonstration is over. I began the demonstrations with old ana-
tomical works containing many curious and attractive illustrations, so
as to cultivate this habit of personal examination ; in the subject before
us to-night the illustrations must be drawn from selected passages
which I will read from the books before you.
The next point of difficulty which had to be faced was the selection
of an audience. Our over-pressed students can scarcely be expected to
take the trouble of learning about anything which "does not pay "at
the examinations, although at my second demonstration this winter of
books bearing on Physiognomic Diagnosis, to which students were in-
vited, I had a goodly number of them — as many, indeed, as desired.
After consideration, it seemed to me that the most suitable audience for
my purpose was such as I have to-night — an audience selected chiefly
from the residents at the various hospitals here, according as they were
understood to be interested in such matters, with the addition of any
one else who expressed a desire to come. As most of you here have
been more or less associated with me as hospital assistants, I felt that
whatever deficiencies I showed in carrying through this new enterprise,
I would at least receive a sympathetic hearing and a kindly judgment.
Peter Lowe's Translation of the Prognostics. — In this library it may
be legitimate to begin a demonstration of the Hippocratic writings by
showing you the first translation into English of any portion of them.
This was made by Peter Lowe. He published his translation in 1597,
and obtained a charter for our Faculty in Glasgow from James VI in
1599. His translation is notable as being the first attempt to render
into English, for the use of practitioners, any of the great Hippocratic
treatises. Hut we can not regard it as a very scholarly translation.
Indeed, it appears, from the researches of Dr. Creighton, that his
translation of the Presages (as he calls the Prognostics) was made
neither from the Greek nor Latin, but from the French version by
Canappe, published in Lyons in 1552; this, again, was from the Latin
edition of Rabelais, ami founded on the text of ('opus. The source of
Peter Lowe's translation is shown not merely by such things as the
headings of the chapters in the Presages, but by its association with a
translation of the Oath also; and, above all, by the prefixing of the
same Life which occurs in Canappe's French translation, but not in
Rabelais's edition.* In this Life, by a curious misprint, " Pereno "
occurs in all the four editions of Peter Lowe's translation instead of
Zeno (the Eleatic philosopher), who is referred to as a contemporary of
Hippocrates.
It is m the Prognostics that the celebrated passage occurs describ-
ing what is known as the " facies hippocratica." I will read you Peter
Lowe's rendering of it in his translation of The Booke of the Presages
of deuyne Hyppocrates. I quote from the third edition, but I believe
it is the same text as in the first, published in 1597 :
" How the Physitian or Chyrwgian may presage by signes of the
Face, in sick tiesse. — It is requisite to consider and contemplate the Face
of the sicke. First to know if it be such as in health, or but a little
different : and if it be so, the Mediciner Chirurgian may haue a good
presagment and hope of Recoverie. But if it be greatly altered, and
changed, as followeth, hee shall esteeme it in perill and danger of
death, when the nose and nosthrills are extenuated and sharpened by
the same maladie, and the eyes hollow, and the temples, viz., the parts
hetweene the eares and forehead are cleane, and the skinne of the
brow is hard, dry, and loose, and the eares cold and shronke, or almost
doubled, and all the face appeareth blacke, pale, livide or leaden, and
greatly deformed, in respect of that which it was in time of health."
On reading any rendering of this passage one is at once reminded
* Some further details on this subject may be found in Account of
tin TAfe anil Works uf Mnislcr I 'i ter /,<»//•,•, by .lames l 'inla \ son, M. D.
(Glasgow, 1889); also in an article by Dr. Charles Creighton on Fal-
stall''.- hcathbed, in Black woatV* Magazine, .March, 1889.
of the celebrated description in Shakespeare of the death of Falstaff,
where Dame Quickly says :
" For after I saw him fumble with the sheets and play with flowers,
and smile upon his fingers' ends, I knew there was but one way : for
his nose was as sharp as a pen and a' babbled of green fields," etc. —
Henry V, Act ii, scene 3.
The question has arisen as to how Shakespeare could have obtained
access to the description of the fades hippocratica, and it has been sug-
gested that Peter Lowe's English translation may have been available
for one who had " small Latin and less G reek." So far as the dates
go, they might, indeed, fit in, as Peter Lowe's translation was issued in
London in 1597, and King Henry V was first published in 1600. After
a full investigation of the subject, however, Dr. Creighton has come to
the conclusion that this translation i< not the source of Shakespeare's
phrases.*
Chronology — Hippocrates a lleaHfy. — 1 have placed nu the board
some dates to guide you in your ideas of the time, according to the
best authorities, when Hippocrates flourished, adding various dates
selected from different countries for the sake of comparison :
b. c.
Hippocrates (about) 460-357
Socrates 469-399
Zeno, the Eleatic philosopher, born 488
Plato 428-389
Aristotle 384-322
Roman Decemviri created 451
Virginius killed his daughter 458
Second return of the Jews under Ezra 458
But on looking at such a table one is reminded of important preliminary
questions which have been raised — viz., Was there such a man ? Were
not the Hippocratic writings merely a miscellaneous collection, issued
under a traditional name?
The first question seems capable of a satisfactory answer in the
affirmative. M. Littre, in his valuable edition of Hippocrates, in the
ten volumes now before you, has gone into this matter critically in the
elaborate introduction contained in the first volume. M. Littre was a
learned member of our profession ; he is the same of whom you have
all heard as the author of this great French dictionary, in four large
volumes, which I show you here. Some of you may also have heard of
him as an exponent of the positive philosophy of Comte. M. Littre
(vol. i, p. 29) quotes a passage from one of the dialogues of Plato (Pro-
tagoras), where Socrates is represented as saying to one of his auditors,
who happened to be called Hippocrates —
" If for example you had thought of going to Hippocrates of Cos,
the Asclepiad, and were about to give him your money, and some one
had said to you : You are paying money to your namesake Hippocrates,
0 Hippocrates : tell me, what is he that you give him money ? How
should you have answered?
" I should say, he replied, that I give money to him as a physician.
" And what will he make of you ?
" A physician, he said." f (Jowett's Translation, second edition,
vol. i. Oxford, 1875.)
M. Littre contends that this passage from Plato, who lived shortly
after the date ascribed to Hippocrates, proves that Hippocrates was a
physician ; of the Island of Cos ; of the family of the Asclepiadae ; that
he taught medicine, and received fees for doing so ; further, that as
the words are put into the mouth of Socrates, these two great men must
have been contemporaries. This little glimpse shows you the kind of
evidence which can be adduced to prove the veritable existence of Hip-
pocrates and his approximate date. Another passage is quoted by M.
Littre (vol. i, p. 72) from Aristotle, who, although somewhat later, is
still near enough to be an important witness (Polities, Lib. vii, cap. 4),
" When we speak of the great Hippocrates we understand not the man,
but the physician."
* See Blackwood's Magazine, March, 1889.
f M. Littre quotes another passage from Plato (Phmdrus) where
Hippocrates is spoken of as an individual and as a writer of authority.
The passage is quoted also by Dr. Warburton Begbie (Selections from
the Works of): London, 1882, p. 385.
April 23, 1892".]
MISCELLANY.
473
In his elaborate and learned introduction, M. Littre goes into this
discussion in great detail, quoting from Plato, Aristotle, and others ;
certain phrases in their works being adduced to show that these ancient
authors were familiar with certain portions of the Hippocratic writings.
From the necessity of this accumulation of proof, it must be evident
to you that there is no reliable Life of Hippocrates. Three lives are
referred to, the most important being one by Soranus, or rather accord-
ing to Soranus (koto. Swpavbv). This has been repeatedly published,
and is appended to the edition by Ermerins, as I show you, both in a
Greek and Latin text. There are insuperable difficulties in deciding who
this Soranus really was. It seems certain that he was not the same as
the K]»liesian Soranus otherwise well known in medical literature, al-
though this biographer is also said to have been of Ephesus ; it has
I icon further supposed that there was also a Soranus of Cos, who ex-
plored the records of that island, and whose materials were used for the
purpose of this biography.
The portraits of Hippocrates are all without authority. I show you
some representations copied from busts or antique gems. I also show
you portraits prefixed to certain editions of his works, but as none are
authentic, we need not linger on this subject.
Hippocratic Writings : Genuine and Spurious. — Although the per-
sonality of Hippocrates as a physician and an author is clearly estab-
lished by the best historical evidence, the authenticity of the various
treatises ascribed to him is quite open for discussion. The general con-
sensus of critics points to there being three different groups of the
treatises bearing his name.
1. Genuine works, undoubtedly Hippocratic.
2. Spurious works, certainly not written by the great Hippocrates.
3. Dubious works.
Of the spurious and dubious works one or two may have been ear-
lier, but the most of such are regarded as being of later production.
It is quite possible that some of the spurious writings of later date
may have been " Hippocratic " in the sense of being written by one of
that name, although not by our author, who is distinguished sometimes
by the adjective " Magnus," * to indicate his pre-eminence among all
those of the same name, and often, indeed usually, by the adjective
" Cous," to indicate the place of his birth.
Pre-Hippocratic Works. — The most interesting question as to the
authenticity of the writings turns on the date of certain of the works
ascribed to Hippocrates being really before his time, a subject discussed
with great learning by Houdart, Littre, Ermerins, Adams, Greenhill, and
others. That there were ancient medical writings before Hippocrates
may be taken as certain. One of the Hippocratic treatises regarded as
undoubtedly genuine by M. Littre (tome i, p. 320) is that On Ancient
Medicine. His opinion is based on a quotation from the Phccdrus of
Plato, and is supported by an elaborate argument ; this argument is not
admitted as conclusive by Dr. Adams ; but the latter points out, as an
"evidence of the reality of an ancient medical literature before the time
of Hippocrates, that " Xenophon, who was almost contemporary with
Hippocrates, puts into the mouth of Socrates, who was certainly nearly
of the same age, the saying that there were many medical works then
in existence (Memorab., iv)." If we accept the treatise On Ancient
Medicine as really by Hippocrates Magnus, its very title may be taken
as implying a pre-existing literature. If this treatise is rejected, we
have the testimony of another, universally admitted as written by Hip-
pocrates— viz., The Regimen in Acute Diseases. In this book the writer
begins with the words "Those who composed what are called The
Cnidian Sentences " ; we have thus clear proof of some ancient literature
in medicine available for Hippocrates to profit by and criticise. It
would seem as if Cnidos had been a rival school to that of Cos, to
which latter Hippocrates belonged; and these Cnidian Sentences have
been supposed to be the analogue in that school of the Coan Pronations
pertaining to Cos. This latter work was long regarded as a production
of Hippocrates, but is now supposed by many to be a part of that ear-
lier literature on which our author founded his work.
It could not escape attention that three of the Hippocratic treatises
— (1) The Prognostics, (2) The Conn Prenotiom, and (3) The Prorrhet-
* See the passage already quoted from Aristotle, where he is called
" the great Hippocrates."
ics — were in many ways similar. The first was universally regarded as
the most perfect, and so at one time the others were ascribed to subse-
quent and somewhat inferior authors or imitators. The resemblances are
well brought out in tabulations, such as I now show you in M. Houdart's
book. A critical comparison shows that both the Prorrhetics and the
Prenotiom contain the names, in detail, of individual patients from
whose cases some special prognostic is drawn, whereas the Prognostics
contain no such personal details. It seems pretty clear, therefore, that
the Prognostics, a much more finished production, omitting all personal
memoranda, must have followed instead of preceded the other two ;
and, as the Prognostics are universally admitted to be by Hippocrates, we
have very probably, in these other two, specimens of the work of ear-
lier observers, by whose labors Hippocrates could profit, and in doing
so could fairly enough rear for himself such a surpassing reputation as
the " Father of Medicine " ; for then, as now, acuteness of personal ob-
servation and independence of thought were quite compatible with
profiting by the labors of others and the experience of the past. I have
already read a short extract to you from the Prognostics, describing the
" facies hippocratica." This work is undoubtedly one of the greatest
and most celebrated of the Hippocratic writings.
Aphorisms. — Another equally famous is the Aphorisms. I have se-
lected the first and last aphorisms as specimens. The translations which
I propose reading to you are from Dr. Adams's admirable rendering ; but
I avail myself of two of his alternative translations in the first aphorism,
as somewhat more impressive, in my view, than those in his text :
I. 1. " Life is short, and the art long ; the time is urgent ; experi-
ment is dangerous, and decision is difficult. The physician must not
only be prepared to do what is right himself, but also to make the pa-
tient, the attendants, and externals co-operate."
The first clause, familiar to so many, is recognized by comparatively
few, even of the cultured, as being in the works of Hippocrates. The
first portion of the aphorism has the gravity of the philosopher ; the
second shows the practical experience of the physician ; I am sure you
will find as you go on in the profession that all the difference between
success and failure often depends on whether the physician possesses
this invaluable power of compelling patient, attendants, and even exter-
nal circumstances to co-operate with him in the proper management of
the illness. Mere knowdedge and skill often fail for the want of some
measure of this power.
The last aphorism is also celebrated, and I read it to you now, al-
though some doubts exist as to whether it has not crept into the first
book of the aphorisms from a continuation by a later writer :
VI. 87. " Those diseases which medicines do not cure, iron (the
knife ?) cures ; those which iron can not cure, fire cures ; and those
which fire can not cure, are to be reckoned wholly incurable."
Hippocratic Oath. — The Hippocratic Oath is so widely known that
perhaps it is scarcely necessary to read it ; some modification of it was
used when graduates in medicine were sworn in at the University here
in my time ; and even now it survives, to some extent, in the declara-
tion still made by you. It will be better, however, for me to read this
short Hippocratic piece in full, so that you may catch its full spirit and
meaning. The rendering is by Dr. Adams, whose translations I use here
whenever available :
" I swear by Apollo the physician and .Esculapius and Health [Hy-
geia] and All-heal [Panacea] and all the gods and goddesses, that, ac-
cording to my ability and judgment, I will keep this oath and this stipu-
lation— to reckon him who taught me this art equally dear to me as my
parents, to share my substance with him, and relieve his necessities if
required ; to look upon his offspring in the same footing as my own
brothers, and to teach them this art, if they shall wish to learn it, without
fee or stipulation ; and that by precept, lecture, and every other mode of
instruction, I will impart a knowledge of the ai t to my own sous, and
those of my teachers, and to disciples bound by a stipulation and oath
according to the law of medicine, but to none others. 1 will follow that
system of regimen which, according to my ability and judgment, I con-
sider for the benefit of my patients, and abstain from whatever is dele-
terious and mischievous.
" I will give no deadly medicine to any one if asked, nor suggest any
such counsel ; and in like manner I will not give to a woman a pessary
to produce abortion.
474
MlSt'ELLAXY.
[N. Y. Med. Joub.,
" With purity and with holiness I will pass my life and practice
my art.
" I will not cut persons laboring under the stone, lmt will leave this
to be done by men who are practitioners of this work.
" Into whatever houses I enter, I will go into them for the benefit of
the sick, and will abstain from every voluntary act of mischief and cor-
ruption, and, further, from the seduction of females or males, of free-
men and slaves. Whatever, in connection with my professional prac-
tice, or not in connection with it, I see or hear, in the life of men, which
ought not to be spoken of abroad, I will not divulge, as reckoning that
all such should be kept secret.
" While I continue to keep this oath unviolated, may it be granted
to me to enjoy life and the practice of the art, respected by all men, in
all times ! But should I trespass and violate this oath, may the reverse
be my lot ! "
There are two points in this oath to which I wish to call vour atten-
tion. The opening phrase, " I swear by all the gods and goddesses,"
has been recognized as mentioned by Aristophanes, where one speaker
says: "What better oath than that of the brotherhood of Hippocrates ? "
The other answers : "Well! I swear l.\ all the ^<>.ls " (Littre, tome i, p.
31 *). The other point in connection with the oath, to which I direct
your attention, is the remarkable passage forbidding those who are thus
sworn to cut for the stone. Hippocrates practiced various grave surgi-
cal operations, and it has been a matter of wonder that this one should
be forbidden. Some, indeed, have sought to solve the difticultv !>\ sug-
gesting that he does not refer to lithotomy, but to castration. f
It is almost certain that the operation referred to was really lithoto-
my; the separation of this operation from the ordinary practice of sur-
gery is indicated by the Founder of our Faculty here, for Peter Lowe
passes it over in his Discourse <>/ the Whole Art of Chyrwrgerie, which
was published while he was in Glasgow in 1612, referring its discussion
to his treatise entitled The Poorc Mans Guide. The operation from
the time of Hippocrates till very recently was practiced by a set of men
outside of the profession. In the Burgh Records of our city we have
the following suggestive entry :
" 27th March, 1G88. — The said day there was ane testitieat produced
in favor of Duncan Campbell, Bubscryvit be the haile doctors and
most part of the chirurgianes in toune, of his dexteritie and success
in cutting of the ston, as also in sounding with great facilitie, and lies
given severall proofes thereof within this burgh, whilk being taken to
the said Magistrats and Counsell their consideration, they nominal and
appoynt him to cutt such poor in toune as he shall be desyred lie the
Magistrats, in place of Evir M'Neil, who is become unfit to doe the
same through his infirmitie." — Memorabilia of the City of Glasgow,
Glasgow, 1868, p. 258.
Qualifications and Functions of the Physician. — With regard to the
necessary conditions for the successful study of medicine, I read you
the following short extracts from " The Law " ; I desire your special
attention to the profound wisdom of the last clause:
" Whoever is to acquire a competent knowledge of medicine ought
to be possessed of the following advantages : A natural disposition ; in-
struction ; a favorable position for the study ; early tuition ; love of
labor ; leisure. First of all, a natural talent is required ; for when Na-
ture opposes, everything else is vain ; but when Nature leads the way
to what is most excellent, instruction in the art takes place, which the
student must try to appropriate to himself by reflection, becoming an
early pupil in a place well adapted for instruction. He must also bring
to the task a love of labor and perseverance, so that the instruction
taking root may bring forth proper and abundant fruits.
. . . "But inexperience is a bad treasure and a bad fund to those
* M. Littre departed from this view of the passage while treating of
the oath (see tome ii, p. 48) ; M. Petrequin, however (Chirurgic d'/fip-
pocrate, tome i, Paris, 1877, p. 172), still adheres to this meaning of the
passage.
\ This question is discussed in an elaborate note, at the end of the
oath, by 11. Petrequin (Vhirurgie d^Jippocrate, tome i, Paris, 1877, p.
1!)2) ; lie comes to the conclusion that the oath refers to lithotomy, and
that it was proscribed owing to the disasters following its practice at
that time.
who possess it, whether in opinion or in reality, being devoid of self-
reliance and eontentedness, and the nurse both of timidity and audacity.
For timidity betrays a want of power and audacity a want of skill.
There are, indeed, two things, knowledge and opinion, of which the one
makes its possessor really to know, the other to be ignorant."
The following celebrated passage is from the First Hook of the
Epidemics (ii, 5) :
" The physician must be able to tell the antecedents, know the
present, and foretell the future — must meditate these things and have
two special objects in view with regard to disease — namely, to do good
or to do no harm. The art consists in three things — the disease, the
patient, and the physician. The physician is the servant of the art,
and the patient must combat the disease along with the physician."
Objection has been taken to the instruction that the physician
should " do no harm " as being unnecessary and too trivial, but after
twenty-three centuries the retention of this clause must be held to be
still essential by all who have seen much of practice. In connection
with this same spirit, I may refer to what has been called the " Hippo-
cratic Paradox." A thesis by (i. A. Langguth, I)c paradoxico hijipo-
cratico (4to, Wittembergae, 1754), discusses this paradox at some length
as you see. The paradoxical passage referred to is found in the treatise
on Articulations (40), which is regarded as genuine; it occurs in con-
nection with the treatment of injuries to the ears:
" For it is a good remedy sometimes to apply nothing at all, both to
the ear and to many other cases."
In connection with these same ideas, I have to call your attention
to a passage in one of the Hippocratie treatises ; although it is con-
sidered to lie of a later date than our author himself, this is of little
importance under the circumstances ; he speaks of Herodieus (his own
teacher and the inventor of medical gymnastics I as having occasioned
the death of not a few patients, affected with fever, while subjecting
them to treatment by means of vapor baths and violent exercises instead
of rest (Littre, tome v, p. 303).
The passage in which Hippocrates, according to the usual transla-
tion, speaks of " Nature " as the healer of our diseases has been dis-
cussed by Professor Gairdner in one of his essays, and subjected to his
fruitful criticism. The meaning of the phrase vovamv <pvoits i-qTpol
(Epidem., vi, 5) is shown by him to be somewhat different from the gen-
eral dictum about the " vis medicatrix naturae. " He shows that what
Hippocrates alleges is that "our natures are the physicians (or healers)
of our diseases," and he paraphrases it thus : " that normal function is
in every instance to be evoked and supported, and protected, as what is
usually the only way open to us for effectually overcoming abnormal
function." * This Hippocratie view of our natures being themselves the
physicians of our diseases is at present receiving fresh illustrations in
the remarkable studies now being pursued regarding the processes
which secure " immunity."
Are any Diseases Sacred or Divine? — The view taken by Hippoc-
rates of " the sacred disease," as epilepsy was called, is most philo-
sophical. The mysterious outbursts of this remarkable disease by
which a person, often in perfect health, is suddenly struck down and
given over to the most violent convulsions, which may quickly pass off,
so that he can resume his usual course in a short time, have suggested
in various ages and countries the idea of some special supernatural
agency, whether divine or demoniacal. He begins thus :
" It is thus with regard to the disease called sacred ; it appears to
me to be nowise more divine nor more sacred than other diseases, but
has a natural cause from which it originates like other affections. Men
regard its nature and cause as divine from ignorance and wonder, be-
cause it is not at all like to other diseases. And this notion of its
divinity is kept up by their inability to comprehend it, and the sim-
plicity of the mode by which it is cured, for men are freed from it by
purifications and incantations. But if it is reckoned divine because it is
wonderful, instead of one there are many diseases which would be
sacred ; for, as I will show, there are others no less wonderful and pro-
digious, which nobody imagines to be sacred."
* W. T. Gairdner, The Physician as Naturalist (Glasgow, 1889, p.
26(1); see also Dr. Warburton Begbie, Selections from the Works of
(London, 1882, p. 386).
April 23, 1892.)
MISCELLANY.
475
In a similar strain, he writes in the treatise On Airs, Waters, and
Places (22), with repaid to some disorder prevailing among the Scyth-
ians :
" It appears to me that such affections are just as much divine as all
others are, and that no one disease is either more divine or more human
than another, but that all are alike divine, for that each has its own na-
ture, and that no one arises without a natural cause."
It has been a great puzzle that, with such a clear statement of his
views on the subject, Hippocrates should himself, in his Book of Prog-
nostics (Lib. i), say that we are to ascertain
" Whether there be anything divine in the diseases."
It has been supposed that he may here use the word " divine " in
the sense of atmospheric or pestilential, or that he may be adapting
himself, for the time, to the popular language.
Hippocratic A uscultatory Signs. — In modern times we are so saturated
with physical methods of diagnosis, especially in chest disease, that we
can scarcely think of diagnosis without them. Although nearly all
these methods have been introduced within this century, there is \ at
least, which goes back to ancient times, and is even now termed " Hip-
pocratic suceussion." I have marked the passages in Littre's edition
so that you may see where this is referred to. In some of the passages
it is merely named or alluded to in passing, as a thing well known, but
I will render from Littre's translation one passage where the process is
described :
" You will place the patient on a seat w hich does not move, an as-
sistant will take him by the shoulders, and you will shake him, applying
the ear to the chest, so as to recognize on which side the sign occurs "
(Littre, tome vii, p. 153).
A very similar passage occurs in tome vii, p. 11. Both of these are
from the treatise De morbis (Lib. iii and Lib. ii respectively). The fact
that this sign may be absent in cases requiring operation is recognized
and ascribed to the quantity or density of the pus being too great.
The bulging and the pain are then to be taken as guiding to the affected
side. (Other passages referring to suceussion may be found in Littre's
edition, tome v, p. 681, and tome vi, pp. 151 and 309.)
The practical importance of suceussion seems to have depended
specially, in his view, in determining which side to operate on in cases
of empyema.
Another passage has been pointed out as referring to auscultatory
signs apart from suceussion. I will translate for you Littre's rendering
of this passage, the exact meaning of which is still involved in con-
siderable obscurity :
" And if applying the ear against the chest, you listen for a long
time, it boils within like vinegar" (De morbis, Lib. ii ; Littre, tome vii,
p. 95).
What auscultatory sound this was, which was to guide the operator
to the side on which the incision should be made, is not clear. That it
really was a sound which constituted the sign is clear from the con-
text, and amid various readings M. Littre prefers the word meaning to
boil.*
A sound resembling that made by new leather is described in pleu-
risy (De morbis, ii, 59 ; Littre, tome vii, p. 93). These and other refer-
ences to auscultation are given by Dr. Gee in his book on Auscultation
and Percussion (third edition, London, 1883), p. 100.
Cheyne- Stokes Breathing. — It is not in physical signs, but in general
symptoms, that the power of observation, undoubtedly pertaining to the
Hippocratic school, comes out most strongly. The Prognostics are
full of the keenest clinical observation. It is very interesting, and
even startling, to read a description of Cheyne-Stokes respiration in
those old times. This remarkable form of breathing is generally re-
garded as being a matter of observation only in recent times, noted by
the two great clinical observers whose names it bears. But, according
to Dr. Warburton Begbie (Selections from the Works of, p. 39(1), the
ease of Philiscus, in the First Hook of the Kpidcmics (13), as described
by Hippocrates, agrees with this type of breathing. It seems to me
that Dr. Begbie makes out his ease; but I will read the passage in
full, from Dr. Adams's translation, so that you may judge for your-
selves :
* Zffi : o£'et : : b<j/€<.
"Philiscus, who lived by the Wall, took to bed on the first day of
acute fever ; he sweated ; toward night was uneasy. On the second
day all the symptoms were exacerbated ; late in the evening had a
proper stool from a small clyster ; the night quiet. On the third day,
early in the morning and until noon, he appeared to be free from fever ;
toward evening, acute fever with sweating, thirst, tongue parched ;
passed black urine; night uncomfortable; no sleep; he was delirious
on all subjects. On the fourth, all the symptoms exacerbated ; urine
black; night more comfortable; urine of a better color. On the
fifth, about midday, had a slight trickling of pure blood from the nose;
urine varied in character, having floating in it round bodies, resembling
semen, and scattered, but which did not fall to the bottom ; a supposi-
tory having been applied, some scanty flatulent matters were passed ;
night uncomfortable, little sleep, talking incoherently; extremities alto-
gether cold, and could not be warmed ; urine black ; slept a little to-
ward day ; los.-. of speech ; cold sweats ; extremities livid ; about the
middle of the sixth day he died. The respiration throughout like that
of a person recollecting himself, was rare and large, the spleen was
swelled up in a round tumor, the sweats cold throughout, the paroxysms
on the even days."
Dr. Adams says in a note : " The modern reader will be struck with
the description of the respiration — namely, that the patient seemed like
a person who forgot for a time the besoin de respirer, and then, as it
were, suddenly recollected himself. Such is the meaning of the expres-
sion as explained by Galen in his Commentary, and in his work On
Difficulty in Breathing. By 'rare' is always meant 'few in number.'"
[The remainder of the demonstration related to the various editions
of the Hippocratic writings and to those of commentators.]
The History of a Forgotten Compress. — The Lancet for April 2d
prints the following in a letter from its Paris correspondent :
At the Societe de chirurgie on March 23d the following remarkable
occurrence was reported by M. Pilate, of Orleans: On April 4, 1890,
abdominal section was performed on a woman, aged forty-four, for a
painful tibro-myoma of the uterus. The uterus was removed with con-
siderable difficulty, the pedicle fixed to the abdominal wound, the edges
of which were then brought together. In order to protect the neigh-
boring viscera during the operation, a certain number of sponges and
gauze compresses — all carefully asepticized— were introduced into the
abdominal cavity, each compress and sponge being held with a forceps.
The same evening vomiting and pain came on, lasted for six days, with-
out any elevation of temperature. A month after the operation the
woman was considered cured. In the month of August, however, pain
attributed to the presence of gall-stones appeared in the right hypo-
chondrium ; this disappeared in a few days. In September there was a
renewal of the pains, which now involved the whole of the abdomen,
and were accompanied by vomiting and tympanites, without fever.
Palpation revealed the presence, in the region formerly occupied by the
uterus, of a series of hard, movable nodules, resembling cancerous
masses. A re-examination under the microscope of the tumor removed
showed that it was a pure fibro-myoma. The patient remained in much
the same condition for two months, when one day she passed per rec-
tum a gauze compress enveloped in a hard fajcal mass. All the un-
pleasant symptoms very soon subsided, and the woman has remained
well since that event. This curious occurrence demonstrates the im-
portance of counting sponges and compresses used in such operations,
and furnishes one more proof of the harmlessuess of foreign bodies
which have been rendered thoroughly aseptic. The course of events
must have been as follows: The compress, after having lain encysted
must have excited an attack of peritonitis, with perforation of the in-
testine. That the occurrence of such a contretemps is not altogether
unknown in the practice of the most careful surgeons is well attest-
ed. One operator now uses in abdominal sections fifteen compresses,
hemmed in red, the enumeration of which is carefully made on the
completion of the operation. A well-known surgeon once left a forci-
pressure forceps in the abdominal cavity. The instrument remained in
the cavity for eight months, and was then eliminated through an ab-
scess which formed in the umbilical region. Another relates how he
once left a sponge in the abdomen, the patient dying of peritonitis three
days after the operation. He no longer employs sponges.
476
MISCELLANY.
[N. Y. Med. Jouk.
An Ancient Epigram and a Modern Instance. — The British Medical
Journal states that one of the physicians of the Glasgow Western In-
firmary objects to his patients being handled on cold mornings by stu-
dents having cold hands. In order to call attention to this evil, com-
plained of anciently by Martial in his epigram to Symmachus, his physi-
cian, the Glasgow professor offered a small prize for the best, translation
of Martial's epigram:
Languebam ; sed tu comitatUE protinus ad me
Venisti, centum, Symmache, discipulis.
Centum me tetigere manus Aquilone gelatae. '
Non habui febrem, Symmache; nunc habeo.
The committee has decided that two of the translations are equally
good. One is by Mr. J. F. R. Gairdner, after the manner of Burns :
Smart cam' ye, sir, to me na weel,
A hundert students at your heel ;
A hundert harms did ower me feel
Wi' Boreas blue.
I had nae fever then, but deil,
I have it noo.
The other rendering, by Mr. J. P. Gemmill, reads :
I lay in number twenty-one, a case for rest and tonics,
And "ood old G came round to me with all his train of chronics ;
A hundred meds., with fingers blue, palpated me like Lister,
And now, no longer weak and cold, I'm frizzling like a blister. 1
In this connection, attention is called to Dr. Dupouy's rendering in
his Medians et maws de Tancienne Rome, aVapres lets poetex latins:
.T'etais dessus mon lit, couche uonchalamment ;
Le mediein Symmaque arrive incontinent.
Les disciples nomhreux, imitant son audace,
Portent sur moi les mains plus froides que la glace,
Et me tatent le pouls alternativement.
Je u'avais pas la fievre, je l'ai maintenant.
The Alkaloids of Aconitum Napellus. — Two papers of unusual in-
terest, says the lancet for March 19th, were read at the last meeting of
the Chemical Society, on the 3d inst,, by Professor Dunstan. The first*
paper was a record of the research carried out jointly by Mr. Umney
and Professor Dunstan on the properties of the roots of Aconibmri
napellus. For the purpose of experiment they dried the fresh roots at
a low heat, and then, after powdering, exhausted them with fusel oil.
The alkaloids were dissolved out of the fusel oil with weak sulphuric
acid, and the acid mixture was treated with chloroform to remove
resin. The liquid was next made alkaline with ammonia and shaken
with ether and then with chloroform. The ethereal solution yielded a
gummy residue, from which they extracted aconitine as a crystalline
hvdrobromide, all attempts to crvstallize the residue having failed.
Crystalline aconitine was successfully prepared from the hydrobromide,
and it was found that the base dissolves only to the extent of 1 in
4,431 of water. The base does not appear to exist naturally in a com-
bined state, as the juice squeezed out of the fresh root contained very
little aconitine. All attempts to crystallize another alkaloid found in
the ethereal liquid failed. It possesses a bitter taste, does not produce
numbness, and Mr. Umney and Professor Dunstan have given it the
name " napelline." The chloroform solution contained aconine,
CaoIIuXOn, the properties of which and its relation to aconitine
formed the subject of the second paper, contributed by Professor
Dunstan and Dr. F. W. Passmore. The authors showed that by heat-
ing aconitine with water in a sealed tube at 150° C, aconine and ben-
zoic acid are formed, as originally stated by Wright and Luff. The
properties of aconine have been studied ; it is dextrorotatory, while its
salts, like aconitine, are laevorotatory. The authors made attempts to
synthesize aconitine by heating aconine with ethyl benzoate, and the
successful results which followed the experiments are calculated to be
of the utmost importance to pharmacy and medicine. The action
which takes [dace may be represented as follows: C^H^NOi, (aco-
nine) + CellsCO.OC^lL (ethyl benzoate) = C26H40(C6H6CO) NO,, (anhy-
dro-aconitine) + CaH60H (ethyl alcohol). Anhydro-aconitine so ob-
tained forms aconitine with water. The experiment indicates that
aconitine is monobenzov) aconine, C«&4o (C«H»C0) NO,,. Due or two
derivatives were prepared — aconitine methyl iodide, for example — the
physiological action of which, as well as the other new compounds, is
being studied.
The New York Academy of Medicine. — The special order for the
meeting of Thursday evening, the 21st inst., was a paper on Hydro-
therapy, by Dr. W. II. Draper.
At the next meeting of the Section in Laryngology and Hhinology,
on Wednesday evening, the 27th inst., Dr. C. A. Powers will read a
paper on Partial Laryngectomy, and Dr. J. K. Xewcomb will read one
on Syphilis of the Lingual Tonsil.
At the next meeting of the Section in Obstetrics and Gynaecology,
on Thursday evening, the 2Kth inst,, Dr. H. J. Holdt will read a paper
on Carcinoma Uteri, and Dr. C. A. von Ramdohr will read one on The
Treatment of Puerperal Fever.
Messrs. Reed & Carnrick's Preparations. — In our last issue we copied
an article from the Lancet to which we gave the heading An Apprecia-
tive Notice of American Pharmaceutical Preparations. By inadvertence
we omitted the Lancet's heading showing that the article related to
Messrs. Heed \ Carnrick's preparations.
To Contributors and Correspondents. — The attention of all who purjiose
favoring us with comrnunicat ions ts respectfully called to the follow-
ing:
Authors of articles intended for publication under the head of " original
contributions " are respectfully informed that, in accepting such arti-
cles, we always do so with the understanding that the following comlr-
lions are to be observed: (1) vihen a manuscript is sent to this jour-
nal, a similar manuscript or any abstract thereof must not In or
have been sent to any other periodica', unless we are specially no ifieil
of the fact at the time the article is sent to its; (2) accepted article*
are subject to the customary rules of editorial revision, and u id be
published as promptly as our other ingagenants will admit of — we
can not engage to publish an article in any specified issue ; {3) anu
conditions which an author wishes complied with must be distinct/-
slated in a communication accompanying the manuscript, anil »«<
new conditions can be considered after the manuscript has been fui
into the type-setters1 hands. We are often constrained to decline
arti les which, although tliey may be creditable to tlieir authors, are
not suitable for publication in this journal, either because they art
ton long, or are loaded with tabular matter or prolix histejnrs of
cases, or d<al with subjects of little interest to t/ie medical profession
at large. We can not enter into any eorrespondime concerning our
reasons for declining an article.
All letters, whether intended for publication or not, must contain the
writer's name and addr ss, not necessarily for publication. No » -
tenlion will be paid to anonymous communications. Herea fter, cur-
respondtnts asking for information that we are capable of givinri.
and that can properly be given in this Journal, will, be answered by
number, a private communication being previously sent to each cor-
respondent informing him under what number the answer to his note
is to be looked for. AH communications not intended for publication
under the author's name are treated as strictly confidential . We can
not give advice to laymen us to particular cases or recommend indi-
vidual practitioners.
Secretaries of medical societies will con fer a favor by keeping us in-
formed of the dates of their societies' regular meetings. Brief notifi-
cations of matters that are expected to come up at particular meet-
ings will be inserted when they are received in time.
Newspapers and other publications containing matter which the person
sending them desires to bring to our notice should be marked. Mem-
bers of the profession who send its information of matters of interest
to our readers will be considered as doing them and us a javor, and,
if the space at our command admits of it, we shall take pleasure in
inserting the substance o f such communications.
All communications intended for the editor should be addressed to him
in care of the publishers.
All communications relating to the business of the journal should be ad-
dressed to the publishers.
THE NEW YORK MEDICAL JOURNAL, April 30, 1892.
(Original (Communications.
RESULTS IN CASES OF HIP-JOINT DISEASE
TREATED BY
THE PORTABLE TRACTION SPLINT
WITHOUT IMMOBILIZATION,
EXCEPT DURING THE INFLAMMATORY STAGE OF THE DISEASE.
By LEWIS A. SAYRE, M. D.,
PROFESSOR OP ORTHOP.EDIC SURGERY
IN THE BELLEVTJE HOSPITAL MEDICAL COLLEGE.
In the last few years so many papers have been pub-
lished on hip-joint disease, advocating absolute immobiliza-
tion of the joint during the entire treatment of the case, and
in many cases without traction, and some of them condemn-
ing the portable traction splint, which has yielded such ex-
cellent results in my hands, as well as in those of many
others who have used it properly, that I have taken the
trouble to look over my note-books and ascertain the re-
sults in the various cases of which I have record.
In some cases the recovery has been so perfect and com-
plete, in reference to both form and motion, that the ques-
tion has been raised whether the patients had ever been
troubled with hip disease. It is on this account that I have
selected only such cases to report as had been examined by
other surgeons of the highest standing, and whose knowl-
edge and ability to make a correct diagnosis would certainly
be unquestioned in the professional world.
Case I. — In August, 1877, while on a visit to London, I was
requested to see J. C. O'C, an Irish boy of five years, in con-
sultation with Mr. William Adams and Sir James Paget, who
had been attending the lad, in connection with Dr. Quain, for
disease of the right hip joint since April, 1877. The mother
was an uncommonly healthy and vigorous woman of about
thirty. The father, an unusually stout and robust man, had died
of apoplexy.
The boy had fallen out of a broughnm while driving on a
hard road in Ireland in November, 1876, during his mother's
absence, and the nurse had concealed this fact for some months.
He gradually grew stiff in his gait, and then became quite lame.
The lameness increased and the joint became very painful, espe-
cially at night, waking him out of a sound sleep with frequent
paroxysms. The mother brought him to London to consult Dr.
Quain, who called Sir James Paget and Mr. William Adams in
consultation, and they all agreed in the diagnosis of hip disease
of the right side, and confided him to Mr. Adams for treatment,
Sir James Paget and Dr. Quain seeing him occasionally. Mr.
Adams applied a stiff molded leather to the hip and a splint to
the leg, with extension by weight and pulley, and forbade the
child to walk — an imitation, or, as he said, " a modification of the
American plan of treatment."
The case not progressing favorably. Sir James Paget, became
dissatisfied with the American plan, and I was called in consul-
tation in August, 1877. There was no difference of opinion as
to the diagnosis. We all agreed that it was an unmistakable
case of hip disease in the first stage, rapidly advancing to the
second stage. There were flexion of the thigh, abduction of the
limb, oversion of the toes, and perfect immobilization of the
joint from muscular rigidity, and the very slightest pressure on
the trochanter, or upward from the knee or heel, caused the
most exquisite pain. The slightest attempt at movement with-
out traction was unbearable. But as soon as slight traction was
made in the direction of the distorted limb, while the pelvis
was held immovable, very slight motion could be made at the
joint without pain.
We did not agree in the opinion as to the cause of the trouble.
They were disposed to attribute it to the strumous condition of
the boy, on account of the great disparity in the ages of his
parents. But, as they were both in perfect health at the time of
his birth, and the boy had always been in perfect health up to
the time he was thrown from the brougham, I was disposed to
attribute the disease to this accident, and not to any constitu-
tional diathesis.
We also differed in our prognosis of the case. They con-
sidered recovery with ankylosis a very good result ; and I con-
tended that many patients recovered with good motion, and
sometimes with little or no deformity. I was therefore re
quested by Mr. Adams to take charge of the case.
No change was made in the mode of extension of the leg by
the weight and pulley ; but I removed the leather splint from
around the thigh and pelvis, and, passing a handkerchief around
the upper part of the thigh, attached it to a cord, with a weight
and pulley to make lateral traction * from the side of the bed,
and fixed the body and well limb to a long splint, thus keeping
the body in a horizontal position and absolutely at rest until the
acute symptoms subsided and the limb was in proper position
to apply a splint.
Mr. Ernst, Mr. Adams's instrument-maker, manufactured
under my supervision a very perfect long splint, which I ap-
plied to the boy in the last of August, 1877. In a very few days
he was able to walk on this splint, with his sound leg elevated
on a high shoe, without any pain, and could sit down with but
very slight inconvenience. This splint was used by day, and
the weight and pulley extension at night, the nurse having been
very carefully instructed as to the proper application of the in-
strument as well as the night extension. He returned to his
home in Ireland in September, and Dr. Hobart, of Cork, ap-
plied the Maw's moleskin adhesive strips about every three
months, or as often as necessary.
This long splint was worn for eleven months, when he had
so far improved that my short hip splint, with double perinea
bands, was substituted for it. With this short splint he was
able to get about very much more comfortably, particularly in
sitting down, as it gave full power to flex his knees, the lack of
which is one of the objections to the long splint. He wore this
splint about a year, and when I removed it, in the fall of 1879,
he was perfectly well of the disease, with no perceptible de-
formity and quite free motion of the joint. The limbs were of
equal length, but the right one was much atrophied from want
of use.
He had a very competent nurse, who gave the limb massage
and manipulation daily, carefully increasing the range of motion
without exciting fresh inflammation, and in a few months the
motions were as perfect in one joint as in the other, and have
continued so. He was under treatment a little over two years.
He is now nineteen years old, in perfect health, can run, jump,
and undergo severe military drill for many hours as well as the
average. He is perfect in form, can flex the thigh to an acute
angle, and cross the foot over the thigh of the opposite side, as
* As there lias been considerable discussion as to priority in the ap-
plication of lateral traction in hip-joint disease, I may say that on look-
ing over my notes I find that I applied it to L. A. McC. in L868 in the
presence of Dr. L. M. Yale, this being the case to which I first applied
a platform joint with abducting screw with a short splint, the original
drawing of which, by Dr. Yale, I found in my note book.
478
8A YRE: HIP- JOINT DISEASE.
[N. Y. Med. Jour.,
seen by the photographs. This last motion is very difficult to ac-
complish if there is the least rigidity about the hip joint. Most
patients having recovered from hip disease, even with quite good
motion of the joint and with hut a very slight limp, yet can not
cross the foot to the opposite side to tie their shoes, but always put
their foot to the side and behind them in order to get at their
foot. I therefore look upon this test as the best proof of per-
fect motion in the joint.
Case II. — J. McC, aged four years, daughter of A. McC,
Troy, N. Y., was sent to me in July, 1864, by Dr. Brinsmaid
and Dr. Thorn, of Troy, who had been attending her for six
months for a very painful trouble of her right hip, which was
supposed to be rheumatic. As she made no improvement, Dr.
Alden March, of Albany, was called in consultation and diag-
nosticated hip disease in the second stage, rapidly progressing,
and with very great constitutional disturbance. Dr. March
thought the disease due to a fall the child had received the
winter previous, and advised them to send her to me for treat-
ment.
I saw her on the 9th of July, 1864, at the St. Nicholas Hotel
in this city. She was rather small for her age, very pale and
ansemie, exceedingly irritable, and almost all the time crying
from pain when she was not under the influence of an anodyne,
which had to be repeated frequently, especially at night. The
limb was flexed forty-five degrees, abducted, and strongly
rotated outward, with the toes everted. There was some
fullness over the hip joint, which was exceedingly sensitive to
the slightest touch, and the least pressure on it in any direction
caused her to scream in agony, as did also the slightest attempt
at motion when made without traction or extension. When,
however, the pelvis was held still by an assistant and the limb
was seized firmly, and slightly flexed, «Jducted, and rotated out-
ward, then slight traction on the limb while held in this posi-
tion gave her perfect relief from all pain, and she seemed
happy. The instant the traction was removed she screamed in
agony, and was only relieved by a repetition of the traction
in the same line as at first applied while the pelvis was held
still and free from movement.
Diagnosis. — Hip disease, second stage.
Treatment. — Extension in the line of the deformity, the line
of traction to be daily changed until the limb was in normal
position, then apply a short hip splint for daily exercise,' and
extension by weight and pulley at night. In the mean time
to apply a blister 2x4 inches behind the trochanter, to be
repeated if necessary. Messrs. Otto & Reynders measured her
for my short hip splint, which they said was the smallest one
they had ever made. I applied adhesive strips from the ankle
to two inches above the knee, and secured them by a firmly-
applied flannel roller. To the lower ends buckles were at-
tached for the purpose of making extension. The whole
limb was raised on a pillow and slightly abducted ; the body
was also propped up by a chair behind the back to relax the
psoas and iliacus muscles, the foot of the bed being ele-
vated and a four-pound weight attached. In less than an
hour the child was in a sound sleep, which the parents said
had not occurred before for many months without an ano-
dyne. The blister had a beautiful serous discharge in about
seven hours, and dried up in about two days. It was repeated
twice in the course of the next ten days. The line of traction
was gradually changed, and in two weeks the leg was parallel
with the other. I then applied my short hip splint with
the single perineal band for counter-extension, and she was
perfectly comfortable. The following day she was able to sit
up in a chair, and after some little instruction was able to walk
around the room on her crutches quite comfortably.
She returned to Troy that night by the steamboat, and as it
was difficult for them to apply the night extension by weight and
pulley in the berth on the steamer, I advised them not to re-
move the splint for that night, but allow her to sleep in it,
which was done, and " she arrived at home the following day
without any pain or inconvenience," as stated in a letter to me
from Dr. Brinsmaid a few days after.
I received letters from Dr. Brinsmaid every few weeks dur-
ing the summer and fall, stating that she was entirely free from
pain and growing very rapidly ; that he " had no occasion to
change the plasters, as the splint was retained in position as
I had left it, and that he increased the extension as the limb
grew longer by keying out the splint a notch or two every few
weeks as the case required."
In February, 1865, while attending the meeting of the State
Medical Society in Albany, Dr. Alden Marsh and myself were
invited to dine with Mr. McC. in Troy, and to see the great im-
provement that had taken place in his daughter's hip. Dr.
Brinsmaid, of Troy, was also present at the dinner. We found
the little girl running around the room with her crutches, in
perfect health, and in very good shape ; but when we stripped
her for examination I was very much surprised to find the
splint and bandages exactly as I had applied them in July, 1864,
nearly seven months before, the splint having never been re-
moved during all that time, and the night extension by weight
and pulley had never been applied. The extension had been
kept up by keying out the splint occasionally, and as the ad-
hesive plasters had remained in situ, as I had originally placed
them, the traction was perfect.
Dr. Brinsmaid explained that the reason of his leaving on the
splint at night was the fact that she had slept so comfortably
with it on in the boat on her way home that he was afraid to
remove it, fearing that he might not again be able to replace it
in exactly the same position, and, as she had suffered so many
months of intense pain before, and was so perfectly comfortable
since it had been applied, he preferred to leave it, merely cover-
ing over the soiled bandages with a clean roller as occasion re-
quired, but never disturbing the original bandage or adhesive
plaster.
This was to me an entirely new revelation, but, as she was
so perfectly comfortable, I advised them to continue the same
plan, but to send her to me as soon as I returned to the city,
that I might make a new application of fresh plaster.
She was sent to the city on ihe 1st of March, 1865, and I
removed the dressings, which, of course, were very much
soiled ; but the plasters were in exactly the position as origi-
nally applied in the preceding July, and, on carefully removing
them, the scarf-skin came off with them, but left no abraded
surface underneath. As the skin was not in a tit condition for
the immediate application of the plaster again, I put her to bed
with an extension from her foot for a few days until the skin,
by the daily washing with alcohol, should be in proper condi-
tion for the reapplication of the Maw's adhesive plaster for the
extension splint. On the 4th of March, 1865, the adhesive
plasters, bandage, and splint were applied as in the first in-
stance, and she returned to Troy. She wore this splint con-
stantly, day and night, for two years and a half, and was then
perfectly well. She had returned to the city four times during
that period to have the plasters removed, and there was never
any abrasion of the skin.
I saw her mother at the Mizzen Top Hotel, in Putnam
County, in September, 1890, and she stated that her daughter
was in perfect health, married, and had two children. Her
form was perfect, the limbs were of equal length, and she had
perfect motion of every joint.
Case III. — D. E., son of one of New York's most distin-
guished physicians, both of whose parents were perfectly
April 30, 1892.]
SAYRE: HIP-JOINT DISEASE.
479
healthy, foil inT869, when he was six years old, from a trapeze
in Wood's Gymnasium, striking on the wooden floor on his left
hip and thigh, and driving a splinter of wood into the outside of
tiie left thigh just below the trochanter major. This splinter of
wood was cut out by Dr. George A. Peters the same afternoon,
and the wound healed kindly in a short, time.
Some two months after this accident he began to limp, and
walked so stiffly and awkwardly that he was taken to Dr. Valen-
tine Mott, who advised him to be put to bed, with a stimulating
liniment applied to the joint. In a few weeks he seemed so
much better that he got up and walked very comfortably, but,
going down stairs, caught his left foot in the banister and fell
down a flight of twelve steps, striking on the marble hall floor
on the same left hip that had been previously hurt. Having
disobeyed the orders of Dr. Mott as to perfect rest in bed, they
did not inform him of this last accident, thinking that the
trouble would soon subside by rest again in bed. But at the
end of three weeks he had grown so much worse that Dr. Mott
was called again to see him, and, finding him so much worse
than at his last visit, some two months before, he called Dr.
W. H. Van Buren in consultation, who at once diagnosticated
it as a case of hip disease, and advised to have me see him. I
saw him in consultation with Dr. Mott and Dr. Van Buren, and
found him with the left thigh flexed, abducted, toes everted,
aud hip apparently ankylosed from muscular rigidity. The
least attempt at movement without traction caused the most
exquisite pain, as did pressure on the joint from any direction.
Very slight traction, with flexion and eversion, relieved the pain,
and permitted the slightest movement of the joint when the
pelvis was held immovable.
Diagnosis. — Hip disease, second stage, with effusion in the
joint, in which opinion we all agreed. Dr. Van Buren requested
that I should take charge of the ease, to which Dr. Mott cheer-
fully consented.
1 placed him in bed with the foot elevated, applied a long
splint to the right side of the body and leg, and applied adhesive
plaster with weight-and-pulley extension to the left leg, and
also applied traction from the upper and inner portion of the
thigh by a weight and pulley at the side of the bed. A blister
4x4 inches behind the trochanter was applied. A pillow was
placed under the thigh and leg to accommodate the flexion of
the limb, and the thickness of this support was gradually 're-
duced as the limb became straighter, and in a few days it was
down in the bed and parallel with the other limb. The blister
had a very decided influence on the effusion in the joint, and
was repeated three times in the course of a few weeks.
From the moment that the double traction was applied to
the limb his pain was entirely relieved. No sedatives of any
kind were used from this time, although he had been compelled
to resort to them every night for some time previous to the ap-
plication of the traction. He was kept rigidly in this horizontal
position, with the traction, for a little over three months, when
he was so much improved that I then applied to him my short
hip splint, with which and a pair of crutches he was able to
walk about during the day, while the extension was continued
at night by the weight and pulley. The splint was reapplied
every few months as the plaster became loose, and was worn
for nearly two years, when he was entirely cured, and had quite
good motion of the joint, the limb was considerably atrophied,
but apparently of equal length with the other.
The motions gradually increased with exercise and the limb
developed until it became in time as large as the other, and he
was the champion athlete of Columbia College, having won a
mile-and-a-quarter run in 1879. He is now perfect, as seen in
photograph.
Case IV.— In December, 1864, I was requested to meet Dr.
Naudain, of Westchester, in consultation with Dr. Valentine
Mott, to examine the youngest son of Mr. G. M., of Morrisania.
He was a lad of four years and sir months, rather delicate in
appearance, and apparently suffering great pain on the lea*t
movement in any direction, but more especially if any move-
ment was made of his right lower extremity, which was slightly
drawn up and abducted, but rigidly fixed by muscular contrac-
tion. There seemed to be some fullness around the hip joint,
but no distinct fluctuation could be detected. The least press-
ure or motion of the joint caused him to scream violently ; but
when the pelvis was held, and slight traction made on the limb
in the line of flexion and abduction, he was almost immediately
relieved.
The boy's father was very vigorous and robust, but suffered
from rheumatism and gout. The mother was very delicate and
suffering from phthisis, from which she eventually died.
The boy, although delicately built, had always been very
active and venturesome. In the early spring of 1864 he had
climbed upon the stone wall of the garden to pick some lilac
flowers, and in breaking off the branch had lost his balance and
fallen about four or five feet into a pile of stones. He cried very
bitterly for some time, but the next day seemed as well as ever;
and the accident was forgotten. After a few weeks the mother
noticed that he was a little stiff in the morning and favored one
leg when standing, but in a few hours he would run about as
before without any complaint of pain, and she therefore attrib-
uted it to "growing pains" and gave no attention to it until
later in the fall, when his lameness became so much worse that
Dr. Naudain was again called to see him.
As the father was a martyr to rheumatism and gout, the
doctor thought the boy had inherited the diathesis, and treated
him accordingly. But after some weeks, as he did not im-
prove, Dr. Mott was called in consultation and diagnosticated
the case as one of hip disease, and advised them to place him
under my treatment.
I saw him the following day in consultation with Dr. Mott
and Dr. Naudain, with the symptoms already described in this
paper, and of course confirmed the diagnosis of Dr. Mott. I
applied traction to bis limb in the line of the deformity by means
of adhesive plaster and weight and pulley, and also lateral
traction from the upper part of his thigh by a handkerchief
around the limb attached to a weight by the side of the bed, and
applied a blister 2x2 inches behind the trochanter.
As soon as the traction was properly adjusted he fell asleep
without any opiate, which the mother said he had not done for
some months. He was kept in his bed a little over two months*
Dr. Naudain changing the line of traction as required, until his
limb was perfectly straight at the pelvis and parallel with the
other. I then applied my short hip splint, and in a few days
he could walk with the aid of crutches very well. At night the
splint was removed, and the extension applied by weight and
pulley. The splint was reapplied every few months, as the ad-
hesive plaster became loose, and was worn constantly, except at
night, for a little over two years. At the end of two years and
a half he was perfectly well, and had quite free motion of his
joint. This gradually increased until it became perfect, and lias
remained so.
Some two years ago, w hen I first thought of preparing
this paper for the meeting of the Orthopaedic Society in
Philadelphia, I wrote to him to send me his photograph in
the different positions I have described, in order to illus-
trate the perfect motion of the joint. I received no replv.
and was then taken very ill, and the paper was not com-
pleted. Some months after I received the following letter,
and in a few days the accompanying photographs.
480
SAYRE: HIP-JOINT DISEASE.
[N. Y. Med. Jock.,
Glenwood Springs, Colorado, September 9, 1890,
My dear Doctor: Your letter was delayed some time in
reaching me by being misdirected, and consequently going to
the Dead-letter Office.
I have had photographs taken as you wished, and they will
be sent you by the photographer. 1 had to have each position
taken right and left, for I do not know which leg was injured.
I do not know just how old I was, nor what kind of splint or
brace I wore. I am very well and athletic, riding on bucking
horses, and using all my limbs and muscles with absolute ease
and comfort.
Hoping the photographs will be satisfactory, and with much
love, I am Your grateful friend, R. M.
I saw him in January, 1892, on his way to Europe, and
he was perfect in form and motion.
Case V. — L. EL, aged thirteen, Buffalo, N. Y. Father and
mother apparently healthy ; an aunt died of phthisis, and grand-
mother had Pott's disease. She was brought to me on April
17, 1886, by Dr. Jewett, of Buffalo. Menstruation began at
eleven, has always been rather profuse, and the patient is now
quite anasmic.
In November, 1885, complained of great pain in right hip.
Shortly before that her cousin had given her a severe twist by
catching her around the neck and pulling her backward. For
some time after this she complained of great pain in her back.
For the past two months has had nocturnal startings. Six weeks
ago was put to bed, and had blisters applied over and behind the
trochanter, but no extension. Dr. Kirtland, of Dtica, and Dr. F.
B. Johnson, of Towanda, then saw her in consultation with Dr.
Jewett, and they all diagnosticated hip disease of the right side,
with probably sacro-iliac disease of the same side.
She was brought to the city, and I saw her in consultation
with Dr. Jewett on April 17, 1886. Very limited motion of
right hip from muscular rigidity ; great pain on compression,
both longitudinally and laterally ; also great pain over the right
sacro-iliac junction, and pain on lateral pressure of the ilia, and
the body strongly bearing to the left; thigh flexed, abducted,
and fixed by muscular rigidity, and the toes everted.
Diagnosis. — Hip disease, right side, second stage, and sacro-
iliac disease of right side.
Treatment. — Put to bed, with weight-and-pulley extension
to reduce the limb to the normal position. From this time all
night spasms ceased, and she slept quietly without any narcotic-
although she had been compelled to resort to them once or twice
every night for some weeks before.
May 17, 1886. — The limbs had become so nearly parallel that
the long hip splint was applied, and, by the aid of crutches and
a high shoe on the left side, she was able to walk quite com-
fortably, and went back to Buffalo.
October 4th. — Returned, very anaemic from profuse menor-
rhagia. Tenderness over the trochanter and just above; deep
fluctuation posterior to the trochanter.
10th. — Put on new adhesive plaster, and applied the actual
cautery over the tender spot on the trochanter, and also over the
sacro-iliac junction on right side, which was tender.
December 10th. — Wounds from actual cautery entirely well.
The abscess which seemed to be forming above and behind the
trochanter has disappeared, and no fluctuation can be felt.
January, 1887. — The hip is much less tender; opened the
knee joint in splint to allow the knee to be bent while sitting.
November. — Very greatly improved ; is free from all pain;
can flex, extend, adduct, abduct, and rotate the leg almost as
perfectly as the other. Removed the plasters from the leg and
applied the splint, with a box in the sole of the shoe and flexion
at knee joint when sitting
This was worn until August, 1888, when she was found to
be perfectly well, and all treatment was abandoned. The limb
was very nearly of the same length as the other, but not so large
in circumference. The motions in the joint were almost per-
fect and complete.
June, 1890. — Is in perfect health, and has no difficulty in per-
forming any motion of the joint, as seen by photographs taken
by Dr. Reginald II. Sayre, January, 1890.
Case VI. — F. N., aged nineteen years, 18 West Twenty-
eighth Street. On October 21, 1872, I was requested by Dr.
Barker to see Mr. F. N., aged nineteen, who had been sent borne
from Harvard University by Dr. Bigelow, of Boston, on account
of bis suffering from hip disease, which prevented him from at-
tending to his college duties. I fully confirmed the opinion of
Dr. Bigelow, which greatly disturbed his mother, as she could
not believe that he could have any such serious trouble, because
he had always been so strong and healthy, and she did not like
him to give up his college course, and she therefore wished Dr.
Van Buren to be called in consultation, hoping that he might
differ with Dr. Bigelow and myself.
Dr. Van Buren saw him with Dr. Barker and myself on the
22d of October, 1872, and, after a most careful examination,
pronounced it hip disease, first stage, far advanced toward sec-
ond stage. The limb was apparently longer, flexed, a&ducted,
and rotated outward, and firmly fixed by muscular rigidity,
apparently ankylosed. The slightest pressure on, or the
least motion of. the joint caused intense pain and made him cry
severely.
In the early spring of that year, while running across coun-
try at Lenox, he had slipped one foot into a deep ditch, while
the other leg was stretched out sideways on the ground. He
was considerably hurt, and kept his bed for two weeks, at the
end of which time he thought himself well, yet there remained
a slight pain, which, in fact, never entirely disappeared. In
August he again hurt his hip in Newport, slipping on the grass,
which confined him to his bed about ten days. He afterward
went to Harvard, and in getting off a horse-car slipped, hurting
his hip very badly.
Dr. Bigelow, of Boston, was then called to see him, and
after attending him some weeks told him he had confirmed
chronic hip disease and advised him to return home.
After Dr. Van Buren had confirmed the diagnosis of Dr«
Bigelow and myself, he was placed by Dr. Barker under my
treatment. I applied the extension by weight and pulley on
October 29, 1872, with a blister 3 x 4 inches behind the tro-
chanter. This was repeated three times during the next two
months, during which time he remained constantly in bed.
December 24, 1872. — Applied my long hip splint and put a
high shoe on his sound foot, and by the aid of crutches he
could walk quite comfortably. The plasters were reapplied
every few months as occasion required until the first of May,
1874, when the splint was removed and has not again been re-
applied.
The motions of the joint were limited at the time, but by
daily massage and manipulation they gradually increased, and
in a few months were as perfect as in the other limb, and have
remained so. His limbs are of equal length, and every motion
of the joint is perfect, as seen in these various photograph?,
taken by my son, Dr. Reginald H. Sayre, March 8, 1892.
Case VII. — S. C. II., aged seven years; healthy parents and
family. Child an unusually tine boy up to October, 1873, when
he had a fall while jumping about on the floor ; cried a good deal
from the injury, saying his hip was hurt. In a tew days after,
a very severe attack of scarlet fever prostrated him, a large ab
scess under left jaw formed, and was opened. Convalescence
was quite slow. After the abscess of the neck ceased to discharge
April 30, 1892.]
SAYRE: HIP-JOINT DISEASE.
481
he oomplained-of his left hip and knee. Was treated for rheuma-
tism for some time, and then by weight and pulley incorrectly
applied. I found him, December 1, 1878, confined to bed in a
very feeble state, and applied weigbt and pulley correctly by
simply modifying the line of traction, wbich gave instant re-
lief. On January 10, 1874, he was brongbt before the class at
Bellevue and my short hip splint applied.
January 22d. — Roy up, feeling much relieved. Not con-
fined to bed a day since the splint was applied.
February 20th. — Splint readjusted to-day. Boy in most ex-
cellent condition. No pain or tenderness on manipulating the
joint ; walks readily with no crutch. Has not suffered a day
since the splint was applied.
January S, 1875.- — Perfectly well, with no deformity, and
all the motions of the joint quite free and normal.
January 22, 1886. — Mr. H. called on me to present his
splint and crutches for some other case. He is in perfect
health, five feet six inches in height, weight one hundred and
thirty pounds. Has every motion of the hip joint as perfect as
the other. Can ride horseback and do full labor. The left
limb is half an inch shorter than the right, and the thigh three
fourths of an inch smaller than the other, but this defect can
not be detected without careful measurement. Cure perfect.
February 19, 1890. — Mr. H. called to-day to ask whether it
would be advisable to join a bicycle club. Has ridden at differ-
ent times, but not steadily. More careful examination shows
that motion was limited in outward rotation Can cross the
knees, but can not put the foot on the olher knee and drop the
knee to right angle. Abduction also limited. He was advised
not to try the bicycle riding.
I am very glad this patient is here this evening, that I
may show7 the difference between what I call a perfect cure,
as in the case of Mr. E., and a good cure, as in the present
instance.
I had recorded the case as a perfect cure, as he could
flex and extend the hip joint, cross his knees, and walk with-
out limping with an elevated sole, hut, on later examination,
find that he can not put the left foot in his lap, and I have
therefore included him in the list of good instead of per-
fect cures.
In the cases which I have reported in full this evening
the patients had undoubted morbus coxarius, as diagnosti-
cated by surgeons of marked ability, in addition to my own
testimony, and yet they have all recovered with useful,
movable hip joints, as seen this evening, in spite of the fact
that several of them were of tubercular families, and prove
the fact that absolute immobilization during the entire
progress of the disease is not always essential to perfect
recovery.
I have had my note-books looked over by Dr. H. W.
Frauenthal and Dr. B. F. Parish, who have kindly prepared
a synopsis of the cases therein recorded, and to whom I wish
to return my thanks for their arduous labors.
I wish the time at my disposal had been sufficiently long
to render the table more complete by recording the cases
complicated by abscesses and those complicated by disease
of other joints, but, as the chairman had requested the paper
for this meeting, I have gathered together such facts as I
could in the time at my disposal, and hope at some future
time to present these statistics more fully elaborated.
Many of the cases on my books have been seen by me
only once or twice in consultation with other physicians, and
these have not been included in the record ; and in other
cases it has not been possible to ascertain the ultimate re-
sult ; but the cases as recorded in my books I have collected
and here present to you. The cases in which excision of the
hip joint was practiced have not been included, as they have
already been published, and many of these were not in a
condition to allow anything short of radical operations at
the time when I first saw them.
Statistics of 1(07 Cases of Morbus Coxarius treated between 1859
and 1889, exclusive of Exsections.
Of these there were in the
First stage 118
Second stage 119
Third stage 82
Not mentioned 88
Total number of cases 407
Results.
Cured, motion perfect 71
" " good 142
" " limited 83
" " ankylosed 5
Unknown 78
Under treatment 14
Abandoned treatment 3
Discharged 2
Died of exhaustion 2
" " phthisis 1
" " pneumonia 1
" " tubercular meningitis. 5
Total deaths 9
Total number of cases 407
Cases in which I know the Result and the Kind of Splint worn
beticeen 1859 and 1889, excluding Cases under Treatment.
Cures with perfect motion :
Long splint 19 = 21 "59 per cent.
Short " 54 = 28-12 " "
73
Cures with good motion :
Long splint 34 = 38*63 per cent.
Short " 86 = 44-79 " "
120
Cures with limited motion :
Long splint 29 = 32-95 per cent.
Short " 49 = 25-52 " "
78
Cures with ankylosis :
Long splint 3 ~ 3-40 per cent.
Short " 1 = 0-52 " "
4
Deaths :
Long splint 3 == 1-56 per cent.
Short " 2 = 1-04 " "
5
482
SACHS AND ARMSTRONG: MOR VAN'S DISEASE.
[N. Y. Med. Jouh.,
Treated with long splint 88
" " short " 192
Total number of cases 280
I have had no personal experience in the treatment of
hip disease by perfect immobilization, but had to exsect in
one case in which the joint had been immobilized by a plaster-
of- Paris cast from axilla to foot for two years. The first cast
being applied in the very early stage of the disease, the limb
was retained perfectly straight by the plaster casting ; but as
no traction was used, the reflex muscular action caused con-
stant pressure of the head of the femur against the acetabu-
lum, causing absorption of the head of the femur and per-
foration of the acetabulum. An abscess forming inside of
the pelvis peeled off the periosteum and opened above Pou-
part's ligament. As there was not the usual deformity of
hip disease, and no pain on upward pressure of the limb,
the surgeons in attendance did not recognize it as hip dis-
ease, and I was called in consultation. I gave as my opin-
ion that the joint was already destroyed, and that exsection
was the only chance for saving the child's life.
Dr. Krackowizer was then called in consultation to de-
cide the question, and, confirming my diagnosis, I exsected
the joint in the presence of Dr. S. Sabine, Dr. Krackowizer,
Dr. Yale, Dr. Markoe, and others. The head and neck of
the femur were absorbed and the acetabulum perforated.
The operation was a success, and, eight months after, I
saw the boy riding on horseback in the mountains of Vir-
ginia.
He went back to Texas, and two years after was at-
tacked with nephritis and died from suppuration of the
kidney.
In 1859 I was requested to go to Frankfort, Ky., to see
a young lad suffering from hip disease of three years'
standing. As I could not leave the city at the time, I re-
quested my friend Dr. Baur, then of Brooklyn, to go in my
place. The doctor divided the contracted muscles, straight-
ened the limb under chloroform, and placed the boy in the
wire breeches, which made him perfectly comfortable. In
fact, he was so comfortable that Dr. Rodman, his attend-
ing physician, was afraid to remove him from the wire
breeches, fearing that he would not again be able to replace
him as comfortably as he then was.
He was carried down on the Kentucky River every day
for a row, and was perfectly free from pain from the time
that Dr. Baur placed him in the cuirass. He was not re-
moved from the wire breeches for nine months, and when
he was taken out the disease was perfectly cured, but the
joint completely ankylosed, as were also the hip of the op-
posite side, both knees, and both ankles, as well as the en-
tire lower portion of the spine. In fact, he could only
move his arms and neck. He remained in this solidified
condition till his death some years later.
In 1872 a girl was brought to me from Hamilton Junc-
tion, New Jersey, with double hip disease of eighteen
months' standing. The right, third stage ; the left, proba-
bly the same. After gradually straightening the limbs, she
was placed in the wire cuirass.
The limbs were removed from the cuirass occasionally,
and slight motion was given to all the joints, while the limb
was kept extended by traction with the hand.
Her general health improved greatly, and in six months
she returned home in the cuirass, the mother having been
carefully instructed as to the manipulation and dressing of
the limbs. I received a letter from the mother in the latter
part of 1873, saying that "she had entirely recovered, with
good motion of both legs and no deformity."
Four years later, in March, 1877, the father called on
me and said that " Mary was entirely well and very stout,
but that the joints were stiff," as he found it too much trou-
ble to take her out of the splint so often, but that he was
perfectly delighted and satisfied with the result. I was not.
My impression is that, had the limbs been occasionally re-
moved from the cuirass and the joints slightly moved short
of the amount that caused pain, this ankylosis would not
have taken place.
MORVAN'S DISEASE.
By B. SACHS, M. D.,
PROFESSOR OP MENTAL AND NERVOUS DISEASES,
and S. T. ARMSTRONG, M. D., Ph. D.,
INSTRUCTOR IN MENTAL AND NERVOUS DISEASES, NEW YORK POLYCLINIC.
In 1883 Dr. Morvan, residing in a little town in Brit-
tany, published a paper on a disease that he had observed
there to which he gave the name of analgesic paresis and
panaritium of the superior extremities, or pareso-analgesia.
In this paper he stated that at the commencement the dis-
ease was limited to one extremity, subsequently passing to
the other, and always terminating in the production of one
or more felons.
In the cases as first described by Morvan the symptoms
are initiated by a weakness of the muscles, and sometimes
by a pain in the forearm, that is succeeded by a swelling of
the member, with the formation of deep palmar fissures and
felons, usually painless, with phalangeal necrosis. It was
for the latter condition that the physician was consulted,
and at that period there was usually paresis of the muscles
of the affected region that was afterward followed by
atrophy of the thenar, hypothenar, and interosseous mus-
cles. While faradization would produce energetic con-
tractions in the muscles of the forearm, no reaction would
be obtained in the atrophied muscles. There was analgesia
of the forearm, sometimes of the arm, neck, and chest ; and
also thermal, but no other anaesthesia. Exertion produced
occasionally hyperidrosis of the analgesic region ; and the
existence of vaso-motor disturbance was further evidenced
by the bluish or mottled discoloration of the affected part
in cold weather, and the occasional formation of phlyc-
taenulae. Of his reported cases, seven were in males and
two in females, and the disease had lasted from a few to
twenty-five years without involvement of other regions.
It seems to us that the report that Morvan made of
what seemed to him to be a new disease should be con-
sidered in giving it a place in nosology. The existence of
paresis, loss of pain sense and thermal sense, circumscribed
atrophy of the forearm or hand muscles, and trophic dis-
turbances evidenced by the formation of cutaneous fissures
April 30, 1892.]
SACHS AND ARMSTRONG: MORVAN'S DISEASE.
483
and felons, would constitute what is known as Morvan's
disease. In all reported cases of the disease made at a
subsequent date these have been the essential symptoms,
and the following- case is added to the literature of the
subject, the patient having been presented for examination
to two medical societies of this city :
W. H., aged twenty-eight, a native of Germany, a laborer,
was referred to Dr. Sachs's clinic at the New York Polyclinic
by Dr. Gerster. The patient had a venereal ulcer and a bubo
in the right groin ten years ago, but otherwise he has always
been healthy until four years ago, when he was employed as a
dish-washer, his hands lost their muscular power, there was
slight twitching and enlargement of the fingers, and the skin of
the fingers and hands became thickened and fissured. He was
treated by a physician, and the enlargement in the fingers sub-
sided, except in the index and third finger of the left hand, in
which felons formed, that were incised without causing any
pain. He thought that the condition of his hands resulted from
the use of soda in the wash-water; but it is now four years
since he stopped washing dishes, and his hands have not im-
proved. At the time of examination the skin of each hand was
of a purplish color, that was intensified by cold weather, the
discoloration under such influence extending up the arm.
The hands themselves presented the following appearance :
Fig. 1.
Right. The skin on the dorsum seems to be normal, but on the
dorsum of the fingers it is thickened; there is a slight con-
tracture at the second phalangeal joint in all of the fingers, but
more pronounced in the middle and index fingers. There is a
small eschar on the dorsum of the thumb, but this member is
not contractured. There is a marked atrophy of the first dorsal
interosseous muscle. On the palmar surface the skin is thick-
ened, and there are numerous ragged excoriations, especially on
the finger-tips and at the base of the middle and ring fingers;
in these excoriations deep fissures, having indurated edges, have
formed. On the anterior surface of the right forearm is an area
of dermatitis resembling a mild degree of ichthyosis. At the
bend of the elbow there is an area four inclj^s long by an inch
wide, in which there are numerous small depressed atrophic
areas that might be described as a dermatrophia circumscripta
albida ; the patient thought that this had resulted from carry-
ing a basket on his arm, the markings resembling somewhat
those that would be produced by the pressure of the twisted
willow in the handle thereof. There is a scar over the olec-
ranon, caused by an incision (painful) for an abscess in 1890.
Left hand : The skin on the dorsum and palmar surfaces of the
hand and fingers presents a similar appearance to that of the
right hand, but the nails of the index and middle fingers are
thickened and deformed, and the end of the index finger is
conical while that of the middle finger is clubbed. The nail of
the latter finger presents white opaque strice, and a portion was
examined microscopically to see if these striae were caused by a
mycelial growth ; but no fungus was found. There is moderate
atrophy of first dorsal interosseous. Dynamometer showed :
Manus dextra, thirty kilogrammes ; manus sinistra, sixty kilo-
grammes ; but this disparity has been lessened during the course
of the electrical treatment, and the muscular power is almost
equal at the time of writing this report, though it is yet less
than that of a healthy man. The muscular sense was normal,
and, excepting in those muscles above mentioned, no atrophy was
apparent. The forearms were well developed and were equal
in circumference. The tactile and pressure senses were normal,
the patient locating a straw drawn over the skin, and discrimi-
nating between different weights. The pain sense is abolished
in an area on the dorsum of the right hand ; also over the dor-
sum of the fingers, hand, and ulnar side of the left forearm ;
but there is no loss of pain sense in the palms or the anterior
surface of either forearm. Fig. 2 shows the analgesic areas
on the hands ; the test was made by forcing a needle into
the flesh. The temperature sense did not recognize a tempera-
ture of 212° F. on either forearm, excepting at the flexure of
the elbow, where it felt hot ; but at this point a temperature of
150° F. felt cold. Temperatures of 190° to 200° F. were recog-
nized as warm on the upper portion of the arms and back,
though lower temperatures were called cold. In the regions
above mentioned a temperature of 32° F. was not recognized as
very cold, even if it was placed on a spot on which a tempera-
ture of 212° F. had just been placed. These observations were
made with test tubes containing boiling water and a freez-
ing mixture. There is fibrillary twitching of the muscles of
the forearm and hand. Fig. 1 shows the atrophy of the inter-
Fki.
ossei, the deformity of the fingers of the left hand, a
tendency to the main en griffe. An electrical
showed an absence of the faradaic reactions in t
nd the slight
examination
he extensor,
484
SACHS AND AEMSTROSH : MORVAN'S DISEASE.
[N. Y. Med. Johb.,
thenar, and interossei muscles, though the flexor group reacted
well. Galvanic reactions, ACC>KCC in the extensor muscles
of each forearm and the interossei. It might be here stated
that since the treatment by electricity has been commenced, the
faradaic reactions have returned in the extensor groups and the
difference in the galvanic reactions is diminishing.
There is no history of pain in the forearms preceding the
appearance of the other symptoms ; his attention was first
called to his hands by the fact that, when immersed in hot
water, he had no sensation of its heat — a phenomenon asso-
ciated with the swelling and inability to use his hands. When
his entire skin is perspiring his forearms will be cold. He has
had to give up positions as a waiter because he has been unable
to firmly hold articles of glass or crockery in his hands.
In this case we have paresis of the muscles of the
hand; analgesia of certain regions of the dorsum of the
hands and of the posterior aspect of one forearm ; ther-
mal anaesthesia of both forearms, and felons on one hand
— the congeries of symptoms constituting Morvan's dis-
ease.
The pathology of the disease, and, in fact, whether there
was any such morbid entity as this disease, has been ques-
tioned. Osier (2) considers it a peripheral neuritis of toxic
origin, and Gowers (3) considers it a peripheral neuritis
with myelosyringosis.* This theory that the disease is a
peripheral neuritis seems to be verified by an examination
of Morvan's first reported cases ; his first case is one of
traumatic neuritis following a fall, with persistent motor
and sensory paresis for ten years ; his second case present-
ed symptoms of multiple neuritis, in which the affection of
the nerves of the lower extremity disappeared in the course
of years, certainly a result that would never have occurred
in myelosyringosis ; his third case seems to be one of
chronic neuritis, as is evidenced by the occurrence of pain-
ful paroxysms during twenty-four years; his fifth case re-
sembles traumatic neuritis; and his seventh case resembles
one of multiple neuritis. Monod and Reboul, in their re-
port of a case of the disease, took the position that it was a
variety <>f peripheral neuritis, having found in an examina-
tion of the nerves of an amputated finger an acute paren-
chymatous and interstitial neuritis. Dejerine (13) thought
that the frequent appearance of the disease in the popula-
tion of a small province showed that it was a neuritis of
toxic or infectious origin.
Surgical pathology teaches us that felons do not origi-
nate spontaneously, but in consequence of the introduction
of the Streptococcus pyogtnes ; and the fact that the felons
are usually painless seems to show that the micro-organism
gains access to the tissues in consequence of the trophic
disturbances, and that the felons are merely an incident that
might be prevented in such cases by due attention to cleanli-
ness.
The dissociation of sensory symptoms is the chief
argument against the theory that Morvan's disease is due to
peripheral neuritis, but there is evidence that all sensations
are not equally affected in neuritis, as has been asserted by
* Our attention has been called to the barbarism in the composition
of syringomyelia, and we have adopted myelosyringosis as a term that
avoid- the etymological error in the more usual wo- '
Starr (5) ; and possibly the paucity of such records is due
to failure to make special tests.
As it is a physiological fact that the conduction chan-
nels of the tactile, pain, and thermal senses lie in different
parts of the spinal cord, it seems a justifiable assumption that
their peripheral terminations are also different. And that
recorded cases justify this assumption is evidenced by the
cases of Weir Mitchell (U), in which there was a lessened
sense of pain with no loss of touch ; those of Gowers, in
which he has seen loss of pain sense while the muscular
sense is preserved ; and those of Grainger Stewart (7), in
one of which the thermal sense was diminished while the
pain and muscuiar senses were normal, and in another the
thermal and pain senses were diminished and the muscular
sense was normal. The latter case is especially serviceable
in supporting the possibility of the existence of such phe-
nomena in neuritis, because the necropsy showed that in
the median, ulnar, and tibial nerves certain " bundles of
nerve fibers were totally, others partially destroyed, while
some were comparatively healthy " ; and in the cervical en-
largement of the spinal cord there were tracts of second-
ary degeneration, affecting only the columns of Goll and
the outermost part of the lateral columns.
These cord degenerations were in consequence of an
ascending neuritis, and an explanation of the gliomatosis of
the cord, in cases of Morvan's disease, is possible on the
ground that there was an ascending neuritis of the sensory
fibers, with later slow gliomatous degeneration in their
tracts in the spinal cord. Gombault (8) found in a necropsy,
in a patient who had Morvan's disease for forty-four years,
intense changes in the peripheral nerves, with a mild degree
of sclerosis of the posterior horns and columns. These
facts justify the statement of Gowers regarding this disease,
that "we must be cautious in inferring that the pathologi-
cal state is the same in origin in all cases." But physio-
logical, pathological, and clinical data support the idea that
a peripheral neuritis may be the cause of the disease, though
Morvan himself considers it is of spinal origin.
Myelosyringosis so closely resembles Morvan's disease
in its early stages that several prominent neurologists — such
as Bernhardt, Jolly, and Charcot — have considered them
identical ; and the latter proposed that the congeries of symp-
toms constituting the former disease should be denominated
myelosyringosis of Morvan's type. Now, myelosyringosis is
a purely pathological condition that may include, according
to Cheron (10), first, dilatation of the central canal, or
mvelohydrosis ; second, the excavating myelitis of Jotfroy
and Charcot : third, the peri-ependymal sclerosis of Hallo-
peau ; and, fourtfl, gliomatosis of the region of the central
canal. And with these various pathological conditions
Joffroy and Achard concluded (11). from a study of the
disease in general, that often a sufficient number of the sup-
posedly pathognomonic signs are not present to allow a
diagnosis to be made ; again, that where all of these signs
are present they may suddenly disappear, and a spontaneous
recovery is hardly to be expected in such a disease — in
other words, a peripheral neuritis has been mistaken for
myelosyringosis. In the following table we present a com-
parison of the essential features of both diseases :
April 30, 1892.]
SACHS AND ARMSTRONG: M OR VAX's DISEASE.
485
Myelosyringosis. Morvan's Disease.
Felons rarely present, and Formation of painless
only as a symptom <»t' a felons,
trophic disturbance.
Fissures rare. Palmar cutaneous fis-
sures.
Analgesia of areas sup- Analgesia of fingers, of
plied by the segment of the hand, and forearm ; later and
affected cord ; usually arms rarely of arm and neck,
and upper half of trunk ;
rarer in lower part of trunk
and legs.
Thermal anaesthesia of Thermal anaesthesia ex-
analgesic and other regions ; tending moderately beyond
sometimes unequal for heat the analgesic areas,
and cold, sometimes per-
verted.
Muscular atrophy of re- Muscular atrophy usually
gion supplied by nerves limited to thenar, hypothe-
emerging at or immediately nar, and interosseous re-
below the level of the af- gions ; more rarely the fore-
fected segment of the cord. arm.
Tactile sense sometimes Tactile sense normal,
lost.
Often neura'gic pains in Bain raay precede the
joints of the affected region otner symptoms, rarely per-
and in the spine. sist.
Occasional Romberg No Romberg symptom,
symptom. Unsteadiness of
movements. Paralysis of
one vocal cord ; of tongue
or face. Dysphagia. Dysp-
noea. Cardiac irregularity.
Inequality of pupils. Occa-
sional nystagmus and ptosis.
Occasional spastic paralysis
of lower limbs.
Bones may become thick Rarely any affection of
and brittle and tabetiform bones (excepting necrosis
joint changes may occur. from felon) or joints.
Bilateral in eighty per Bilateral in forty-five per
cent. cent.
Mains de predicateur in Main en griffe in eonse-
consequence of predomi- quence of predominance of
nance of extensor paralysis flexor paralysis.
[Morvan].
Symptoms usually devel- Symptoms usually devel-
op slowly, increasing gradu- op rapidly ; most often con-
ally in the course of years ; fined to the forearm and
death from exhaustion or im- hand. No extension of
pairment of function. Re- symptoms in from ten to
covery rare. forty years. Recovery, or at
least marked improvement,
not infrequent.
Joffroy and Achard (14) reported a necropsy made on a
woman who had, forty-five years before her death, painful
felons of both hands, leaving deformities of the fingers re-
sembling Morvan's disease ; sensibility both to pain and
heat was, just before her death, greatly diminished in the
palmar surface of her hands and fingers, and the tactile sen-
sibility was diminished ; but there was no muscular atrophy
and the electrical reactions were normal. She also had
kyphosis'. At the necropsy not only was a cavity found in
the spinal cord, but the nerves of the forearms had under-
gone extensive degenerations ; these latter they regard as
secondary to the lesion in the spinal cord, just as is the
peripheral neuritis that has been observed in posterior
spinal sclerosis. It might be questioned whether, excepting
in physical appearance, this case presented any similarity to
Morvan's disease. The feluns were painful; the deformi-
ties that followed them did not interfere with the useful-
ness of the hands ; the muscles were not atrophied ; the
electrical reactions were normal ; and the sensory disturb-
ances occurred at the age of seventy-five, when sensation
would naturally be rather sluggish, and even then a tem-
perature of 140° F. was recognized as something warm, and
the pin prick was indistinctly felt in the thickened skin of
the palm and fingers.
We do not desire to maintain that cases of myelosyrin-
gosis do not present symptoms in the earlier stages of the
disease closely simulating all the phenomena of Morvan's
disease ; and it is furthermore probable, as Joffroy and
Achard have stated, that lesions in the bulb may produce such
symptoms, and that supposed cases of Morvan's disease have
really been cases of myelosyringosis. But we would main-
tain that cases of the latter disease of sufficiently long stand-
ing will present later and more serious complications than
those reported as characteristic of the former malady.
That it is not necessary to found the existence of the
disease on a pathological condition in the spinal cord is, we
think, demonstrated by the observations of Charcot, who has
found sensory dissociation in hysteria just as it is observed
in the disease under consideration, and myopathic phe-
nomena also. These would leave the felons as the single
absent symptom, and we know their presence is due to a
definite cause. Minor, of Moscow, has observed sensory
dissociation in traumatic inyelaematoma ; and the presence
of this dissociation is so frequent in anaesthetic leprosy that
the possibility of the identity of that and Morvan's disease
has been broached.
For instance, Dr. Zambaco(12) has held that both my-
elosyringosis and Morvan's disease are identical, and that the
disease is only a form of anaesthetic leprosy that has been, so
to speak, attenuated by the manners and climate of Europe;
this has been warmly controverted by Thibierge (16), and
one of us can personally state that there is no resemblance
between the present case or those reported cases that have
been consulted and the cases of anaesthetic leprosy he has
observed in the southern American states and in Norwegian
leper hospitals.
We believe that Raynaud's disease, ei vthromelalgia, and
sclerodactylia are sufficiently typical not to he confused with
Morvan's disease.
While, therefore, it is to be distinguished from myelo-
syringosis, hysteria, and, in leprous countries, from anaes-
thetic leprosy, we believe the presence of other phenomena
in those cases will enable a diagnosis to be made.
From the preceding presentation of facts, and our own
486
VAUGIIAN: A NEW METHOD OF TREATING ACUTE URETHRITIS. [N. Y. Med. Joint.,
experience with myelosyringosis and neuritis, we infer that
the typical cases of Morvan's disease may be due to a pe-
ripheral neuritis. On the other hand, we have conceded that
cases of myelosyringosis may so closely resemble Morvan's
disease as to make a distinction impossible ; but the strict
limitation of the disease usually for many years and the
early appearance of the painful felons, as well as the im-
provement, if not recovery, in given cases would weigh
strongly in favor of the diagnosis of Morvan's disease rather
than myelosyringosis. And, lastly, it must be conceded that
it is possible for an ascending neuritis to lead to gliomatous
degeneration in the central canal of the spinal cord, such
cases presenting later the typical clinical features of myelo-
syringosis.
References.
1. Gaz. hehd. de med. et de chh'urg., August 31, 1883.
2. Principles and Practice of Medicine.
3. Manual of Diseases of the Nervous System, vol. i, 1892.
4. Arch. gen. de med., July, 1889.
5. Am. Jour, of the Med. Sci., May, 1888.
6. Injuries of Nerves and their Consequences, 1872.
7. Bowlby. Injuries and ' Diseases of the Nerves, 1890.
8. Gaz. des hop., April 30, 1890.
li. Prog, med., March 15, 1890.
10. V Union med., November 14, 1889.
11. Arch, de med. exp., January, 1891.
12. Gaz. hebd., 1891. p. 196.
13. La Med. mod., July 10, 1891.
14. Arch, de med. exper., vol. ii, 1890.
15. Gaz. hehd., 1891, p. 199.
A NEW METHOD OF TREATING
ACUTE URETHRITIS.*
By B. E. VADGHAN, M. D.,
ATTENDING SIRGEON. NEW YORK DISPENSARY ;
ASSISTANT ATTENDING SURGEON, NEW YORK CANCER HOSPITAL. ETC.
Whex I began the work for this paper I intended to
speak of my results in treating urethritis at the New York
Dispensary, where I have had during the past two years
about two thousand two hundred cases. But in the past
three months I have been developing what I may call a new
plan of treatment, which, although not new in all its de-
tails, is enough so, I think, to warrant such a designation.
I use the term acute urethritis to include all forms of
acute inflammations of the anterior urethra, whether specific
or non-specific, — first, because I did not have the time to
make microscopical examinations, and, second, because the
same rules of treatment apply, I think, to all acute cases.
I can not expect that my method of treatment will be
approved by all, but I hope it may call out full discussion
and expression of opinion which may tend to throw more
light on the treatment of a disease which by many is con-
sidered hardly worse than a cold, but the results and com-
plications of which cause many deaths and so much suf-
fering.
In a conversation with Dr. Bangs a few months ago, he
said, in answer to my question, How he treated acute ure-
* Read before the Hospital Graduates' Club.
thritis, that he had no routine treatment, but followed sur-
gical indications, rest, drainage, and soothing applications
to the mucous membranes. It impressed me as being so
rational that I made it my basis for work, and have tried to
follow it out in my treatment of cases.
Dr. Powers asked me to try dermatol (subgallate of bis-
muth), an astringent, drying, non-irritating, and non-poison-
ous drug, which he describes in the Medical Record of Oc-
tober 17, 1891. I first tried it in suspension, as it is
insoluble, but the results were negative. Subsequently I
succeeded in finding a vehicle which has proved satisfactory.
I am indebted to Daggett Ar Ramsdell, of 328 Fifth
Avenue, for a vehicle which seems to answer every require-
ment, known under the name of plasment. They have fur-
nished me the following notes :
" Plasment consists of the mucilaginous principle ex-
tracted from Chondrus crispus and Cetraria islandica (Irish
and Iceland moss) combined with Siam benzoin and gly-
cerin. The steam heat used in the extraction, together with
other details of the process, render the preparation aseptic
and it keeps perfectly. It combines readily with all sub-
stances used in dermatology, in most instances producing
preparations which are superior, from a pharmaceutical point
of view, to ointments. We have used it extensively in the
prescriptions of several of our leading dermatologists com-
bined with such remedies as resorcin, salicylic acid, ichthyol,
sulphur, oils of cade and tar, bismuth, zinc oxide, creasote,
starch, carbolic acid, potassium iodide, iodine, subiodide of
bismuth, dermatol, aristol, mercury, boric acid, etc., in all
cases giving great satisfaction both to the patients and
physician."
Plasment is about of the consistence of vaseline. It is a
demulcent and soothing to all mucous membranes. It is
soluble in water, while the oils are incompatible ; it coats the
mucous membranes and is readily absorbed in a canal, de-
positing the medicament on the membrane, and at the same
time protecting and keeping apart the opposing surfaces.
With this as a vehicle I use three or five per cent, of der-
matol. You will readily see how this, through mixture of
the dermatol with the vehicle, increases its action, if I quote
from the paper of Dr. Powers.
" Experiments were made regarding its antiseptic proper-
ties, and it was found that when the dermatol was added to
a fluid nutrient gelatin, decomposition or bacterial growth
was hardly hindered. The same occurs with iodoform,
iodol, bismuth subnitrate, and aristol. The dermatol can
take effect only when it comes in direct contact with the
germs and when it is evenly mixed with the nutrient medi-
cine. This they accomplish in the following manner: Gela-
tin was warmed in a reagent glass until it was just fluid
(28° to 30° O), and with it large amounts of dermatol were
mixed. This was then mixed with a pure culture shaken
and poured on cooled trays. As it stiffened in cooling, the
dermatol was held in a uniform admixture. The anthrax
bacillus, Staphylococcus pyogenes aureus, Bacillus prodigio-
sus, bacillus of typhus and pneumonia, were used. In all
of these the growth was stopped."
Now comes the question how to best apply such a mixt-
ure to the mucous membrane that is diseased.
April 30, 1892.] VAUGHAN: A NEW METHOD OF TREATING ACUTE URETHRITIS.
487
I had a special soft-rubber catheter made by Tiemann,
about five inches long, with several small openings near the
end on all sides.
As a syringe I use in private cases the compressible
tube such as paints come in, with a special hard-rubber tip
screwed on the end, furnished me by Daggett & Ramsdell.
In this way the substance is kept absolutely clean.
In my dispensary cases, where 1 make a great many
injections, I use a hard-rubber syringe, and fill it with a
spatula after unscrewing and removing the piston. It re-
quires very little for each injection, and a small quantity
goes a long way. The catheters are made in two sizes —
10 and 20 F. scale. I prefer the larger size, if the urethra
is large enough, as it makes the application more thorough.
The method of treatment is as follows :
The patient is first requested to urinate, not only that
he may wash out the urethra, but that it may be as long as
possible before it is necessary for him to pass urine again.
Then the catheter is attached to a fountain syringe (any
other syringe could be used), about seven feet from the floor,
filled with warm water of an agreeable temperature to the
hand (best, one drachm of chloride of sodium to the pint).
The catheter introduced, the water goes to the bottom of
the anterior urethra and then flows back around the tube
and out at the meatus. The catheter should be small
enough to allow the backward flow. After douching for a
minute or more, the tip of the syringe is withdrawn from
the catheter, and the syringe, with dermatol in plasment, is
applied, and about half a drachm injected as the syringe is
gradually withdrawn. In this way the whole length of the
anterior urethra is coated with the medicament.
As soon as the catheter is withdrawn, a small piece of
absorbent cotton is applied over the meatus, and the patient
is directed to change this frequently.
Thorough antisepsis of instruments and hands in mak-
ing application.
This method of application to the urethra through a
catheter was suggested by Dr. Fox, about twelve years ago,
at the meeting of the State Medical Society, and I have a
glass tube which Dr. Fox used at that time.
Dr. Vander Poel and Dr. Halsted used iodoform, one
part, and cold cream, eight parts.
Dr. Bransford Lewis recommends vaseline and lanolin
(Med. Rec, Aug. 17, 1889) as a vehicle; boric acid and
resorcin used as active agents with a catheter four to five
inches long.
Dr. Rice (Med. Rec., July 20, 1889), boric acid and gly-
cerin, three drachms to the ounce.
Bartholow mentions subnitrate of bismuth and glycerin,
and Finger lanolin, as a basis for urethral applications.
You will notice that all these vehicles are emollients,
while plasment is a demulcent.
Brunton's definition for emollients is substances which
soften and relax. Demulcents are substances which protect
and soothe the parts to which they are applied.
You will appreciate the difficulty in dispensary practice
to get patients to return daily for treatment, and also the
difficulty in keeping them under observation until sure that
their cures have been permanent.
I will give you the histories of a few of the average
cases :
December Jfth.— Mr. W. has had gonorrhoea several times ;
last time, two years ago; profuse discharge, with pain on urina-
tion and balanitis tor a week. Dermatol, five per cent, in plas-
ment. Mist. pot. bicarb., t. i. d. Potassii bicarb., gr. viij ;
tinct. liyosryam., flliv; aquaa, 3 j-
5th. — Pain less; discharge improved.
8th — Discharge very slight ; no pain.
10th. — Discharge very slight; no pain.
12th. — Discharge very slight ; no pain.
13th. — No discharge.
The patient was under observation for two weeks; ten days
under treatment; five visits. Duration of disease, seventeen
days.
December 5th. — Mr. B., gonorrhoea several times; last time,
two years ago. Profuse discharge for a week, with pain on
urination. Dermatol and plasment. Bicarbonate of potassium,
as in No 1.
10th. — Discharge improved, but pain worse.
12th. — Discharge improved; pain less,
16th. — Only very slight watery discharge; no discomfort.
llth. — Slight moisture.
18th. — No discharge.
19th. — No discbarge.
21st. — No discharge.
23d. — The patient considered cured.
From the beginning of treatment to the stopping of discharge,
thirteen days; five visits. Duration of disease, twenty days.
November 23d. — Mr. M., no gonorrhoea before; discharge for
two days profuse, with marked swelling of mucous membrane
and severe balanitis. No injection given on first day, but bi-
carbonate of potassium given.
24th. — Increased discharge and marked pain on urination.
Dermatol and plasment used. Passing catheter irritated slightly.
25th. — Condition about the same.
30th. — Patient not here for five days. Discharge still pro-
fuse.
December 1st. — Markedly improved. Pain on urination
disappeared.
2d. — Continued improvement ; no discomfort.
5th. — Continued improvement.
8th. — Continued improvement.
10th. — Continued improvement.
llth. — Continued improvement.
16th. — Continued improvement. Patient came regularly ;
discharge growing less. On the 30th it entirely ceased and did
not return. Discharge lasting in all five weeks, but course and
symptoms mild after first week.
1 will also give the result of its use in two private cases,
where 1 had acute exacerbation of chronic urethritis:
1. Young man under treatment by deep injections of nitrate
of silver for chronic posterior urethritis.
After free indulgence in beer and connection with a prosti-
tute, he came to my office with a profuse discharge. Pain and
swelling of the whole penis. One application relieved all the
acute symptoms and the discharge entirely stopped.
488
VAUGIIAX: A NEW METHOD OF TREATING ACUTE URETERITIS. [N. Y. Med. Jura.,
2. While patient's wife was abroad he contracted gonorrhu>a.
The discharge had stopped after six weeks' treatment by copaiba
and injections of nitrate of silver. Two weeks after this, his
wife having returned, there developed an acute urethritis fol-
lowing first intercourse. The discharge was profuse; the whole
mucous membrane of urethra was swollen, painful, and tender
to the touch. After the first injection of the dermatol and plas-
ment all acute symptoms subsided.
The following arc histories of sixty-four cases:
Name.
Mr. C.
Mr. Con.
Mr. II.
Mr. L.
Mr. K.
Mr. G.
Mr. I).
Mr. B.
Mr. S.
Mr. Z.
Mr. C.
Mr. S.
Mr. Oil.
Mr. Gar.
J. H.
Mr. B.
Mr. T.
Mr. H.
Mr. Har.
Mr. B.
Mr. J.
Mr. M.
Mr. R.
Mr. Coh.
McG.
McC.
History .
Gonorrhoea
twice ; 1 week.
None before ;
3 weeks.
None before ;
10 weeks.
None before ;
1 week.
None before ;
4 days.
None before ;
6 weeks.
None before ;
1 month.
None before ;
5 days.
None before ;
4 days.
None before :
3 weeks.
Treated for near-
ly a month with
copaiba.
None before ;
1 week.
Gonorrhoea sev-
eral times ; not
entirely free;
5 days.
None before ;
5 days ago.
None before ;
10 days.
None before ;
3 weeks.
Several times :
1 week.
Discharge ;
4 weeks.
3 days.
Gonorrhoea 1 yr.
ago; 1 week.
None before ;
5 days.
(ionorrluea oyrs.
ago ; 9 (la vs.
None before ;
2 days.
Gonorrhoea 1 yr.
ago ; 4 days.
None before ;
2 days.
No gonorrhoea ;
2 days.
Nature.
Profuse discharge, with
painful micturition.
Profuse and purulent dis-
charge, with balanitis.
Moderate discharge.
Profuse discharge.
Profuse discharge; pain
on urination.
Profuse discharge, and
pain on uiination.
Profuse discharge ; some
pain.
Copious discharge.
Profuse, with pain on
urination.
Profuse and purulent.
Profuse, and pain on
urination.
Profuse discharge, pain,
and frequent micturi-
tion.
Profuse and purulent
discharge ; pain and
chordee.
Watery discharge ; pain
on urination.
Quite profuse.
Moderate.
Profuse, and pain on
urination.
Purulent and frequent
micturition; balanitis;
phimosis.
Profuse ; no pain.
Chancroid for 1 week ;
discharged ; pain.
Profuse, with pain on
uiination.
Thick, white, with pain
on urination.
Profuse, witli pain on
urination.
Treatment .
twice daily; dermatol
and plasment.
Solution of dermatol,
five per cent.
Solution of dermatol,
five per cent., until 12
days, and then derma-
tol and plasment.
Solution of dermatol,
five per cent.
Solution of dermatol,
five per cent. ; irregu-
lar.
Solution of dermatol,
five per cent., for 2
weeks, improvement ;
dermatol and plasment.
Dermatol, five per cent,
for 2 weeks ; dermatol
and plasment.
Dermatol and pot. bicarb,
for 1 1 days ; dermatol
and plasment used.
Solution of dermatol,
five per cent. ; after 3
weeks, pot. bicarb. ;
dermatol and plasment.
Sol. of dermatol, five per
cent. ; pot. bicarb. ;
dermatol and plasment.
Solution of dermatol,
2 weeks ; pot. bicarb. ;
dermatol and plasment.
Solution of dermatol,
five per cent., 1 week ;
dermatol and plas-
ment ; pot. bicarb.
Solution of dermatol,
pot. bicarb.
Solution of dermatol,
pot. bicarb., 1 week ;
dermatol and plasment.
Solution of dermatol,
pot. bicarb.
Solution of dermatol, pot.
bicarb.; then dermatol
and plasment used.
Solution of dermatol, pot.
bicarb., 1 week ; der-
matol and plasment.
Dermatol and plasment,
pot. bicarb.
Remarks.
Length of treat-
ment.
Improved in 3 days. All treatment
stopped, but in 3 days slight return
due to beer ; cured by one injec-
tion.
Improved after first injection; stopped
in 3 days.
Improved in 2 days.
20 days.
3 days.
3 days.
Patient did not return.
Discharged stopped in 7 days.
10 days.
Improved in 2 days.
12 days.
3 weeks no discharge ; then 2 weeks
no discharge ; then slight return
after drinking beer.
7 weeks.
5 days discharge less, no pain ; slight
showing at meatus for 8 days, and
then stopped.
Less pain and discharge the following
day. In 10 days only slight dis-
charge ; then no treatment for a
week. Came back with epididymitis.
Discharge stopped in 3 weeks.
1 'i djiv^
3 weeks.
Improvement ; stopped in 10 days.
lo days.
Improved first 1 1 days ; very slight
discharge continued for 2 weeks
longer, then stopped.
25 days.
Discharge stopped in 5 days ; 2 weeks
later, nodule near meatus, which
burst into urethra.
t; weeks.
•
Discharge stopped in 5 days ; returned
in a week, cured by one injection.
12 days.
Discharge stopped ; returned 5 days
later ; stopped after 4 days.
3 weeks.
Improvement in 2 days; patient ir-
regular ; discharge stopped, and did
not return.
24 days.
Discharge stopped in 3 days.
3 days.
1 1 days.
9 days.
5 days, improvement; dermatol and
plasment given ; cured in 4 days.
Improved ; discharge stopped in 2
days ; patient did not return.
Discharge stopped in 7 days.
Very little improvement, 8 days; 14
days, no discharge.
Patient did not
return.
14 days.
Stopped in 8 days ; slight return at
intervals for 3 weeks; cured.
3 weeks.
No discharge after 2 weeks ; irregular
treatment.
No discharge on third visit ; patient
irregular; did not return for 8 days.
Discharge again profuse; improver
ment in 4 days.
2 weeks.
15 days.
April 30, 1892
] YAUQHAN: A NEW METHOD OF TREATING ACUTE URETHRITIS.
489
Name. *
McD.
Mr. V.
Mr. M.
Mr. It.
Mr. Hein.
MeC.
Mr. St.
Mr. D.
Mr. M.
Mr. S.
Lewis.
Mr. B.
Mr. G.
Mr. W.
McG.
Mr. B.
Gross.
Mr. J.
Mr. G.
Mr. F.
Mr. H.
Mr. C.
Mr. S.
Mr. K.
Mr. S.
Mr. D.
Mr. H.
Mr. 0.
Mr. M.
Mr. W.
Mr. L.
History.
Nature.
Gonorrhoea 1 yr. Moderate, with pain on
ago; 2 days. ] urination.
Treatment.
No gonorrhoea ;
2 days.
No gonorrhoea ;
2 days.
No gonorrhoea ;
3 days.
Discharge ;
3 weeks.
Gonorrluva ami
stricture before ;
3 days.
2 weeks.
Gonorrhoea 2 yrs.
2 days.
No gonorrhoea ;
2 days.
No gonorrhoea ;
3 weeks.
No gonorrhoea ;
3 weeks.
Gonorrhoea 3 yrs.
ago ; 3 days.
Gonorrhoea 2
years ; 1 day.
Gonorrhoea sev-
eral times ; 1 wk.
Several times ;
2 weeks.
Several times ;
1 week.
2 months.
1 week.
No gonorrhoea ;
1 week.
No gonorrhoea ;
1 week.
2 days.
4 weeks.
Profuse, with
urination.
Profuse, and
urination.
Ordinary.
pain on
pain on
Slight, and pain on uri-
nation.
Profuse discharge, and
pain on urination.
Profuse discharge, and
pain on urination.
Profuse discharge; bala-
nitis.
Profuse ; balanitis ; small
meatus.
Profuse.
Considerable discharge,
with pain.
Profuse, with pain.
Quite profuse.
Discharge ;
balanitis.
Ordinary.
pain
and
Gonorrhoea
twice ; 2 weeks
No gonorrhoea
before ; 2 weeks,
No gonorrhoea ;
2 days.
Gonorrhoea 4
months ; 1 wk.
Gonorrhoea 8 yrs. Ordinary
ago ; 1 week.
Small meatus ; profuse
discharge.
Profuse discharge ; swell-
ing of glands and oede-
ma of prepuce.
Profuse discharge; chan-
cre and balanitis.
Profuse.
Profuse ; treated 4 wks.
by copaiba.
Ordinary.
pain on
Profuse, and
urination.
Profuse; copaiba, 3 days.
No gonorrhoea ;
1 day.
Gonorrhoea
three times;
last time 2 years
ago; 1 day.
No gonorrhoea ;
2 days.
2 years ago ;
2 days.
Profuse, with pain.
Profuse, with pain; bala-
nitis.
Sol. of dermatol, 1 week ;
dermatoland plasment,
pot. bicarb.
Dermatol and plasment,
pot. bicarb.
Solution of dermatol,
live per cent. ; pot.
bicarb. ; dermatol and
plasment.
Dermatol and plasment,
pot. bicarb.
For 2 weeks patient was
treated by AgN03 (1
to 3,000), no improve-
ment ; dermatol and
plasment, pot. bicarb.
Dermatol and plasment,
irregularly ; pot. bi-
carb. ; thirteen visits
in a month.
Dermatol and plasment,
pot. bicarb.
it u
Remarks.
Treated 1 month, although most of
time no discharge.
Improvement in 4 days.
Discharge stopped after a week ; re-
turned again in 4 days. Injection
given of dermatol and plasment ; 2
days better, but slight moisture in
the mornings for 2 weeks.
Discharge stopped in 24 hours, with-
out perceptible return.
In 2 days the discharge disappeared ;
but with very slight returns, with-
out any pain or irritation, for 1 mo.
Discharge improved after three visits ;
did not return for 10 days, and with
another trouble ; no discharge since
visit.
Discharge stopped in 3 weeks, but re-
turned and continued slightly for
1 week.
Stopped entirely in 5 weeks ; meatus
was irritated by catheter.
Following day very much improved ;
second injection given.
No discharge on second and third
visits; then very slight for 10 days.
No discharge at 3 weeks ; patient re-
turned 2 weeks later with discharge
following use of beer.
Patient very irregular ; cured after 5
weeks, only 6 visits.
No discharge in 11 days.
Discharge stopped in 1 week ; re-
turned twice later due to excessive
indulgence.
Discharge stopped temporarily in 13
days ; in 16 days stopped and did
not return.
4 days, stopped ; but returned in 1
week slightly after beer in excess ;
stopped by one injection.
No discharge in 19 days.
Stopped in 12 days; slight return at
intervals for 2 weeks longer.
Discharge stopped in 6 days.
Stopped in 3 days.
In 2 days discharge disappeared ; in
10 days cured.
Stopped in 13 days; returned slight
on 17th ; cured in 20 days.
After 5 days only slight moisture at
meatus ; stopped entirely in 15 days.
Practically stopped after one injec-
tion ; cured in 10 days.
Second visit practically no discharge.
Stopped in 6 days ; no discharge for
10. Indulgence in beer brought
back discharge for 3 days.
Four injections; much improvement.
:i days, no discharge; slight return in
3 days, then no discbarge for 5 days.
Slight return, frequent urination,
and pain. Discharge stopped in 13
days ; pain on urination disappeared
after 5 days.
Improvement for 21 days.
Gradual improvement; no discharge
after 13 days.
Length of treat-
ment.
month.
1 month.
1 month
(no return).
2 days.
5 weeks.
3 davs.
5 weeks.
5 weeks.
Patient did not
return.
12 days.
5 weeks.
3 weeks (not
satisfactory).
11 days.
1 week ; under
observation for
4 weeks.
16 days.
12 days.
19 days.
1 month.
6 days.
Patient did not
return.
3 days.
10 days.
20 days.
15 days.
10 days.
21 days.
Patient did not
return.
13 davs.
Patient did not
return.
13 days.
490 ELLIS: ERRORS OF REFRACTION. [N. Y. Med. J
No.
Name.
History.
Nature.
Treatment.
Remarks.
Length of treat-
ment.
58
59
60
61
62
63
64
65
66
Mr. G.
Mr. L.
Mr. Lewis.
Mr. F.
Mr. H.
Mr. R.
Mr. A.
Fifteen cas<
Twenty-five
No gonorrhoea ;
3 days.
No gonorrh(ea ;
4 days.
No gonorrhoea ;
4 weeks.
Gonorrhoea onee
before ; 1 week.
Gonorrhoea 2 yrs.
ago ; 1 week.
Gonorrhoea
twice before ;
3 weeks.
No gonorrhoea
before ; 4 days.
;s under treatmei
cases could not i
Profuse, with pain.
a it
Ordinary.
Quite profuse.
a tt
Ordinary.
Profuse ; purulent, with
pain on urination and
opflpnif* 'tluiiit
vcjcuic* til jyjiAL \" ill .
it less than 10 days ; all d<
ittend regularly ; treatmen
Dermatol and plasment,
pot. bicarb.
tt tt a
a tt tt
tt tt a
ring well,
t not given.
Patient on third visit had no discharge,
and it has only been very slight with
no discomfort since.
Discharge stopped in 4 days, did not
return; saw patient 10 days later.
Discharge stopped by one injection.
After 3 injections discharge stopped ;
patient returned 10 days later for
another trouble.
Improved ; very slight watery dis-
charge only ; ] 6 days.
No discharge in 3 days, but returned
8 days later ; again stopped after
two injections ; four injections.
Improved after first injection ; still
under treatment, but discharge prac-
tically cured.
Still under
treatment.
8 days.
2 days.
1 week.
Under treat-
ment.
12 days.
Still under treat-
ment ; 1 2 days.
Treatment.
Duration.
Treatment.
Duration.
Weeks.
Days.
Weeks.
Days.
Weeks.
Days.
Weeks.
Days.
2
6
3
3
3
6
3
5
Irreg.,
beer.
5
2
1
7
I
5
4
5
2
4
Irreg.
tt
5
3
1
5
5
5
5
5
1
7
Irreg.
7
5
1
4
3
4
1
6
2
3
2
2
3
2
1
3
4
3
1
3
3
7
1
5
9
5
]
3
4
1
2
5
3
5
6
6
5
3
6
1
5
3
1
2
3
3
3
4
5
3
4
3
6
1
6
1
4
2
6
1
1
1
2
• 2
2
3
4
3
5
1
1
3
3
3
1
2
2
2
6
4
6
2
2
2
2
1
%i
3
3
3
4
1
3
2
3
2
2
2
1
4
2
1
2
3
1
6
2
4
4
2
1
6
2
1
4
4
2
1
1
1
5
1
2
2
4
2
1
5
4
5
4
4
3
3 did not return.
2
3
2
3 under treatment.
5
Irreg.
3
5
2
2
3
5
Irreg.
5
2
Treatment.
Duration.
12
1
2 weeks, more
than 1
20
7
3 "
2
10
10
4 " 4
3
4
10
5 "
4
5
14
6 "
1
8
7 "
1
2
1
9 "
Total
53
53
Although the results of treatment do not make a brill-
iant showing in these tables, yet I think you will all admit
that it is far above the average results.
I do not allege that urethritis is aborted by this treat-
ment, but that, when regularly applied, it allays the inflam-
matory symptoms and makes the patient much more com-
fortable, shortening the course and preventing complica-
tions.
In all these cases there has developed only one case of
epididymitis, and in that the patient had absented himself
a week from treatment.
Other complications — such as cystitis and balanitis —
have been absent, unless present at beginning of treat-
ment.
Conclusions. — 1. That in the treatment of acute urethri-
tis soothing applications rather than irritants should be
used.
2. That the passage of the soft-rubber catheter recom-
mended does not, as a rule, irritate the urethra ; that if it
does it should not be used.
3. That plasment is an excellent vehicle for urethral
medicaments.
4. That dermatol in plasment is the most efficacious
drug I have used in urethritis, although I have used no
other drug with plasment.
5. That treatment by the above-described method has
produced a milder course and fewer complications than that
with other remedies that I have used.
Note. — Since the foregoing was written, six of the patients reported
as cured have returned with a discharge. In all these cases there was
a history of previous attacks, and examination showed evidences of
chronic urethritis.
209 West Fifty-fifth Street.
ANALYSES OF TWO HUNDRED CASES OF
ERRORS OF RE FRACTION.*
By H. BERT ELLIS, B. A., M. D.,
LOS ANGEI.ES, CAL.,
PROFESSOR OF PHYSIOLOGY IN
THE COLLEGE OF MEDICINE OF THE UNIVERSITY OF SOUTHERN CALIFORNIA.
These analyses are based upon cases met in private
practice during the past two years, and I offer them to your
consideration, with a few remarks in the shape of explana-
tions and conclusions, not in the hope that there is any-
thing new in them which you are not already all well aware
of, but with the idea that by the constant repetition of
well-known facts the foundation may be laid for the more
* Read before the Southern California Medical Society at its eighth
semi-annual meeting, held at Riverside, December 2 and 3, 1891.
April 30, 1892.]
ELLIS: E It BOBS
OF BEFBA CTION.
491
general attention of the profession to eye-strain as a causa-
tive factor in human ailments.
I may state, as a prefatory note, that in the preparation
of these tables I have followed closely in the path blazed
by Dr. George M. Gould, of Philadelphia, in a paper read
in the Section on Ophthalmology, at the forty-second an-
nual meeting of the American Medical Association. I have
trod in Dr. Gould's footsteps because my experience, al-
though much more limited, has been quite similar ; and
further because, if my summaries are worth anything, they
will be the more valuable modeled after a standard.
During the time covered by the cases here recorded in
my ophthalmic practice I have had but eleven patients
whose conditions I did not consider would be benefited by
the wearing of glasses. Of these eleven, three I have noted
as emmetropic ; but it is only of one of them that I can
speak with assurance. Eight had very slight hyperopic or
myopic errors, but were without ocular or other reflex neu-
roses. That is to say, 94 -5 per cent, of my eye cases have
needed glasses, and only one half of one per cent, have been
certainly emmetropic. Of the two hundred cases recorded,
forty-three were presbyopic; that is, 21 "5 per cent.; and
of the remaining one hundred and fifty-seven, one hundred
and one were examined under a mydriatic ; the others
should have been, but in private practice it is many times
almost impossible for the business men or the women who
depend upon their eyes for their daily bread to stop their
work for even two to four days, the time necessary when
homatropine is employed.
The proportion between males and females is favorable
to the latter, the figures showing one hundred and fifty girls
or women and only fifty boys and men. This disproportion
may be accounted for by the difference in habits and out-
of-door exercise, these rendering the women less physically
perfect, giving them less resistance, and making them —
with their highly wrought nervous systems — greater slaves
to surrounding conditions.
Table I.
General Refraction of Three Hundred and Ninety-five Eyes.
Eyes.
Per cent.
Per cent.
of H.
of all.
Simple hyperopia
116
36-2
29-3
Simple livperopie astigmatism
61
19-1
15-5
Hyperopia with astigmatism
143
44-7
36-2
Total livperopie
320
100
81
Per cent.
of M.
Simple myopia
19
25-3
4-8
Simple myopic astigmatism
18
24
4-6
Myopia with astigmatism
38
5.0-7
9-6
Total mvopie
75
100
19
395
100
In Table I, 1 have given the general refraction, and in
it you will perceive that eighty-one per cent, have been
hyperopic ; and of these about sixty-three per cent, were
astigmatic. Among the myopes, seventy-five per cent, had
more or less astigmatism. That Dr. Gould found eighty-
three and ninety-one per cent., respectively, of hyperopic
and myopic astigmatism, where I found but sixty-three and
seventy-five per cent., may be explained by the fact that all
of his cases, excepting those far advanced in presbyopia,
were examined under a mydriatic ; while twenty-eight per
cent, of my patients would not be subjected to such incon-
venience.
The percentages in the subdivisions of the myopic and
hyperopic table you will find very much closer than Dr.
Gould's analysis shows. Thus simple H. and simple M.
were thirty-six and twenty-five per cent. Ah. and Am.
were nineteen and twenty-four, while the compound Ah.
and compound Am. were 44-7 and 50-7 per cent., respect-
ively.
Table II.
Refraction of Two Hundred and Fi fty-nine Hyperopic Eyes, Astigmatism
not included.
D.
H. eyes.
HI. Ah.
H. and HI.
eyes.
Ah. eyes.
0
25
12
19
31
0
60
25
31
56
0
75.
9
15
24
1
24
30
54
1
13
16
29
1
50
9
4
13
1
75.
5
1
6
2
2
3
5
2
25
5
4
9
2
50
1
1
2
75
2
3
5
3
2
4
6
3
25
1
1
3
50
3
3
4
1
1
2
4
50
2
2
4
5
2
2
5
50
2
2
6.
2
2
4
6
50
■ ■$ ,'
2
116
143
259
OROUPS.
Eyes.
Per cent,
of all H.
Per cent,
of all eyes.
J- 87
33-6
22
j- 78
30-1
19-8
}-
16-2
10-6
43
2-8
6
259
8-1
2-3
2- 3
3- 1
100
53
1 -5
1-6
65-5
Table II is a summary of the refraction of the hyperopic
cases excluding the astigmatic errors. One third of the
hyperopes and about a quarter of all the cases had an error
of 0*50 D. or less. Sixty-four per cent, of the hyperopes
and forty-two per cent, of all the patients had an error of 1
D. or less, and I corrected a great majority of these low
errors. Only three per cent, of the hyperopic cases had
errors over 5 I).
An examination of Table III — a summary of myopia
without the astigmatism — reveals quite a different percent-
age relation. Only thirty per cent, of the myopes had an
error of 0*50 D. or less ; and only forty-two per cent,, a
little over a third, had 1 D. or less ; while nineteen per
cent, had between 5 D. and 17 D.
Among the hyperopes, sixteen per cent, had errors <>\ci
•1 I>., while forty-four per cent, of the myopes had corre-
sponding errors, showing that errors of a high degree oc-
curred three times more frequently among the myopes.
The hyperopic and myopic astigmatic errors are sum-
marized in Table IV, and include both the simple and com-
pound corrections. The same facts are to be noted in this
table which 1 have already called your attention to in the
two preceding tables — namely, the low degrees, 1 I >. or
492
ELLIS: ERRORS OF REFRACTION.
[N. Y. Med. Jock.
Table III.
Refraction of Fif/y-si •ecu Myopic Eyex, Axtiymatixm not iticl 'nihil.
D.
0-25
0-50
0- 75
1...
125
1- 50
1- 75
2. :.
2- 50
2- 75
3...
3- 50
4. . .
4- 50
5- 50
6. . .
6- 50
7*50
8. . .
9. . .
10. . .
13. . .
16. . .
M. eves.
Ml. Ah.
eye*.
19
38
M, and Ml.
Am. eyes.
Eyes.
17
7
3
5
57
57
Per cent,
of all M.
29 8
12-3
5-2
8-8
12-3
8-8
3-5
19-3
100
Per cent,
of all eyes.
41
1-8
0- 8
1- 3
1-8
1-3
0-5
2-8
14-4
below, are both relatively and absolutely more numerous
in byperopia, constituting ninety per cent., while seventy
per cent, of the myopic cases had errors of 1 D. or below.
In but two patients did I find astigmatism to the extent of
5 D., and both of these were myopes.
Tablk IV.
Refraction of Tiro Hundred and Sixty Astir/mafic Eyex.
D.
H. As. eyeB.
0
25..
0
50..
0
75..
1
1
25..
1
50. .
1
75..
2
2
25. .
2
50. .
3
25. .
3
50. .
4
4
5
77 I
69 \
22 )
16 \
V )
•■ \
5 I
2 )
1
2
1
146
38
7
204
M. As.
eyes.
1\
9 i
11
1 I
1 I
4 ^
1i 3
56
260
H. As. and
M. As. eyes.
975>
12/ 19
1 \
6 I
6 S
1
3
1
2
1
1
1 )
2 S
H. As.
Per cent,
of all
H. As.
Ml. As.
Per cent,
of all
M. As.
Total As.
Percent,
of all
eyes.
71-6
34
63-5
18-6
35
■1
22-3
3-4
10
■ 7
5
3-4
8
■9
4-6
2
1
•8
1-9
1
3
•6
1-5
5
•3
1-2
100
100
100
In astigmatism the question of axes is one of consider-
able interest to the oculist therefore I have carefully tabu-
lated two hundred and sixty eyes in Tables V and VI. In
the hyperopic astigmatic eyes I found fifty per cent, ac-
cording to rule — that is, with axes at 90°. Among the un-
.syinnietrical are classed fifteen cases, in which one axis was
90°. This would make fifty-seven per cent, of astigmatic
hyperopic eyes, according to rule. Sixteen per cent, had
their axes at 180°, thirty-one percent, were unsyinmetrical.
Tahlk V.
Axex of Tiro Hundred and Sixty Axtiymiitir.
Hypkkopic.
Axis, 90°
Axis, 180°
Symmetrical — not 90" or 180' .
Asymmetrical
Total .
Myopic.
Axis, 90°.. . .
Axis, 180°
Symmetrical . .
Asymmetrical.
Total
Grand total.
Eyes.
Per cent,
of 11.
Per cent,
of all As.
102
50
39-2
32
15-7
12 3
6
2-9
2-4
204
100
Per cent,
of Am.
78-5
13
23-2
5
20
35-7
7-7
8
14-3
3-1
15
26 8
5-7
56
100
21-5
260
100
Tablk VI.
Asymmetrical Axex, Forty-four Caxex.
Per cent, of
Per cent, of
Cases.
asymmet.
asymmet.
H. axes cases.
axes cases.
Hyperopic.
One axis, 90°
15
42-8
34
One axis, 180°
5
14 3
11-4
Both axes the same — not 90° or 180°.
1
2-9
2-3
Sundry not in the above
14
40
318
Total
35
100
79
5
Per cent, of
Myopic.
asymmet.
M. axes cases.
One axis at 90°
■1
22-2
4
6
One axis at 180'
4
445
9
1
Both axes the same — not 90° or 180°.
Sundry not in the above
3
33-3
6
8
Total
9
100
20
5
44
100
Among those with myopic astigmatism I found thirty-
six per cent, according to rule — that is, with axes at 180°;
to these we may add those unsyinmetrical cases in which
the astigmatical angle of one eye was 180°, which makes
forty-three per cent, of my astigmatic myopic eyes which
had their axes according to rule. Twenty-one per cent, of
the myopic astigmatic eyes had axes at 90°, while twenty-
seven per cent, were unsyinmetrical.
Of all astigmatic eyes, fifty-one per cent, had their axes
at 90°, and seventy-four per cent, had their axes at either
90° or 180°. From this you see that, in any given case, we
are more than twice as likely to find the angle of astigma-
tism at 90° than at 180°, and three times as likely to find
the angle at 90° or 180° as at all other angles.
Besides those with axes at 90° or 180°, 1 had but six
symmetrical axes, or four per cent.
About thirty per cent, of both my astigmatic hvperopes
and myopes had unsyinmetrical axes ; the total number of
cases was forty-four. Fifty-nine per cent, of these had one
of their axes at 90° or 180°, but the axes of the other eyes
were exceedingly variable, following no rule. In four the
90°
- : in two cases
60
90° . , 90°
axes were — b ; in three cases
/ 5
, in two cases — 0 ,
April 30, 1892.|
ELLIS: ERRORS OF REFRACTION.
493
' 90° _ . . 180°
two other cases □ ; and in two patients — — -- ; no other
105 45
two eases were alike.
Of the other eighteen asymmetrical cases, there was but
one in which the axes of both eyes were the same ; and
there were no two cases with the same astigmatic angles.
In the application of glasses to several of my astigmatic
patients I have had no little trouble, because of the abso-
lute non-acceptance of a glass at a certain angle on the
return of accommodation which had been unmistakably
indicated under a mydriatic. At first I was greatly puz-
zled, and I still am, by these cases ; for as yet I am cer-
tainly " at sea," in so far as a satisfactory explanation is con-
cerned. " Spasm of the accommodation " is but a cloak to
hide our ignorance. The explanation which to me seems to
be the most reasonable is " irregular astigmatism " — that is,
the curvature near the periphery of the cornea differs from
that of its center, through which the individual usually
looks.
Without entering further into the details of these
tables, which I can not expect you as a body to be deeply
interested in, let me call your attention for a few minutes
to the manifestations of eye-strain which, as general prac-
titioners, we are constantly brought in contact with.
The eye-strain reflexes which I have been able to trace
with reasonable certainty in my practice I have classified in
Tables VII and VIII.
Table VII.
Eye-strain with Ocular Reflexes.
Symptoms.
Cases.
Per cent, of
all refraction.
13
6-5
4
2
5
2-5
5
2-5
8
4
7
3-5
i Direct
Photophobia and distress from light < jjefleet,4d '
20
18
10
9
80
40
Table VIII.
Reflex Neuroses of possible Ocular Origin.
Per cent, of
Per cent, of
Symptoms.
Cases.
all reflex
all refract-
neuroses.
ive cases.
93
87-7
46-5
Digestive and assimilative disorders.. .
ti
5-7
3
Mental symptoms, loss of memory, etc.
2
1-9
1
4
3'8
2
1
0-9
0-5
Total
106
100
53
Table VII contains all those cases in which the eye-strain
has manifested itself by ocular reflexes. Forty per cent, of
all my patients with refraction have had some ocular mani-
festation. Many others had conjunctivitis, blepharitis, or
some other symptom ; but whenever these cases were spe-
cific, or could be traced to some definite cause, they have
been excluded from this summary.
The most common ocular reflex was some degree of
photophobia or distress from light. In southern California,
where we have such perpetual sunshine, this is a symptom
of no little moment. In the table I have grouped these
cases under two heads for convenience, because of my be-
lief of the different causes producing the symptoms, and
the different methods employed in relieving the same.
These subdivisions are photophobia from the direct rays
which, outside of the ocular defect, are irritating from in-
tensity ; and photophobia from ref ected rays, from our arti-
ficial stone sidewalks, asphalt streets, and nearly white
country roads. The irritation in these cases I believe to be
chiefly due to the red or heat rays. If correction of the
defects fails to relieve these symptoms, I prescribe for those
who suffer most from the direct rays varying shades of
"London smoke " glasses ; but for those whose great dis-
tress arises from the reflected rays I order blue.
Pain in the eyeballs was another common symptom, as
was also lacrymation. Although forty per cent, of all the
patients had some ocular symptom, in the great majority of
these cases the ocular reflex was slight and not to be com-
pared with other reflex neuroses. Some patients had many
ocular and reflex neuroses, so that there was considerable
duplication and no little indefiniteness as to origin, although
in the majority of cases I was inclined to the belief that
they should be ascribed to eye-strain.
The reflex neuroses I have placed in Table VIII ; of
these, headaches formed eighty-eight per cent, and 46'5
per cent, of all refractive cases. The character of the head-
aches has been variable, and justifies an additional descrip-
tive summary, which is to be found in Table IX.
Table IX.
Headaches.
Per cent .
Per cent.
Variety.
Cases.
of all
of all
headaches.
refraction.
Frontal, brows, temples
27
'29
135
Sick headaches
11
11-8
5-5
Neuralgic headaches
12
13
6
First frontal, then extending to vertex.
2
2-1
1
First frontal, then extending to occiput.
3
3-2
1-5
First frontal, then general
2
2-1
1
Vertex
6
6-5
3
Occiput
7
7-6
3-5
General
20
21-5
10
3
3-2
1-5
Total
93
100
46-5
Twenty-nine per cent, had frontal, brow, or temporal
headaches ; twenty-one per cent, had general headaches ;
thirteen per cent, were of a neuralgic character ; while
twelve per cent, had sick headaches.
In many the headaches would at first be frontal, but
before they ceased would become vertical, occipital, or gen-
eral. If we leave off the forty-three patients who were
presbyopic, then in sixty per cent, of the patients headache
was a marked symptom, and in probably fifteen per cent,
more it was an occasional, but not a prominent, symptom.
The importance of headaches can hardly be overesti-
mated. It is certainly a conservative estimate which places
sixty per cent, of all headaches as due to ocular defects
and continued headache works ruin slowly, but none the
494
LEADING
ARTICLES.
[N. Y. Meu. Joub..
less certainly. Some maintain that at least seventy-five per
cent., and others that ninety per cent., of all headaches are
caused by some error of the seeing apparatus; and at least
two thirds of the patients who have their refraction cor-
rected before twenty-five to thirty years of age are cured
or greatly alleviated ; but those who are older may be
benefited, or even completely relieved ; but, as a rule, the
length of time for the accomplishment of this result is con-
siderable.
I have said nothing about several of the reflex neuroses,
and I have given no summary of muscular insufficiency, lie-
cause I desired to keep this paper within reasonable limits
as to length, and make it of general as well as special in-
terest.
107 N. Spuing Street.
Tannin in Tea. — " Some examples which have been forwarded to
us," says the British Medical Journal, " of the results of analyses for
tannin and theine in tea indicate considerable variation in the amount
of tannin, accordiltg to the quality of the tea ami the state of growth at
which it is picked. In some blends of China teas the percentage of tan-
nin extracted by infusion for thirty minutes was 7'44; theine, 3*11 ; and
a similar result was given in the examination of the finest Moninp; w hile,
on the other hand, with tine Assam tea a percentage of 17'7:j of tannin
by weight was extracted after infusion for fifteen minutes, and two
blends of Assam and Ceylon tea gave, respectively, 8-91 and 10-26 of
tannin. On the whole, it is probable that the Indian teas are much more
heavily loaded with tannin than the China or Japan teas. .Moreover, the
common method of prolonged infusion in boiling water is well calculated
to extract all the tannin, while it dissipates the flavor of the tea. To
be drunk reasonably, tea should not be infused for more than a minute,
and with water of which the temperature does not exceed 170° F. It
should be taken without sugar or milk, which would drown the flavor of
the delicate and aromatic infusion thus obtained. This at least is how
tea is drunk both in China and Japan, whence we have borrowed the
use of it. With our European method of prolonged infusion in boiling
water we destroy all the best flavor of the tea, and we extract such
heavy proportions of tannin as to cultivate indigestion as the result of
tea-drinking. Indigestion is unknown among tea-drinkers in the East,
and it is in all probability only the result of our defective use of the
leaf."
Filariasis. — "Among twenty-six officers and colonial officers admitted
to the Val-de-Grace Hospital between May 1, 1890, and February 1, 1891,"
says the Lancet, " Professor Moty observed four cases of the above disease,
and two other cases in the parents or friends of the patients. Four, how-
ever, of those admitted to the hospital had been abroad for so short a
time that they may be left out of the calculation, leaving six cases
among twenty-two persons who had spent a considerable time in the
colonies. In spite of its frequency, this disease does not appear to be
generally recognized abroad, as in none of the above cases had it been
diagnosticated. It was only upon undertaking an operation for the
radical cure of a supposed hernia that the tumor was found to consist
of dilated lymphatics. Professor Moty came to the following con-
clusions : That filariasis is an aseptic parasitic disease due to the pres-
ence of the filaria sanguinis hominis ; that it is of frequent occurrence
in the French colonies, and has been recently met with in Xew Cale-
donia. It most often appears as an enlargement of the glands and
lymphatics of the groin and spermatic cord, due to the irritation of the
filaria and its embryos. It can be recognized by such symptoms as
chyluria, hematuria, etc. ; but the diagnosis in each case should be
confirmed by the detection of the embryos in the blood. Neither in-
ternal nor palliative treatment is of the slightest use. Excision or am-
putation i- necessary in severe cases, and is attended with the happiest
results, the removal ol the hypertrophied tissue causing the adult filaria
to disappear."
THE
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by Edited by
D. Appi.eton & Co. Frank P. Foster, M. D.
NEW YORK, SATURDAY. APRIL 30, 1892
PHYSICIAN'S' BUSINESS METHODS.
In a recent address to medical graduates the Rev. Dr. Alex-
ander very pertinently remarked that the physician's first duty
to society was to make a living and keep out of the poor-house.
That this will he a question of most vital interest in the near
future with a majority of the young men to whom the remark
was addressed no medical man of ten years' experience will
doubt. It is true that the primary object of medicine as a pro-
fession is not the accumulation of wealth. A physician who
has amassed a fortune by the practice of his profession is an ex-
treme rarity. Many acquire a competence, and it is the duty of
every man, professional or non-professional, to do so if it is
within his power. The philanthropic idea is stronger in medi-
cine than in any other calling, except perhaps that of the
clergyman. But the doctor must pay his taxes or rent; he
must eat, drink, and be clothed: he must be supplied with in-
struments and hooks; he must support his family and educate
his children. The effusive thanks of grateful patients do not,
unfortunately, pay the bills. Fees alone will do that.
We thoroughly believe that medicine is a calling, not a
trade ; that the tradesman and business man may with entire
propriety adopt methods that would degrade the physician. He
can not practice his profession on strict commercial principles
without losing his self-respect and forfeiting the esteem of the
community. There is, however, a nusiness side to medical
practice which the doctor is proverbially lax in managing. The
amount of work he does is by no means the key to the amount
of his income. Laxity in business matters will explain the ap-
parent lack of success of many a physician. Some men are
wholly lacking in practical business capacity : others, from in-
dolence or overwork, neglect to give proper attention to their
collecting; while others, from failure to appreciate the value of
their own services, obtain less remuneration than is their due.
People are very apt to estimate a man according to the estimate
he places upon himself. If his price is habitually helow the
customary fees of the locality in which he lives, and he is diffi-
dent in enforcing his claims, he need not be surprised if his pa-
tients put a low estimate upon his worth and are slow in pay-
ing his bills. Just regard for the poor and the unfortunate is a 1
duty which very few physicians are inclined to evade. The
laborer is worthy of his hire, and there is no more worthy
laborer than the conscientious physician. He is under no moral
obligation whatever to deprive himself and his family of re-
muneration justly due him from the well-to-do. By cutting
rates he gains nothing in the long run. He injures not only
himself but his fellow-practitioners by degrading the value of
medical service.
April 30, 1892.]
MINOR PARAGRAPHS.— ITEMS.
495
There is perhaps no more fruitful source of loss to the
physician than laxity in rendering hills. There is great truth
in the old saying that short accounts make long friends. It is
frequently said that doctors' bills are hard to collect. If this is
true, the doctor is in many instances to blame — not because of
lack ot professional skill, but because the bill is so long delayed
that the patient has forgotten the matter and his gratitude has
evaporated. The age of long credits in commercial life is gone.
This is largely true also of professional work in the great centers
of population. In some country localities and among certain
city physicians it is not true. They allow accounts to run for
months or years without rendering a bill. The doctor's bill
thus becomes a formidable thing and is hard to pay, and must
usually be discounted. If rendered at short intervals, before it
has attained to great size, it is grouped with the current ex-
penses and is quickly paid with comparatively little effort. The
doctor's care, and labor, and sleepless nights are then all re-
membered, and the patient feels that he is paying money for
value received, and does not ask for a discount. Frequent bills,
while they need not show a mercenary or grasping spirit, do
show that the doctor lives by his practice and expects remu-
neration for his labor. It is not wise to place anything on a bill
that will seem to be an apology for rendering it, such as the
statement " bills 'rendered quarterly." A bill should be ren-
dered as a matter of course at stated intervals, which will vary
somewhat in different communities.
The struggle to make a living is" for most medical men a
hard one. They enter on their career without having had the
slightest instruction in professional ethics or business methods,
and the mistakes of the first years are by no means confined to
diagnosis and treatment. Success as a practitioner depends
almost, perhaps quite, as much upon social and business ca-
pacity as upon professional training. There is no person de-
serving of more pity than the scholarly and brilliant physician
hampered by his inability to read and deal with human nature,
and cramped through life by bad business methods and lack of
financial ability.
MINOR PARAGRAPHS.
THE ALUMNI ASSOCIATION OF CHARITY HOSPITAL.
The well-attended and enjoyable annua! dinner of this asso-
ciation, on Saturday evening, the 23d inst., calls to mind anew
the good influence that such organizations are exerting. There
is no danger that the brotherly feeling they promote will de-
generate into cliquism, for each of them generously invites repre-
sentatives of the others to take part in its festivities and in
much of its other proceedings. It'is a good thing for any hos-
pital to have the ex-officers of its house staff thus banded to-
gether.
RETROSTERNAL AUSCULTATION.
In the March number of the Revve <le medecine Dr. Boy-
Teissier. of Marseilles, presents the advantages of what he calls
retrosternal auscultation in many cases of cardiac, and especially
of aortic disease. With the patient lying on his back, the head
being but slightly raised, a stethoscope having an aperture only
12 millimetres in diameter is applied just above the interclavicu-
lar notch and pressed moderately backward and downward, so
as to bring the tube into approximate parallelism with the long
axis of the body. It is said that one readily learns the art of
doing this without discomfort to the patient in cases where the
anatomical conditions are favorable, and that no artificial bruits
are produced by the pressure of the instrument. The sounds
heard in this method of auscultation are all such as can be
elicited also by presternal auscultation, but they are heard with
much greater distinctness.
A MEDICAL DRAMATIST.
At one of the New York theatres, on Wednesday of this
week, a matinee performance was given of a play entitled An
American M. D., written by Dr. J. Mount Bleyer, a New York
physician of literary proclivities. We have often spoken en-
couragingly of medical men's ventures in verse, fiction, and
other branches of general literature, and we think it speaks well
for our profession that such attempts are growing commoner.
AN ADDITION TO OUR NOMENCLATURE.
The New York Times has an excellent department of Answers
to Correspondents, but one day last week it excited our regret
by adding to the already endless catalogue of names of diseases
that of " locomotor agitans," which it makes a synonym of loco-
motor ataxia.
ITEMS, ETC.
The Keeley "Cure" for Inebriety. — At the annual meeting of the
Hampden District Medical Society, of Massachusetts, held on the 20th
inst., the following preambles and resolution were adopted :
Whereas, According to common and newspaper report and upon
information and belief, it is known that a member of this society and
fellow of the Massachusetts Medical Society in regular standing has,
by associating himself with one of the most notorious impostors of this
century, in the application and use of a remedy for the cure of inebriety,
called " bichloride of gold," and whose exact composition it is pre-
tended is known only by, and is the sole property of, a certain indi-
vidual ; and
Whereas, No such stable chemical combination is possible, and the
substance actually used with so much secrecy and profit to the pro-
prietor is and has been employed in suitable cases for years by regular
physicians, who well know its limitations and dangers ; and
Whereas, By associating himself with a regular physician this pre-
tender hopes to gain prestige and the quasi-indorsement of the regu-
lar profession, thus enabling him longer to delude the public ; and
Whereas, The association of a regular physician in such a capacity
is calculated to injure the public and is degrading to those who are in
fellowship with such physician, and recognizing that " naught but evil
can finally result from trifling with moral or physical facts, and that it
is better to cure rightly and really than wrongly and delusiv ely," and
that by the " humhuggery of secrecy, delusion, and hypnotic sugges-
tion," a far less number will, in the end, receive benefit ; and
Whereas, It is the opinion of the members of this society that the
use of the drugs, in the manner employed, for the cure of inebriety by
the aforesaid impostor, produces a cerebral stimulation with intellectual
disorders which arc sometimes quite serious, together with other grave
nervous troubles, themselves constituting a form of inebriety frequently
leading to insanity and suicide, and a lowering of vitality, rendering
the patient less able to resist and recover from ordinary diseases ; and
Whereas, In those eases of inebriety claimed to have been cured by
means of this pretended secret method of treatment, it is our opinion
that such cures resulted not because- of said treatment, but in spite of
it, and there seems little doubt that hypnotic suggestion played an
important part in effecting said cures, and it is our opinion that in all
49fi
ITEMS,— LETTERS TO THE EDITOR.
[N. Y. Jouh. Med..
of tin' so-called "cures" the result attained could have been better se-
cured by improving the moral condition of the patient, by the use of
tonics or hydro^herapeutics, regulating nervous action, and by attention
to the digestive tract, without subjecting the patient to the dangers' of
another form of inebriety, and without the element of secrecy. It is,
therefore,
Resolved, That this society hereby directs its president to refer this
subject to a proper committee, who shall, before the next regular
meeting, ascertain if any member of this society lias identified himself
with the manufacture, sale, distribution, 01 use of any secret remedy,
contrary to the code of ethics under which this society is organized,
and, if so, that such member or members be recommended for expul-
sion from membership in this society ;>t said next regular meeting.
Changes of Address.— Dr. Henry T. Byford, to Xos. 34 and 86
Washington Street, Chicago (May 1st); Dr. C. E. Lockwood, to Xo. 59
West Thirty-fifth .Street (May 1st); Dr. William Oliver Moore, to Xo.
85 Madison Avenue; Dr. J. Rendell, to Xo. 635 Bedford Avenue,
Brooklyn (May 1st).
The Middleton Goldsmith Lecture, to be given before the New York
Pathological Society by Dr. Francis P. Kinnicutt, at the Academy of
Medicine, on Wednesday evening, May 11th, at 8.30 o'clock, will be on
the subject of Xew Outlooks in the Prophylaxis and Treatment of Tu-
berculosis.
Marine-Hospital Service. — Official Lift ejf the Change* of Stations
and Duties of Medical Officers of the United State* Marine- Hospital
Service for the three weeks ending April 16, 1892 :
BailHACHE, P. II., Surgeon. Granted leave of absence for seven days.
March 29, 1892.
Purvianck, George, Surgeon. Detailed as chairman of Board for
Physical Examination of Officer, Revenue-Marine Service. March
30, 1892.
Hamilton, J. 15., Surgeon. Detailed as chairman of Hoard for Physical
Examination of Surfmen, Life-Saving Service. March 31, 1892.
Godfrey, John, Surgeon. Detailed as inspector of immigrants, Port of
New York. April 14, 1892.
Mead, F. W., Surgeon. Detailed as chairman of Board for Physical
Examination of Officers of Revenue-Marine Service. April 16, 1892.
Banks, C. E., Passed Assistant Surgeon. Ordered to examination for
promotion. April 14, 1892.
Carmichael, D. A., Passed Assistant Surgeon. When relieved at Port
Townsend, Washington, to proceed to San Francisco Quarantine for
duty. April 8, 1892.
McIntosh, W. P., Passed Assistant Surgeon. When relieved at San
Francisco Quarantine, to proceed to Xew Orleans, La., for duty.
April 8, 1892.
Petti is, W. J., Passed Assistant Surgeon. Granted leave of absence
for thirty days. April 12, 1892.
Magruder, G. M., Passed Assistant Surgeon. When relieved at Port-
land, Oregon, to proceed to Port Townsend, Washington, for duty.
April 8, 1892.
Kinyoin, J. J., Passed Assistant Surgeon. Detailed as chairman of
Board for Physical Examinations of Candidates and Officers, Reve-
nue-Marine Service. March 30, 1892. Detailed as recorder of
Board for Physical Examination of Officers, Revenue-Marine Service.
April 16, 1892.
VattghaN, G. T., Passed Assistant Surgeon. Detailed as recorder of
Board for Physical Examination of Candidates and Officers, Reve-
nue-Marine Service. March 30, 1892.
Geddings, H. D., Assistant Surgeon. Ordered to examination for pro-
motion. March 29, 1892.
Werten baker, C. P., Assistant Surgeon. Detailed as recorder of Board
for Physical Examination of Surfmen, Life-Saving Service. March
31, 1892. Ordered to examination for promotion. April 5, 1892.
PERRY, J. <'., Assistant Surgeon. To proceed to Gulf Quarantine for
temporary duty. April 9, 1892.
Yoi no, G. B.j Assistant Surgeon. When relieved at St. Louis, Mo., to
proceed to Portland, Oregon, for duty. April 8, 1892.
Stimphon, W. G., Assistant Surgeon. Detailed as recorder of Board for
Physical Examination of Officer, Revenue Marine Service. March
30, 1892.
Brown, B. W., Assistant Burgeon'. Detailed as chairman of Board for
Physical Examination of Officer, Revenue Marine Service. April 1,
1892. To proceed to Port Townsend, Washington, for temporary
duty. April 8, 1892.
Rosen ai , M. J,, Assistant Surgeon. When relieved at Xew Orleans,
La., to proceed to St. Louis, Mo., for duty. April 8, 1892.
Cofer, L. E., Assistant Surgeon. To proceed to Buffalo, X. Y., for tem-
porary duty. April 8, 1892.
Eager, J. M., Assistant Surgeon. To proceed to GaUipolis, Ohio, for
temporary duty. April 8, 1892.
Gardner, C. H., Assistant Surgeon. To proceed to San Francisco, CaJ.1]
for temporary duty. April 8, 1892.
Society Meetings for the Coming Week :
MONDAY, May 2d : Xew York Academy of Sciences (Section in Biolo-
gy); German Medical Society of the City of Xew York ; Morrisania
Medical Society, Xew York (private) ; Brooklyn Anatomical and
Surgical Society (private); Utica, X. Y., Medical Library Associa-
tion; Corning, XT. Y\, Academy of Medicine; Boston Medical Asso-
ciation (annual) ; Boston Society for Medical ( >b c, vation ; St. Albans,
Vt., Medical Association; Providence, R. I., Medical Association;
Hartford, Conn., Medical Society; Chicago Medical Society.
TUESDAY, May 3d: Xew York Obstetrical Society (private); Xew
York Neurological Society; Elmira, X. Y\, Academy of Medicine;
Buffalo Medical and Surgical Association; Ogdensburgh, X. Y.,
Medical Association ; Hudson, X. J. (Jersey City — annual), and
Mercer, X. J. (annual), County Medical Societies; Connecticut River
Valley Medical Association (Bellows Falls, Vt.) ; Androscoggin, Me.,
Count\ Medical Association (Lewiston) ; Baltimore Academy of
Medicine.
Wednesday, Mag Jfth : Society of the Alumni of Bellevue Hospital;
Harlem Medical Association of the City of Xew York; Medical
Microscopical Society of Brooklyn; Medical Society of the County
of Richmond, X. Y. (Stapleton) ; Bridgeport, Conn., Medical Asso-
ciation: Penobscot, Me., County Medical Society (Bangor); Essex
North (annual — Haverhill) and Plymouth (annual), Mass., District
Medical Societies.
Thursday, Mag 5th : New York Academy of Medicine ; Brooklyn Sur-
gical Society ; Society of Physicians of the Village of Canandaigua,
N. Y. ; Medical Society of the County of Orleans (semi-annual —
Albion), XT. Y. ; United States Naval Medical Society (Washington);
Boston Medico-psychological Association ; Obstetrical Society of
Philadelphia; Ocean, N. J., County Medical Society (Tom's River).
Friday, May 6th : Practitioners' Society of Xew York (private) ; Balti-
more Clinical Society.
Saturday, Mag 7th : Clinical Society of the Xew Yrork Post-graduate
Medical School and Hospital; Manhattan Medical and Surgical So-
ciety (private); Miller's River, Mass., Medical Society.
Answers to Correspondents :
No. 381. — For bacteriological investigations and for examinations of
blood, a Zeiss's twelfth immersion; for the other work mentioned, the
same maker's objectives A and E. In each case, of course, a suitable
eye-piece should be used.
fetters to tbc (gbitor.
XOTE ON THE DISAPPEARANCE OF SUGAR IN THE
URINE OF DIABETICS JUST BEFORE DEATH.
108 East Sixteenth Street.
To the Editor of the New York Medical Journal:
Sin: Having recently occasion to review the works of Eb-
stein and Cantani, I noticed that in neither was any explanation
offered of this well-known clinical fact. While I was an interne
April on, lSii-2.]
PROCEEDINGS <>F SOCIETIES:
497
in the London -Hospital Dr. Stephen Mackenzie was making
special observations upon diabetes in the wards of Dr. J. Hugh-
lings Jackson, having twelve cases under treatment. In some
part of the study of the case a "fasting trial " was imposed of
twenty-four hours to note the effect upon the production and
increase and decrease of the sugar. At Id r. m. the last meal
was given. With the exception of plain boiled water, nothing-
whatsoever was allowed for twenty-four hours. These "fast-
ings" having been conducted in over a hundred cases, the results
were always uniform. The urine during the trial was tested
every hour, the patient being called upon to pass his urine " on
time." Singular to say, in all my experience I never failed to
obtain " some" when the time came around. For the fir3t few
testings the percentage of sugar appears as usual, after six hours
for two, three, even four trials it is augmented, then begins to
decrease. With the decrease there is a fall in the specific
gravity; and when this fall occurs it is always followed by the
appearance of albumin at the next trial, and from this on the
albumin remains. At some point after the tenth hour of fast
ing the sugar disappears, and very often with the disappearance
of the sugar blood appears, and often I have been obliged to
break the trial on this account. These trials have been so fre-
qeunt that some positive relation exists between the disappear-
ance of the sugar and the want of food. As most diabetics die
a lingering death, from coma, acetonemia, etc., they seldom re-
ceive any food or nourishment for hours before death.
Recalling the result of my observations, it would seem (aside
from other theories) that the result at the end of several hours'
fasting was akin to the state of the dying diabetic, and if in the
living sugar can be made to disappear, why not in the dying?
If this fact has been noticed before, pardon me; but I have
never come across it, and it just recurred to me while reading
Cantani's masterly paper.
Robert S afford Newton, M. D. (N. Y.)
flroceefjings of Societies.
NEW YORK ACADEMY OF MEDICINE.
section in orthopaedic surgery.
Meeting of March 18, 1892.
Dr. Henry Ling Taylor in the Chair.
Asymmetry of the Extremities.— Dr. L. W. Hubbard pre-
sented two sisters exhibiting this condition. One child had an
inch and a half shortening of the left lower extremity, and
about two inches and a half shortening in the left upper ex-
tremity, which was about evenly divided by the arm, forearm,
and hand. There was also a slight shortening of the left ramus
of the jaw. Her younger sister also exhibited about the same
amount of shortening of the left upper and lower extremities.
The muscles were well developed in both. Their parents were
healthy Germans, and there was no history of a similar de-
formity in other members of the family. An attempt had been
made to explain this asymmetry on the theory that there was an
unequal development of the cerebrum on the two sides.
Dr. A. B. Judson had seen a counterpart of these cases in
a girl of eleven years, in whom the right ear and eye, as well
as the right upper and lower limbs, were congenitally smaller
than the left. He suggested wearing an ischiadic crutch on the
larger side and a high sole on the smaller side during the period
of rapid growth. He thought that hip cases treated in this way
owed the disparity in length of the limbs, which was found in
the tibia as well as in the femur, partly to the disease of one
and the overuse of the other. Advantage should be taken of
this fact in the treatment of these cases of congenital asym-
metry.
Dr. R. H. Saybk said that many writers had denied that
want of symmetry in the lower extremities was a cause of true
ateral curvature, and had said that the occasional association of
the two conditions was a mere coincidence. Personally, how-
ever, he believed that, if the children just presented were al-
lowed to go on to puberty without the employment of measures
to equalize the limbs, they would certainly develop true lateral
curvature. In one of the cases the lack of development did not
seem to him to be entirely confined to one half of the body, as
the left side of the face appeared larger than the right, although
the extremities were smaller on the left side than on the right.
On this account he did not think the theory that this asymme-
try was due to unequal development of the two halves of the
cerebrum could be correct. He agreed with the previous speaker
that much of the atrophy following hip disease was due to lack
of use, and he therefore heartily indorsed his suggestions as to
treatment.
Dr. A. M. Phelps said that his experience had led him to
believe that the shortening of the limb in hip disease was never
due to anything but bone destruction, and that the employment
of the treatment suggested would effect no change in the length
of the limbs, although it might, increase their circumference.
Dr. Sayre said that after patients with club-foot had im-
proved sufficiently to enable them to use their feet, it was no-
ticed that there was not only an increase in the bulk of the feet,
but also in the length of the bones. It had also been observed
in colleges, where careful records were kept of the physical
condition of the students, that those who exercised regularly in
the gymnasium not only had larger muscles, but were taller than
those who did not avail themselves of this opportunity for physi-
cal training.
Results in Cases of Hip Disease treated by the Portable
Traction Splint without Complete Immobilization except
during the Inflammatory Stage; with Illustrative Cases
and Photographs of Cases.— Dr. Lewis A. Sayre read a paper
bearing this title. (See page 477.)
Dr. Judson agreed with the writer of the paper that trac-
tion did not secure complete immobilization, but rather fixation
or a fractional and sufficient degree of immobilization. Fixa-
tion thus produced relieved pain and hastened recovery, but did
not prevent the correction of deformity, which was brought
about conveniently and surely as soon as the patient, wearing
the hip splint or the ischiadic crutch, was taught to observe
habitually the natural rhythm of walking. Adduction and
flexion were thus reduced because the limb reached outward
and downward, and abduction and extension, in order to do
their share of the work of progression, were equalized. He
had been pleased to find that not only was deformity reduced,
but also the range of motion increased in the joint when the
limb was summoned in this way to do as far as it could its half
of the work of locomotion.
Dr. Phelps said that while listening to the paper he had
been impressed with the striking difference between the statis-
tics presented by the author and those published a few years
ago by Shaffer and Lovett, notwithstanding all these gentlemen
used the same plan of treatment. In thirty-nine cases reported by
the two last-named gentlemen, nineteen patients had ankylosis
and seven were in a condition almost equivalent to ankylosis. The
author of the paper which had just been presented deserved to
be congratulated on the large number of magnificent cures that
he had obtained. The speaker admitted that he had become
somewhat prejudiced against the long traction splint, partly as
498
PROCEEDINGS OF SOCIETIES.
[N. Y. Med. Joub.,
a result of experience and partly because of the publication of
the statistics which he had just quoted. Where ankylosis had
occurred, he believed it was due to trauma which had been pro-
duced by allowing the patient to walk upon the apparatus, or to
a joint in the splint which allowed of free motion, or to traction
not having been made in the axis of the neck. He considered
that the introduction of the long traction splint had marked a
distinct advance in orthopaedic surgery, but he thought still a
further advance would follow attention to the points just men-
tioned, and it was on this account that he had adopted the plan
of complete immobilization. The long traction splint was born
of a fear of ankylosis and a desire that the patient should have
exercise, yet in his own experience, which embraced a large num-
ber of dispensary cases of the worst class, ankylosis had not oc-
curred in a single one of the cases that he had treated daring
the past four years. The members would doubtless recall the
patients that he had previously presented, who, although com-
pletely immobilized for periods of about a year, still had com-
plete motion of the joint. He did not believe that fixation of a
joint, either diseased or healthy, resulted in ankylosis. The
fact that ankylosis was not a constant result of fixation proved
this theory to be erroneous. The "ossified man," during the
early stages of his disease, had been subjected to all sorts of
manipulations, yet every joint had become ankylosed. He be-
lieved the case of ankylosis reported in the paper was due to
some affection of the nervous system, and was not the result of
the immobilization. Ankylosis was determined by the character
of the inflammation, its severity and duration, the parts involved,
and the subsequent cicatricial contraction of the capsule of the
joint, and he could not see how passive motion could prevent
such destructive changes. The long traction splint, no matter
how applied, would allow the foot to be elevated 35° by tilting
of the band at the pelvis. He preferred this instrument, how-
ever, to the short traction splint. Although he had employed
lateral traction at first without knowing that it had been used
before, he had since found several references to it in literature,
showing that it had been used many years ago by Busch.
While on the subject of the use of the long traction splint,
he wished to call to mind the fact that cases of hip-joint dis-
ease presented great differences, and that some which ran a
favorable course were accompanied by much pain, while in
others which were associated with extensive destruction of bone
there was very little pain. He hoped that every one using the
long traction splint would have as fortunate an experience as
the author had had, but for the present he felt that he must
continue to use the lateral traction splint.
Dr. Joax Ridlon said that in a paper that he had written a
few years before on the subject of fixation and traction he had
stated that, as he had never met with a patient who had worn
the short splint, he thought this splint could not be used much
in this vicinity. He wished to take this opportunity to say that
since writing that paper he had seen three patients who had
previously worn this splint. He had been especially interested
in Dr. Sayre's statement that he had secured better results with
this instrument than with the long traction splint. Some years
ago he had come to the conclusion that the long traction splint
was positively harmful as a walking apparatus, as it seemed to
increase the pumping action " at the joint. That it should do
so seemed reasonable when one recalled the fact that with a
traction of from five to ten pounds and a splint weighing from
six to eight pounds the patient at each step stood upon the
splint, lifting the sound leg and relaxing all traction. The
effect of this upon the joint could easily be imagined when it was
remembered that a child running about took two or three thou-
sand steps an hour. That this splint did exert a harmful influ-
ence in this way seemed to be still further confirmed by the bet-
ter results that the author had obtained from the short traction
splint. As many of the cases had been treated at different
times by both the long and the short splint, it was difficult to
say how much of the good result was to be attributed to the
one or the other. It seemed to him that some patients with
hip-joint disease seemed to recover, no matter what the method
of treatment adopted, or even when they were entirely un-
treated. We had not yet found out what the essential vital
principle was in the treatment of each individual case. As an
instance of this he cited the case of a child whom he had treated
most carefully for six years, and yet the result was not so good
as in the case of a sister of this child, who had gone through the
entire period of hip disease without any surgical treatment. It
was true that some of his patients who should be on crutches
were walking around on the limb, because he was unable to
control them, yet he was free to admit that it did not seem to
have hurt them.
Dr. T. Halsted Myees said that in the majority of cases of
tubercular osteitis of the hip the primary local focus was in thq
neck of the femur at the junction of the epiphysis and the shaft
We could recognize this condition by appropriate tests, and, as
at this stage there was no involvement of the cartilages of the
joint, it was obviously unnecessary to immobilize the joint; yet
it was most important that concussion and pressure should be
taken from the inflamed and softened bone, and that there
should be no possibility of the weight of the body being thrown
on that limb. He believed that in a number of cases the disease
never extended beyond this location, and was cured in situ. He
had no pathological specimens to prove this [joint, and it had not
been investigated as yet ; he spoke from a clinical standpoint.
In cases where there was erosion of the joint surfaces bearing
against each other he thought motion was injurious, as well as
pressure, as was plainly indicated by the presence of reflex
muscular spasm, which was a reliable guide. We always found
reflex muscular spasm at the point where motion was injurious.
On the other hand, immobilization of a disorganized joint, pro-
vided pressure was also relieved, he had never seen cause any
permanent injury to the joint. To show the importance of the
relief of pressure in this connection, he stated that, in order to
relieve pain, he had had to apply traction to a patient with hip
disease who was wearing a Thomas splint correctly shaped and
applied. Recognizing the importance of this evidence, he had
made repeated careful observations, but always with the same
result — that traction was in this case necessary for the relief of
pain.
Dr. H. W. Berg wished to protest against the feeling of
nihilism that might be engendered by Dr. Ridlon's remarks. If
we were able to make a purely pathological diagnosis instead
of a generic one—" hip disease" — we might be able to point out
in advance those cases which would do well and those which
would do ill.
Dr. W. R. Townsexd said that, while not wishing to detract
in the least from the credit due the author for securing such ex-
cellent results, he desired to point out the fact that one factor
contributing to this end had undoubtedly been the very favora-
ble surroundings of his patients. Agiin, the author could
hardly have selected better cases had he desired to illustrate the
traumatic origin of hip disea-e, and the fact of many of the
cases reported having had such an origin afforded still another
reason for the excellence of his result". Bone tuberculosis and
osteitis due to traumatism might give the same clinical symp-
toms, but they should give different ultimate results.
Dr. Judson said that for a number of years he had kept a
description of all the hip splints he had applied, and their weight
had ranged from a pound and a half in the case of a child to a
little over five pounds for a large adult. He thought that some
April 30, 1892.J
BOOK NOTICES.
499
of lis were dissatisfied with the hip splint because we expected
more than the nature of these cases allowed of. We could not
cut short hip disease as we could break up chills with quinine.
We must put the part and the system in the most favorable
position attainable, and then wait for the natural processes of
repair. This was best done by making traction so long as it is
needed, and protecting the limb throughout the treatment from
the traumatism of walking, while locomotion was freely prac-
ticed. Traction and protection were the features of the Ameri-
can method by which it was distinguished from the Liverpool
method of portable leverage and the London method of re-
cumbent traction. The results obtained by Dr. Sayre had been
good, but not exceptional. They were within the reach of all
who adhered to the plan of treatment that had been outlined.
Dr. R. H. Sayre said that the fact that one man regarded a
case as tubercular, and another as non- tubercular, did not
change the character of the lesion, or influence the progress of
the disease. Regarding the question of the occurrence of anky-
losis, he believed that some cases would end in ankylosis wheth-
er motion was allowed or entirely prevented, and, as an illustra-
tion of this, he recalled a case of double hip-joint disease in
which the disease on one side was very severe and was accom-
panied by extensive suppuration, while on the other side it ran
a much milder course. During the progress of the disease in
the latter joint the patient had been kept in bed or in a wire
cuirass; yet, notwithstanding this treatment and the apparently
mild course of the disease, absolute ankylosis had been the re-
sult, while in the other joint good motion had been secured.
Again, after the disease had apparently been arrested in both
joints, and both seemed to be equally stiff, passive motion had
given a good joint on the side that had suppurated, but had re-
sulted in no benefit to the other side. He had seen a number
of cases of disease of both hips and knees in which the joints
had seemed to be perfectly fixed until passive motion was in-
stituted. He did not approve of leaving these stiffened joints
to be loosened by the ordinary motions which the patient would
make.
Dr. Phelps agreed with the other speakers as to the value
of forcible breaking up of adhesions under anaasthesia, but he
could not understand how motion of a joint during inflamma-
tion could prevent ankylosis. As the inflammatory materia,!
which limited the motion during inflammation was absorbed,
there would be an increased motion of the joint, and. in his
opinion, active motion on the part of the patient was better
than passive motion. He had frequently produced by passive
motion a return of the pain and stiffness in the joint.
Dr. Townsend could not see howr any one could believe that
an osteitis due to traumatism represented the same pathological
process as one due to tuberculosis, although the clinical symp-
toms might be identical.
The Chairman said that, while everybody must admit that,
the statistics presented in the paper were not only brilliant,
but exceedingly valuable, in comparing them with the statis-
tics of those who did not resort to excision of joints, allow-
ance must be made for those joints which had gone on t'j
excision. This would also affect the mortality. One point
which had been very strongly brought out in the paper was
the positive, decided, and immediate relief from pain obtained
in the majority of cases by traction properly applied. In hip-
joint disease it was fair to infer, as was also evident from
the results obtained, that, if the pain was relieved, the treat-
ment was beneficial to the joint. He believed in immobilization
in the acute stage, so far as it could be produced by traction,
but he did not believe it was necessary to go up to the axilla
and immobilize the spinal column. Sometimes traction must
be supplemented by recumbency and sometimes by the use of
crutches; these were all the necessary elements for the proper
management of those cases which could be successfully treated
by mechanical means. His own experience had led him to think
that by far the most efficient method of applying traction was
by means of the long traction splint.
Dr. L. A. Sayre said that the statistics presented were only
those which had been fully completed, and they represented
forty years of work. He thought Dr. Phelps had misunder-
stood him about the question of motion at the joint. He had
always advocated, repeatedly and persistently, rest of an in-
flamed joint, but he permitted such motion as the patient would
himself make. He did not consider that any motion which
would not cause pain was injurious. He applied sufficient trac-
tion to prevent pressure on the joint, and it was all-important
that this traction should he made in the proper direction. He
did not approve of an unyielding strap, which, in the splint used
by Dr. Taylor and Dr. Shaffer, was attached to the pelvic band
and to the shaft of the splint; in his opinion, it should be made
of elastic webbing. As regarded the aetiology of his cases, he
did not pretend to say whether or not the processes had been
tubercular or non-tubercular. At the time he began his inves-
tigations everything was called "scrofula," and medical men
believed that tubercle was always found in the lungs before it
was deposited in other parts of the body. Having learned from
autopsies in some cases of hip- joint disease that there were no
tubercles in the lungs, he had begun to doubt the tubercular
nature of this disease, and he had been led to look upon it as a
chronic inflammation resulting from a greater or lesser degree
of traumatism. Now that the presence of the tubercle bacilli
furnished a definite basis for a diagnosis, he was trying to learn
something about the occurrence of tubercle in these cases.
Clinical experience had taught him, however, that, whether
they were tubercular or not, fresh air, good food, and freedom
from pain were the essentials for a cure. Referring to the oc-
currence of ankylosis, he said that one single case of absolute,
firm ankylosis of all the joints in the body was worth more to
him than any number of experiments on dogs. In the case
which he had reported in his paper there had been no fever, no
evidence of any nervous derangement— in fact, no constitutional
disturbance. To apply a splint without traction was wrong;
nothing made better immobilization than plaster of Paris, and
it was much more comfortable than the Thomas brace ; yet it
was insufficient without traction to overcome the reflex mus-
cular contraction and to relieve pain. The treatment that he
advocated was the best possible one, no matter what the aetiolo-
gy of the disease.
Dr. John Ridlon exhibited a convenient pocket knife with
blades especially designed to facilitate the removal of plaster-of-
Paris bandages.
ill o o d lloticcs.
The Principles and Practice of Medicine. Designed for the
Use of Practitioners and Students of Medicine. By Willi am
Osler, H. I)., Fellow of the Royal College of Physicians,
London, etc. New York: I). Appleton & Company, lsii-J.
With a dedication to certain of his teachers, a brief note
acknowledging obligations to some of his associates, a sentence
from the first aphorism of Hippocrates, and a less familiar quo-
tation from Plato, the author starts in media* rex with his first
section, on the specific infectious diseases. And this brevity of
expression, this absence of padding of introduction, of padding
of text, i9 a characteristic of the work. With the many well-
500
BOOK XO TICKS.
[N. Y. Med. Joue.,
known and popular text-books on the theory and practice of
medicine demanding the consideration and patronage of the
profession, the author Jinust have felt that the discoveries in
pathology and the improvements in methods of treating dis-
ease, as well as the addition to our nosology of new diseases
that are not described in the familiar text-books, offered a
sphere of usefulness for a work that would present the latest,
knowledge on these topics. The medical profession will, we
believe, look upon this expectation as well founded, and give
the volume a cordial and deserved welcome-.
A feature of the work that impresses one is the credit (riven
to discoverers and original workers. In the first article, that on
typhoid fever, one notes with pleasure the tribute to the work
of Gerhard, the Jacksons, Bartlett, and Shattuck for their quick
recognition of Louis's distinction between typhus and typhoid
fever, and their labors in formulating the essential clinical and
pathological features of these diseases: while on a following
page Eberth's, Koch's, and Goffky's work in experimenting
with the specific micro-organisms is concisely considered, and
reference is made to Brieger's typhotoxine and toxalbumin.
So, in treatment, no effort is made to insist upon the adoption
of recent innovations because they are new ; for example, in
typhoid fever the advantages of the so-called Brand method are
referred to, and the author says that "a majority of our pa-
tients complain of it bitterly, and in private practice it is
scarcely feasible."
Sufficient weight is given to the utility ot Laveran's discov-
ery of the hajinatozoon of malarial fever ; and it is true that the
entire group of diseases included under the terms remittent,
bilious remittent, typho-malarial, and pernicious malarial fever,
as well as malarial hsematnria, should be studied anew in the
light of these observations. To many might be commended the
axiom that an " intermittent fever which resists quinine is not
malarial."
The chapter on tuberculosis is very thorough in its survey of
the light that has recently been thrown on the varied manifes-
tations of this disease. Under the question of prognosis, rather
than prophylaxis, the question of marriage of persons who have
had tuberculosis is briefly considered. It is stated that subjects
with healed lymphatic or bone tuberculosis marry occasionally
with personal impunity, and may beget healthy children, and
conceding that in such families scrofula, caries, arthritis, and
cerebral and pulmonary tuberculosis are more common, and it
is considered that the risks are such as may properly be taken.
In regard to arrested or cured pulmonary tuberculosis the
author speaks more decidedly on the subject.
The second section is devoted to the con-titutional diseases,
the various forms of rheumatism, gout, diabetes, rickets, scurvy,
purpura, and haemophilia. In the third section, on the diseases
of the digestive system, in the chapter on t\Tphlitis. we note that
the onus is thrown on the physician to say whether the case is
suitable for an operation, and when the operation should be
performed.
The fourth section treats of diseases of the respiratory sys-
tem and of the mediastinum ; the fifth, of diseases of the circu-
latory system ; the sixth, of diseases of the blood and ductless
glands; the seventh, of diseases of the kidney; the eighth, of
diseases of the nervous system ; the ninth, of diseases of the
muscles; the tenth, of the intoxications', sun-stroke, and obesi-
ty ; and the eleventh, of diseases due to animal parasites. It
would be impracticable to refer to the various chapters in these
sections, but we have not been impressed that any needful
matter has been omitted; and we have been struck with the
care with which many of the rarer varieties of disease have
been considered. At first reading this might impress one as a
rather sketchy manner of disposing of a subject, and yet on
second thought it will be noticed that no established fact in
setiology, pathology, or symptomatology is lacking; and were
not this conciseness exhibited the work would be swelled to
double its present dimensions.
The author is not a therapeutic optimist, and his remarks
on treatment assume a modicum of intelligence on the part of
his reader. In regard to some diseases — such as Weil's disease,
mountain fever, myxoedema, myotonia congenita, and para-
myoclonus multiplex — no suggestions of treatment are made;
and it seems to be true that no satisfactory treatment is known
for such cases.
A word of Commendation for the excellence of the indexing
is deserved ; nothing seems to have escaped the indexer.
It is an excellent text-book, and is sure to be accorded a
generous welcome.
Traiterrient des maladies de la j/eiu. Avec tin abrege de la
symptomatologie, du diagnostic et de l'etiologie des derma-
toses. Par le Dr. I.. Brocq. medecin des hopitaux de Paris.
Deuxieme edition, corrigee et augmentee. Paris: Octave
Doin. 1892.
Ix the first edition of this work the author stated that his
desire was to popularize the treatment of diseases of the skin,
and so satisfactorily has he accomplished this object that his
first edition of his work has been exhausted in eighteen months.
In that short period the progress of dermatology has not been
characterized by any particularly novel discoveries; still our
author has incorporated into his text whatever there is new
that is of value. For instance, certain diseases of the mucous
membrane that have been by tacit consent transferred to the
domain of the dermatologist are included in this edition : such,
for example, as leucoplasia, leucokeratosis, black tongue, margi-
nal exfoliative glossitis, aphthous and contagious inflammation
of the vulva, etc.
Additions have been made in the articles on actinomycosis,
glanders, pyocyanic disease, the parakeratoses, the setiology of
eczema, seborrba>ic eczema, and lichenoid eruptions. The
pharmacological portion of the volume has been revised by M.
Portes, of the St. -Louis Hospital.
The alphabetical arrangement of diseases and the very com-
plete index — a rare feature in many foreign medical works —
make this a very convenient volume of reference, both for the
specialist and for the general practitioner.
A Manual of Autopsies. Designed for the use of Hospitals for
the Insane and other Public Institutions. By I. W. Black-
burx, M. D., Pathologist to the Government Hospital for
the Insane, Washington, D. C. Illustrated. Philadelphia:
P. Blakiston, Son, & Co., 1892.
This little work will be found of great value by those physi-
cians in general as well as hospital practice who have to make
their own necropsies.
The matter is compactly arranged, and the portion of the
work devoted to the examination of the brain is comprehensive
and illustrated by numerous plates.
The volume was prepared at the request of the Association
of Superintendents of American Institutions for the Insane, and
is published with their indorsement.
7'he Age of the Domestic Animals, being a Complete Treatise
on the Dentition of the Horse, Ox, Sheep, Hog, and Dog,
and on the Various other Means of determining the Age
of these Animals. By Pu sh Shii'Rex IIuidekoper, M. D.,
Veterinarian (Alfort, France), Professor of Sanitary Medi-
cine and Veterinary Jurisprudence, American Veterinary
April 30, 1892.]
BOOK NOTICES.— NEW INVENTIONS.— MISCELLANY.
501
College, New York, etc. Illustrated with Two Hundred
Engravings. Philadelphia and London : F. A. Davis, 1891.
8vo. Pp. viii-217.
This book is a well-written and well-arranged treatise upon
an important subject. It is a valuable work for all who have
to do with the animals considered. It is illustrated fairly well,
and is fully indexed.
Human Monstrosities. By Barton Cooke Hirst, M. D., Pro-
fessor of Obstetrics in the University of Pennsylvania, and
George A. Piersol, M. D., Professor of Histology and Em-
bryology in the University of Pennsylvania. Part II. Il-
lustrated with Thirteen Photographic Reproductions and
Twenty-five Woodcuts. Philadelphia : Lea Brothers & Co.,
1892.
In the second part of this work, the first part of which was
reviewed in the Journal for January 23d, the authors consider
the classes of Celosoma, Exencephalus, Pseudencephalus, and
Anencephalus. The six varieties of eventration described by
Isidore Geoffroy Saint-IIilaire, aspalasoma, agenosoma, cylloso-
ma, schistosoma, pleurosoma, and coelosonia, are described and
illustrated. The subdivisions of exencephalus into notencepha-
lus, proencephalus, podencephalus, hyperencephalus, iniencepha-
lus, and exencephalus are well described, and each variety is
illustrated.
The thirteen plates of photo-electrotypes and the twenty-
tive woodcuts are as excellent as in the former volume, and the
general high character of the work is maintained.
Atlas of Clinical Medicine. By Btrom Bramwell, M. D.,
F. R. C. P. Edin, F. R. S. Edin., Assistant Physician to the
Edinburgh Royal Infirmary. Vol.1. Part III. Edinburgh:
T. & A. Constable, 1891.
The third Fasciculus of this admirable work maintains the
high standard of excellence attained by the first two parts. It
contains ten plates and articles on progressive unilateral atrophy
of the face, chronic progressive bulbar paralysis, ophthal-
moplegia, molluscum fibrosum, and xeroderma pigmentosum.
Though the plates are the most marked feature of the work,
the text is worthy of the highest praise, presenting as it does
substantially all that is known of each disease. Every article
is virtually a clinical lecture of the most practical kind, de-
signed not only for the student, but for the general practitioner
of medicine.
BOOKS, ETC., RECEIVED.
Technique d'eleetrophysiologie. Par le Dr. G. Weiss, Ingenieur des
pouts et chaussees, Professeur agrege a la Faculte de Medecine de Paris.
Avant-propos de M. le Professeur Gariel. Paris : Gauthier-Villars &
tils ; G. Masson. Pp. 214.
Maladies des organes respiratoires ; methodes d'exploration ; signes
physiques. Par Leon Faisans, medecin de la Pitie. Paris : Gauthier-
Villars & fils ; G. Masson. Pp. 192.
Gynecologic. Semeiologie genitale. Par A. Auvard, Accoucheur
des hopitaux. Paris: Gauthier-Villars & fils ; G. Masson. Pp.175.
Le delire chronique a evolution systematique. Par le Dr. Magnan,
Medecin en chef a l'asile Sainte-Anne ; et le Dr. P. Serieux, Medecin-
adjoint des asiles de la Seine. Paris : Gauthier-Villars & fils ; G. Mas-
son. Pp. 184.
The Uses of Water in Modern Medicine. By Simon Baruch, M. D.,
Physician to the Manhattan General Hospital and New York .Juvenile
Asylum, etc. Vol.1. Detroit: George S. Davis, 1892. Pp. xvi-115.
[Price, paper, 25 cents ; cloth, 50 cents.]
Dr. G. Zander's mcdico-mechanische Gymnastik, ihre Methode, Be-
deutung und Anwendung, nebst Ausziigen ans der einschlagigen Lit-
teratur. Von Dr. Alfred Levertin. Stockholm: 1'. A. Norstedt &
Soner, 1892. Pp. 201.
A Baby's Requirements. By Elisabeth Robinson Seovil, Superin-
tendent of the Newport Hospital, Newport, R. I. Philadelphia : Curtis
Publishing Company, 1892. 12mo, pp. 55.
IJtcb) Jnbeittirms, etc.
SCISSORS FOR THE REMOVAL OF SUTURES.
By John A. Prince, M. D.,
SPRINGFIELD, ILL.
Scissors exclusively for the removal of sutures may seem a superflu-
ous article in a surgeon's armamentarium, already necessarily large, but
I trust upon trial the verdict may be different.
There exists no instrument whereby the removal of ordinary and
especially of fine coaptation sutures may be done easily and without
pain and annoyance to the patient, who usually dreads the removal of
the sutures almost as much as the original operation, and with reason.
In the removal of a suture it is of course necessary to cut the loop,
and, to facilitate the entrance of the point of the scissors for this pur-
pose, more or less tension is put upon it, thus causing pain. Some time
ago I began to use Stevens's tenotomy scissors for this purpose, and was
surprised to find how easily and painlessly a suture could be removed.
Deriving my idea from his instrument, I have had Messrs. Tiemann
& Company construct for me the scissors shown in the accompanying
cut. The cutting edge is limited to the tapering extremity of three
eighths of an inch.
These scissors are made very strong and are capable of cutting
heavy silk or silver wire, yet they possess a cutting point as fine as the
most delicate eye scissors. Hence, in the removal of a suture by them,
the slightest degree of tension is necessary, and the minimum of pain is
felt.
IP i s c c 1 1 w n ij .
Ocean Holidays. — The following appeared as an editorial article in
the British Medical Journal for April 9th :
The advantages of ocean travel as a means of repose and restoration
to those overwrought by the wear and tear of political, commercial, and
literary life have been illustrated in the columns of the British Medical
Journal for many years. They are every year more fully admitted and
more widely taken advantage of. The sense of motion beguiles what
might otherwise be the tedium of ship-board life — the quiet routine,
the absence of daily responsibilities, the new subjects of consideration;
the salt air, the constantly renewed draughts of oxygen, the conditions
of healthy exercise without fatigue, and the irrestible charms of contact
witli the most sublime aspects of Nature are all influences which act ;is
a mental and bodily tonic. They are re-enforced by change of scene,
transplantation to new countries and genial climates, and the observa-
tion of races, countries, and cities, which never (ail to arouse new feel-
ings of interest in those who behold them for the first time. The facili-
ties for such ocean trips are now greatly multiplied. The Peninsular
and Oriental Company's steamers, which girdle the world, are specially
laid out now for the comfortable, and even luxurious, accommodation
of travelers in search of health and recreation — and the human inter-
ests and physical and mental needs of such traveler's are carefully con-
502
MISCJELLANT.
[N. Y. Med. Joi r
sidered in every way. Circular tours and holiday trips are to be had to
most parts of the world, and at the seasons best suited to enable the
traveler to benefit by the most healthy seasons in eaeh country. Other
lines follow the example. Ocean yachts facilitate shorter and well-
planned holidays, so that it is becoming as common now to take a
winter holiday in Egypt or India, in Madeira or the Canaries, as for-
merly to any part of the continent of Europe. Moreover, as the fatigue
of traveling by sea is far less than that of traveling by land, as the
movement of an ocean steamer generally soon ceases to cause discom-
fort, even to the qualmish, and as the cost is far less, while the comfort
and luxury are greater, "holidays at sea" prove attractive to a vastly
increased and increasing proportion of our population.
But there is a risk, and, indeed, more than a risk, of the enormous
advantages of such a relief from the wear and tear of modern life be-
ing lessened for the invalid and the convalescent by an abuse of the
very facilities which the new development of sea travel offers. The
traveler for health, the invalid with weakened nerve power, is tempted,
perhaps too often, to follow in the rapid footsteps of the ardent "globe
trotter." It is so easy nowadays to do a great deal without fatigue that
the temptation to do too much is not avoided. When formerly the pa-
tient with delicate lungs would find his way to Cairo or Luxor, or slowly
ascend the Nile in a dahabeah, he now pushes on to India, traverses the
whole continent, and returns in three or four months. If he stays in
Egypt he steams up the Nile, and having " done " Phila; and the Cata-
racts, returns to balls and parties and the theatres of the now gay and
Europeanized capital in Cairo; he gets neither the rest nor the healthy,
quiet Oriental life which formerly soothed his nerves, interested his
mind, and invigorated his health. The rush of travelers through Egypt
is a thing to be admired and approved in itself, for the contact with our
dependencies and the personal observation of social conditions in the
East add largely to our intelligence and sympathy as a governing nation.
But the invalid will do wisely to differentiate himself from the globe
trotter. A winter in India or in Egypt or the Atlantic islands offers a
vista of escape from fogs and cutting winds, a substitution of sunlight
and landscape, cloudless sky, warm airs, of brilliant color, and fantastic
life which may well and wisely tempt the weary and the overworked to
follow the sun in search of health and of the sense of a larger life than
can be lived in the routine of daily work in the centers of industry here
or in the restricted formal circles of the winter health resorts of Europe,
delightful as they are. But the holiday in the East, like the holiday
in the Riviera, or Madeira, or Teneriffe, must be one of long periods of
rest and not of continuous movement. The longer the sea voyage and
the less the land travel the more restorative such a holiday is likely to
be where broken health is the cause of the journey.
A medical correspondent, Mr. Hope Lewis, medical officer at Auck-
land, recently wrote to us saying that he had met with a number of pa-
tients on their way through New Zealand, where they were half-way
round the world. Among them all sorts of cases presented themselves
— phthisical, rheumatoid, gouty, nervous, spinal — and in all stages.
They were not by any means all benefited. " Rush," he complains, " is
the axiom now."
The old-fashioned sailing vessel is now almost a thing of the past
for this route. It has more than once occurred to him that a patient
suffering from nervous breakdown has inquired as to a course at the
thermal district of Rotorua, but the answer to the question how long a
stay w as proposed in the colony has been that the Orient steamer was
due at Lyttelton in three weeks, and must be " caught." Such a patient
had left England two months before, spent a few days in Sydney and
Melbourne, and come straight on to New Zealand, where he had just
arrived. This is good traveling for a hale and hearty man, but is not
the sort of thing an invalid should take in hand, although there is
reason to know that many undertake it, keeping up diaries and diligent
note-taking all the time, and going wherever materials may be accumu-
lated for the inevitable " book of travels." Easy and fascinating as is
life on board a great ocean steamer, invalids should be cautioned not to
enter too freely on the amusements which are provided for the young,
strong, and active. "Round the world in eighty days " is a possible
achievement nowadays, but it is the opposite of what the rest-seeker
should hold in view.
The whole world is now open to the doctor who prescribes and to
the invalid who seeks ocean holidays, the best climates, the most glori-
ous natural scenery, the most perfect mountain solitudes, or the most
picturesque populations among which to repose and recruit. But it is
well to choose one or two items in the large bill of fare. The Koekv
Mountains of Canada are now rendered so accessible by the Canadian
Pacific Railway, with its palace cars and traveling table d'AdU, that
without fatigue and without effort the marvelous glaciers — one of
which would swallow up all the glaciers of Switzerland — its river.-,
packed with salmon, and its primeval forests, may be reached in a few-
days. Even Japan in the Far East, the most attractive play-ground of
the world, is little more than a month away from our doors. The spice
gardens of Ceylon, the fairy palaces of India, the temples and desertfi
of Egypt, may all be reached with less fatigue than was former] \ in
volved in a tour in many parts of Europe; while it is as easy to get to
Madeira or Teneriffe as to go b\ sea to Glasgow, and much more com-
fortable ; and the few weeks which we were all u.-cd to spend at a dull
seaside place may now, thanks to the facilities of ocean travel, be spent
far more delightfully, and as a short winter holiday, say, in Malta,
Gibraltar, or Tangier, without any fatigue, and with singular refresh-
ment of mind and body. The hints which we have from more than one
correspondent as to the tendency to hurry away from one town to an-
other, and from continent to continent, prompt us to caution both
doctors and patients that it is easy to spoil the value of holidays at sea,
and health tours generally, by extending them to meet time require-
ments for much sight-seeing, and by confounding health anil rest trips
with "globe trotting," which is the privilege of the healthy and the
curious. The most perfect of all holidays are to the Ear East, but
enough time must be given, and as much steamer put in and as little
railway travel as possible.
The "Ginger-beer Plant." — In the Proceedings of the Royal Society
we find the following abstract of a communication by II. Marshall Ward,
M. A., F. R. S., etc. : The author has been engaged for some time in the
investigation of a remarkable compound organism found in home-made
ginger-beer fermentations.
It occurs as jelly-like, semi-transparent, yellowish-white masses, ag-
gregated into brain-like clumps, or forming deposits at the bottom of
the fermentations, and presents resemblances to the so-called Kephir
grains of the Caucasus, with which, however, it is by no means iden-
tical.
He finds that it consists essentially of a symbiotic association of a
specific sncehnrom.yeete and a sehlzoni.yeete, morphologically compara-
ble to a lichen, but, as met with naturally, invariably has other species
of yeasts, bacteria, and mold-fungi casually associated with these. He
has successfully undertaken the separation of the various forms, and
groups them as follows :
1. The essential organisms are a yeast, which turns out to be a new
species allied to Saeehnromyeex eUipsoidem (Reess and Hansen), and
which he proposes to call 8. pyrifortnis ; and a bacterium, also new and
of a new type, and named by him Bacterium vermiforme.
2. Two other forms were met with in all the other specimens (from
various parts of the country and from America) examined — Mycoderma
cerevisite (Desm.) and Bncteruim net! (Kiit/.ing and Zopf).
3. As foreign intruders, more or less commonly occurring in the va-
rious specimens examined, were the following :
a. A pink or rosy yeast-like form — Cryptoi-nrens </l 'nti nix (Presenilis)?
/3. A small white aerobian top-yeast, with peculiar characters, ami
not identified with any known form.
y. The ordinary beer-yeast — Sneehnrtnuynx erne/site (Mayen and
Hansen).
S. Three, or probably four, unknown yeasts of rare occurrence,
e. A bacillus which forms spores and liquefies gelatin with a green-
ish tinge.
£ A large spore-forming bacillus, which also liquefies gelatin.
7j and 0. Two — perhaps three — other schizomycetes not identified.
j. A large yeast-like form which grows into a mycelium, and tur
out to be Oidurn laetis (Eresenius).
k. A common blue mold — PenieiUinm (ihiueinn (Link).
A. A brown " torula "-like form, which turns out to be DemaHu
p Uulans (Dc Ban ).
April 30, 1892.J
MISCELLANY.
503
fi. One, or perjiaps several, species of " Torula " of unknown origin
and fates.
Of these forms, the author has succeeded in cultivating and exam
iniug very thoroughly all hut those under 0 and /j. in the foregoing list.
Sturharomyces pyriformis (n. sp.) is a remarkably anaerobian bot-
tom-yeast, forming spores, and developing large quantities of carbon di-
oxide, but forming little alcohol. It has also an aerobian form — veil
form of Hansen — in which the rounded cells grow out into club-shaped
or pyriform cells, whence the proposed specific name. It inverts cane
sugar and ferments the products ; but it is unable to ferment milk sugar.
It forms rounded, morula-like, white colonies in gelatin, and the author
has separated pure cultures from these. He has also studied the devel-
opment and germination of the spores which are formed in twenty-four
to forty-eight hours at suitable temperatures on porous earthenware
blocks. They also develop on gelatin. The technological characters
have been kindly determined and confirmed for the author by Mr. Horace
Brown, F. R. S., and Dr. Morris, of Burton-on-Trent.
The specific schizomycete (Bacterium vermiform?, n. sp.) has been
very fully studied by the author. It occurs in the fermentations as
rodlets or filaments, curved or straight, incased in a remarkably
thick, firm, gelatinous sheath, and is pronouncedly anaerobic, so much
so that the best results are got by cultivating it in carbon dioxide under
pressure.
The sheathed filaments are so like worms that the name proposed
for the species is appropriately derived from this character.
It will not grow on gelatin, and separation cultures had to be made
in saccharine liquids by the dilution methods.
It grows best on solutions of beet root or of cane sugar, w ith rela-
tively large quantities of nitrogenous organic matter — e. g., bouillon,
asparagin, and tartaric acid. Good results were obtained with mixtures
of Pasteur's solution and bouillon.
The author has found that the bacterium into which the filaments
subsequently break up can escape from its sheath and become free, in
which state it divides rapidly, like ordinary bacteria. Eventually all
the forms — filaments, long rods, short rodlets — break up into cocci.
No spores have been observed. These changes are dependent especially
on the nutritive medium, but are also affected by the gaseous environ-
ment and the temperature. The jelly-like clumps of the so-called " gin-
ger-beer plant " are essentially composed of these sheathed and coiled
schizomycetes, entangling the cells of Saceharomyccs pyriformis. But
the action of the schizomycete alone on the saccharine medium differs
from that exerted by the latter alone. This was proved by cultivating
each separately, and also by cultivations in which, while each organism
was submerged in the same fermentable medium, they were separated
by permeable porcelain (Chamberland filters), through which neither
could pass.
The author has also constructed the " ginger-beer plant " by mixing
pure cultures of the above two organisms ; the schizomycete entangled
the yeast cells in its gelatinous coils, and the synthesized compound
organism behaved as the specimens not analyzed into their constitu-
ents.
Some very curious phenomena in connection with the formation of
the gelatinous sheaths and the escape of the bacteria from them were
observed in hanging-drop cultures, and are figured and described by
the author. The conditions for the development of the gelatinous
sheaths, and therefore of the coherent brain-like masses of the schizo-
mycete, are a saccharine acid medium and absence of oxygen. The
process occurs best in carbon dioxide ; it is suppressed in bouillon and
in neutral solutions in hydrogen, though the organism grows in the free,
non-sheathed, motile form under these conditions.
The behavior of the pure cultures of the bacteria, in as complete a
vacuum as could be produced by a good mercury-pump, worked daily
and even several times a day for several weeks, is also noteworthy.
The author records his thanks to his friend and colleague, Professor
McLeod, for much assistance in regard to this apparatus. The devel-
opment of the sheaths is apparently indefinitely postponed in vacuo, but
the organism increased, and each time the pump was set going an ap-
preciable quantity of carbon dioxide was obtained. In vacuum tubes
the same gas was evolved, and eventually obtained a pressure sufficient
to burst some of the tubes. The quantity of carbon dioxide evolved
daily by the action of the bacterium alone, however, is small compared
with that disengaged when the organism is working in concert with the
symbiotic yeast ; in the latter case the pressure of the gas became so
dangerous that the author had to abandon the use of sealed tubes.
The products of the fermentation due to the schizomycete have not
yet been fully determined in detail ; lactic acid or some allied com-
pound seems to be the chief result, but there are probably other bodies
as well.
The author owes acknowledgment to Dr. Matthews, of Cooper's Hill,
for advice and assistance in examining the products of these fermenta-
tions.
The pink yeast-like form proved to be very interesting. It has
nothing to do with the "ginger-beer plant" proper, though it was in-
variably met with as a foreign intruder in the specimens. The author
identifies it with a form described by Hansen in 1879;* unfortunately,
the original is in Danish, but the figures are so good that little doubt is
entertained as to its identity. It is also probably the same as Fresenius's
Cryptococcus glutinis in one of its forms. It is not a saccharomycete,
and does not ferment like a yeast ; it is aerobian.
The chief discovery of interest was that in hanging drops the au-
thor traced the evolution of this " rose-yeast " into a large, complex
mycelium, bearing conidia, and so like some of the basidiomycetes that
it may almost certainly be regarded as a degraded or " torula" stage of
one of those higher fungi. Full descriptions and figures are given by
the author.
The form Mycoderma cerevisim was thoroughly examined. The au-
thor's results confirm what is known as to its aerobian characters.
Statements as to its identity with Oidium lactis were not only not con-
firmed, but the author grew these two forms side by side, and maintains
their distinctness. Nor could he obtain spores in this fungus, thus
failing to confirm earlier statements to the contrary. He regards it as
probable that oil drops have been mistaken for spores ; he also finds
that in later stages of fermentation by this organism a strong oily
smelling body is produced.
With regard to Bacterium aceti, the author has little new to add.
A point of some interest was the repeated production of acetic ether,
which scented the laboratory when this schizomycete was growing in
company with the small white aerobian top-yeast referred to under
As this phenomenon was found to have nothing to do with the question
being investigated, the author did not pursue it further. It seemed
probable, however, that the yeast produced alcohol, which the schizo-
mycete, in presence of oxygen, partially oxidized, and that the fragrant
ether was produced by interaction of the products.
With regard to the other forms found, the author was chiefly con-
cerned with testing their relations to the important and essential organ-
isms. It need only be remarked here that the hanging-drop cultures of
Dematium pullulans were very successful, and that some of the molds
and at least one bacillus (of which the spore formation, etc., were
traced also) were traced to ginger used in the manufacture of the well-
known beverage.
The author hopes very shortly to have the honor to lay before the
society a full account of his research, of which the above is only a brief
notice. The fuller account will contain detailed descriptions, as well as
figures, of the apparatus, mode of culture, etc.
The Association of Medical Superintendents of American Institu-
tions for the Insane. — The forty-sixth annual meeting will be held in
Washington, at the Arlington Hotel, on the 3d, 4th, 5th, and 6th of
May, under the presidency of Dr. Daniel Clark, of Toronto, Ontario.
The American Electro-therapeutic Association will hold its second
annual meeting in New York, at the Academy of Medicine, on October
4th, 5th, and 6th, under the presidency of Dr. W. J. Morton.
The late Dr. Henry I. Bowditch, of Boston. — The Edinburgh
Medical Journal, in its April number, prints the following obituary
notice of Dr. Bowditch, written by Dr. W. T. Gairdner:
Although the number of those who made the acquaintance of this
distinguished physician on his visit to this country in 1861 must now
be sadly diminished, it may be permitted to us in this journal to offer
* Organismer i 01 og O/iirt. Copenhagen, 1879,
504
MISCELLANY.
|N. Y. Med. Jouk.
a brief tribute to his memory, from one who is perhaps the onlj hospi-
tal physician now in a position to do so among those who gave a
hearty greeting to Dr. Bowditch in the Edinburgh Royal Infirmary
more than thirty years ago. The writer was thoroughly attracted ;ii
that time, not only by what appeared to him an eminently noble per-
sonality, but also by the narrative of successful results in the treats
ment of pleuritic effusions by the method of what was then called
suction * although under the more pretentious name of aspiration it
came, many years later, to be made a boom in Paris without the slight-
est reference to the first employment of the method in America. Dr.
Bowditch was even then, although in the prime of life and vigor, by no
means a young man, and the steady, persistent, and indeed brilliant
work he had done in connection with this subject deserved a better fate
than to be lost sight of amid the struggles for eclat of a young French
hospital physician not at all careful as to what had been done before
him. Dr. Bowditch made converts in Edinburgh in those days, and at
least two of the hospital staff began to use thoracentesis by suction
from that time onward. One of the two is the writer of these lines,
and Dr. Bowditch has been known to say that Dr. Budd, of King's
College, London, and the present 'writer were the first in this country
to adopt the improved procedure. But Dr. Bowditch, though a most
eminent thoracentesist, was far more than this. He was a most admir-
able and cultured physician in all respects, and not only showed in
diagnosis and in treatment a wide and well-ordered knowledge and a
cultivated judgment, but he appreciated also, as comparatively few
then did, the importance of the preventive service of humanity in its
relations to the curative. The researches which he first brought be-
fore the public in 1862 f into the connection of moisture in subsoils,
and the effect of drainage, or the want of it, on the local distribution
of phthisis in Massachusetts, became stimulus to further fruitful re-
searches, which in England were undertaken at the instance of the
medical officer of the Privy Council, by Dr. George Buchanan, of Lon-
don now the chief of the medical service under the Local Government
Board.! Had Dr. Bowditch done nothing else but these two things,
his merit would still have been great ; but in fact his was a most busy
and valuable life, from many different points of view. He was greatly
trusted as a physician in Boston, and was a personal friend of all of
the manv celebrities of the New England city ; he was a successful
teacher and hospital physician, and for some time Medical Officer of
Health to the State Board of Massachusetts; he was, moreover, a
cultured and most appreciative member of society in the most literary
and scientific atmosphere on the American continent ; and, lastly, he
was an enthusiast for freedom and justice, and as such, an abolitionist
as regards slavery, at a time when to be an abolitionist out and out
required courage and convictions of a very high order. Add to this
that he was one of those men whose character is transparent, and who
could not if he would have done and said anything but what was the
outcome of an honest and fearless nature, and it will be easily under-
* Dr. Bowditch always attributed the invention of this method anil
the appropriate instrument to Dr. Morill Wyman, of Cambridge, Mass.,
who performed his first thoracentesis by suction in 1850. But neither
Dr. Wyman nor Dr. Bowditch seem to have cared to put in a claim of
priority, although, at the date of a most interesting and lucid letter to the
author of this notice, bearing date May 22, 1862, no fewer than 160
operations had been performed upon 85 persons, and with remarkably
favorable results. See Clinical Medicine : Observations recorded at the
Bedside, with Commentaries. Edinburgh: Edmonston & Douglas, 1862,
Appendix, p. "717. Dieulafoy's first publication on the method of aspi-
ration appears to have been in 1870.
f In an address delivered at the annual meeting of the Massachu-
setts Medical Society, founded on the written statements of physicians
in 1n:j> townships,' republished in 1868 under the title Consumption in
New England and Elsewhere; or, Soil Moisture One of the Chief
Causes.
\ In this instance it is satisfactory to be able to state that Dr.
Bowditch'e priority and merits received full acknowledgment. See
the Tenth Report (1867) of the Medical Officer of the Privy Council
(Mr., now Sir John, Simon), pp. 16, 17; Dr. Buchanan's report being in
the appendix to the same volume, published in 1868.
stood that Dr. Bowditch, in his long life of over eighty years, must
have left one of those memories of which Boston and America are
justly proud. The author of these lines experienced only one cause of
deep regret in a recent visit to the United States: that it was nut per-
mitted to him again to grasp the hand of one with whom an unbroken
friendship, maintained mostly by correspondence, hail deepened into
love and reverence as the years advanced. The attachment and the
expectation were equal on each side, but the frail tenement of clay and
the failing mental powers of the veteran seemed to his nearest and
dearest friends to be unequal to a satisfactory interview ; and a letter,
most pathetic alike in its simplicity and its kindliness, announced to
the visitor the anxious though forbidden desire, and the hope that
" somewhere and somehow" it might be possible to resume an inter-
course which was likely to be broken off only too soon on this side the
grave. Dr. Bowditch died, full of years and honors, at Boston, on the
14th of January last, in the eighty-fourth year of his age. His Eng-
lish wife had predeceased him. One son, Dr. Vincent V. Bowditch, is
in the practice of his father's profession in Boston. The civil war
cost him another son, killed while leading a squadron of cavalry. A
brother's son, Dr. Henry I. Bowditch, is well known us the professor of
physiology in the Harvard Medical School.
To Contributors and Correspondents. — The attention of all who purpose
favoring us with communications is respectfully called to the follow-
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dressed to the publishers.
THE NEW YORK MEDICAL JOURNAL, May 7, 1892.
Original (Communications.
THE INFLICTION OF THE
DEATH PENALTY BY MEANS OF ELECTRICITY.
BEING A REPORT OF SEVEN CASES.
With Remarks on the Methods of Application and the
Qross and Microscopical Effects of Electrical Currents of Lethal Energy
on the Human Subject*
By CARLOS F. MacDONALD, M. I).,
PRESIDENT OP THE NEW YORK STATE COMMISSION IN LUNACY ;
PROFESSOR OF MENTAL DISEASES IN THE BELLEVUE HOSPITAL MEDICAL COLLEGE,
LECTURER ON INSANITY IN THE ALBANY MEDICAL COLLEGE.
The widespread interest manifested by the general pub-
lic in the new method of inflicting the death penalty by
means of electricity, and the interest which medical science
would naturally be expected to feel in the humane and
scientific aspects of the subject, especially with reference to
the absence of conscious suffering, and the changes, if any,
in the tissues and organs of the human body resulting from
the passage through it of electrical currents of lethal en-
ergy, together with the fact that this method of executing
criminals may now be said to have practically passed be-
yond the experimental stage, would seem to justify, if not
indeed to demand, the presentation of an authentic sum-
mary of the practical results thus far obtained by some
I one whose data and conclusions would be derived from
actual observation and experience in the application of the
statute. The fact that the writer happens to be the only
physician who has participated in all of the official pre-
liminary experimental tests of apparatus, and witnessed all
of the executions thus far had under the new law — nut,
however, from any zealous interest in the subject, nor even
inclination to be present, but in obedience to the expressed
desire of the chief executive of the State and other official
superiors — furnishes the only excuse he would offer for un-
| dertaking what otherwise might well be regarded as an
undesirable task.
In view of the wide publication of distorted and sensa-
tional accounts of the Kemmler execution, and the amount
of adverse criticism and even condemnation based thereon
of those who were called to act in an advisory capacity in
the administration of the law, the writer, at the request of
f the Governor, prepared an official report of that event,
some portions of which are necessarily here reproduced.
The execution of William Kemmler, alias John Hart, at
Auburn Prison, on August 6, 1890, pursuant to the statute
in such case made and provided, marked the first case in
i the world's history of the infliction of the death penalty by
electricity. Since then six other condemned murderers have
• been legally killed by this method at Sing Sing Prison —
, namely, James J. Slocum, Harris A. Smiler, Joseph Wood
and Schichiok Jugigo, on July 7, 1H91; Martin I >. Loppy,
|on December 7, 1891 ; and Charles McElvaine, on February
' 8, 1892 ; making in all seven cases of successful infliction of
the death penalty by electricity in the State of New York.
* Read before the Section in Public Health of the New York
Academy of Medicine, March 16, 1892; also read by title before the
Medical Society of the State of New York, February,
The execution of Kemmler was under the immediate
direction and control of the prison warden, the Hon.
C. F. Durston, and took place in a room set apart for
the purpose, in the basement of the administration build-
ing of the Auburn Prison, to wrhich the electric current
was conducted by means of an ordinary electric-light wire.
The apparatus consisted of a stationary engine, an alternat-
ing-current dynamo and exciter, a Cardew volt meter, with
extra resistance coil, calibrated for a range of from 30 to
2,000 volts; an ammeter for alternating currents from 0*10
to 3 amperes, a Wheatstone bridge, rheostat, bell signals,
and necessary switches ; a " death chair," with adjustable
head-rest, binding straps, and two adjustable electrodes.
The dynamo was an alternating-current dynamo intended to
supply 750 incandescent lamps of sixteen-candle power
each, and capable of generating, as shown by careful tests
made several months prior to the execution, a maximum
electro-motive pressure of 2,376 volts, the commercial and
mean voltage being 1,680 and 1,512, respectively, the speed
of the dynamo being 1,900 revolutions, and of the exciter
2,700. The chair, a square-framed heavy oaken one, with
a high, slightly sloping back and broad arms, was fastened
to the floor, the feet of the chair being properly insulated.
Attached to the back of the chair, above the head-rest, was
a sliding arrangement shaped like a figure four (4), the base
or horizontal arm of which projected forward, and from
which was suspended the head electrode, so as to rest on
the vertex, or top of the head, against which it was firmly
held by means of a spiral spring. The spinal or body elec-
trode was attached to the lower part of the back of the
chair and projected forward horizontally on a level with the
hollow of the sacrum. The electrodes each consisted of a
bell-shapped rubber cup about four inches in diameter, the
part corresponding to the handle of the bell being of woodT
through the long axis of which the wire passed into the
bell, terminating in a metallic disc about three inches in
diameter, and faced with a layer of sponge. The lower
electrode was also provided with a sliding arrangement and
spiral spring to hold it in place, while a broad strap fast-
ened to the back of the chair and passed around the lower
part of the prisoner's abdomen rendered the contact secure.
The head was firmly secured by means of conjoined broad
leather bands, which encircled the forehead and chin, con-
cealing the eves and upper portion of the face, and were
fastened to the back of the almost perpendicular head
rest, while the chest, arms, and legs were secured by broad
straps attached to corresponding portions of the chair. The
wire attached to the head electrode descended from the
ceiling, and that of the lower one passed along the floor to
the chair, being protected by a strip of wood.
The dynamo and engine were located in one of the
prison shops several hundred feet distant from the execu-
tion room ; the voltmeter, ammeter, switch-board, etc., were
located in a room adjoining the execution room, which con-
tained the death chair, electrodes, and connecting wires.
Communication between the meter room and dynamo room,
was by means of electric signals.
The apparatus used in the subsequent executions at
506
MacDONALD : THE DEATH PENALTY BY ELECTRICITY.
[N. Y. Med. Jock.,
Sing Sing was substantially a duplicate of that above de-
scribed, except as regards the location of the measuring in-
struments, switch-board, etc., and the form and points of
application of the electrodes to be hereafter referred to.
Of the twenty-five official witnesses present, fourteen
were physicians ; two of whom — Dr. E. C. Spitzka and the
writer — were officially designated as physicians by the
warden, in pursuance of the statute.
Before Kemmler was brought into the room the warden
asked the physicians how long the contact should be main-
tained ; the writer replied, Twenty seconds, but subsequently
assented to ten seconds, in deference to the opinion of
another that a considerably less period of time would suffice
— an opinion which doubtless would have been sustained
had the electro-motive pressure been sufficiently great.
Unfortunately, in this instance, the voltmeter, ammeter,
switch-board, etc., were not located in the execution room ;
hence none of the official witnesses could know precisely
how much the electro-motive pressure and current strength
were at the time of making and during the continuance of
the first contact. Nor has the voltage or amperage in this
instance, to the writer's knowledge, ever been officially de-
termined. But reasoning from the known lethal effect of
an electro-motive pressure of 1,600 volts and upward, as
shown by subsequent executions and by deaths which have
occurred from accidental contact with live electric wires, as
well as by numerous experiments on animals whose weight
exceeded that of man, affords solid ground for the conclu-
sion that no human being could survive the passage through
his body of an alternating current of more than 1,500 volts
for a period of even twenty seconds, the contact being per-
fect.
The preliminary arrangements having been completed,
Kemmler was brought into the execution room by the
warden and introduced to the witnesses, who were seated in
a semicircle facing the death chair. On entering the room,
the prisoner appeared strikingly calm and collected. In
fact, his manner and appearance indicated a state of subdued
elation, as if gratified at being the central figure of the oc-
casion, his somewhat limited intellect evidently rendering
him unable to fully appreciate the gravity of his situation.
He was given a chair near the death chair, and, on being
seated, in response to the warden's introduction, said :
" WCll, I wish every one good luck in this world, and I
think I am going to a good place, and the papers has been
saying a lot of stuff about me that wasn't true. That's all
I have to say." At the warden's bidding, he then arose,
removed his coat, and, without the least display of emotion
or nervousness, took his seat in the execution chair, calm-
ly submitting to the adjustment of the electrodes and
binding straps, himself aiding the proceedings by sugges-
tions and fixing his body and limbs in proper position. Ob-
serving the nervousness of the prison officers who were ad-
justing the straps, he admonished them not to hurry, and
to " be sure that everything is all right." He pressed his
bared liaek firmly against the spinal electrode and requested
that the head electrode be pressed down more firmly on the
top of his head, from which the hair had been imperfectly
dipped before he entered the room, remarking, at the same
time, that he desired to perform his part to the best of liis
ability. The preparations terminated with a final moisten-
ing of the electrodes, the whole occupying, at most, between
three and four minutes. Everything being seemingly ready,
the warden signaled to his assistants in charge of the
switches in the adjoining room to turn the lever which
closed the circuit and instantly sent the deadly current
through the prisoner's body. The instant the contact was
made the body was thrown into a state of extreme rigidity,
every fiber of the entire muscular system being apparently
in a marked condition of tonic spasm. Synchronously with
the onset of rigidity, bodily sensation, motion, and con-
sciousness were apparently absolutely suspended, and re-
mained so while electrical contact was maintained. At the
end of seventeen seconds Kemmler was pronounced dead,
none of the witnesses dissenting, and the warden signaled
to have the contact broken, which was immediately dime.
For obvious reasons, the only means of determining the
question of death while the body was in circuit was by
ocular demonstration ; so that it can not be positively as-
serted that the heart's action entirely ceased with the onset
of unconsciousness, though most of the medical witnesses
present thought that it did.
When the electrical contact was broken the condition
of rigidity noted above was instantly succeeded by one of
complete muscular relaxation. At the same time superficial
discolorations resembling commencing capillary post-mor-
tem changes were observed on the exposed portions of the
face. The body remained limp and motionless for approxi-
mately half a minute, when there occurred a series of slight J
spasmodic movements of the chest, accompanied by the ex-
pulsion of a small amount of mucus from the mouth. There
were no evidences of a return of consciousness or of sen-
sory function ; but, in view of the possibility that life was
not wholly extinct, beyond resuscitation, and in order to
take no risk of such a contingency, the current was ordered
to be reapplied, which was done within about two minutes
from the time the first contact was broken. The sudden
muscular rigidity noted on the first closure of the circuit
was again observed and continued until the contact was fl
again broken, when the opposite state of complete muscular
relaxation re-occurred. The second closure of the circuit
was inadvertently maintained for about seventy seconds,
when a small volume of vapor, and subsequently of smoke,
was seen to issue from the point of application of the spinal
electrode, due, as was subsequently found, to scorching of
the edge of the sponge with which the electrode was faced,
and from which the moisture had been evaporated by pro-
longed electrical contact. The odor of the burning sponge
was faintly perceptible in the room. There was also some
desiccation of the already dead body, immediately under-
neath the electrodes, especially under the lower one, which
will be described in connection w ith the autopsy.
A careful examination of the body was now made, in
which the medical w itnesses participated to a greater or less
extent. The radial pulse and heart's action had ceased,
the pupils were dilated, and the cornea1 were depressed and
tiaccid on pressure. In other words, William Kemmler was
dead, and the intent and purpose of the law to effect sud"
May 7, 1892.]
MacDONALD : THE DEATH PENALTY BY ELECTRICITY.
507
den and painless deatli in the execution of criminals had
been successfully carried out.
In the excitement and confusion of the moment, occa-
sioned by the belief on the part of some that death was not
complete, the second application of the current in Kemm-
ler's case was maintained too long — nearly a minute and
a half. If there was a spark of unconscious vitality re-
maining in the prisoner's body after the first contact was
broken — there certainly was no conscious life — it was ab-
solutely extinguished the instant the second and last con-
tact was made. That the man was dead, however, com-
paratively long before the burning of the sponge and desic-
cation of tissue occurred, there is no reason to doubt.
The movements referred to were regarded by most of
the medical witnesses present, including the writer, as
similar in character to those which have occasionally been
observed for a short time in animals experimentally killed by
electricity, when the contact was too brief or the current
strength insufficient, the animal dying, however, in a short
time without regaining consciousness — movements which
may properly be regarded as involuntary or reflex in char-
acter, following the too early interruption of the current,
and in no sense a resumption of respiratory function, how-
ever much they may appear to be so to superficial observ-
ers or to those not familiar with the phenomena referred to,
as observed in experiments on lower animals. These move-
ments are very slight in comparison with those usually ex-
hibited by animals suddenly decapitated, and which usually
continue a considerable period of time.
Dalton, in his work on Human Physiology,* refers to
observations made by Robin on the reflex action of the
spinal cord in the case of a criminal who was executed by
decapitation, the head having been severed near the fourth
cervical vertebra. Muscular contractions were produced
about an hour after execution by scratching with a pointed
instrument the skin of the chest at the areola of the nipple
while the right arm was lying extended by the side. On
irritating the skin at the point and in the manner mentioned
there immediately occurred a series of contractions of the
pectoralis major, the biceps, probably the brachialis anticus,
and lastly the muscles covering the internal condyle, causing
the whole arm to approach the trunk, with inward rotation
and half flexion of the forearm upon the arm, and bringing
the hand toward the chest as far as the epigastrium. On
replacing the arm and repeating the irritation as before, a
similar defensive movement occurred. This experiment
was repeated four times with similar results, except that
each time the movement was less extensive ; and finally
scratching the skin over the chest " produced only contrac-
tions in the great pectoral muscles which hardly stirred the
limb."
Observations made at executions subsequent to Kemm-
ler's tend to show that reflex excitability of the voluntary
muscles disappears much more rapidly after death by elec-
tricity than by any other method of sudden dissolution.
In the case of McElvaine, executed at King Sing on Febru-
ary 8, 1892, Dr. Van Gieson found that reflex action of
* .1 Treatise on Human /'/ii/s/<i/<></t/, seventh edition, p. 40-1.
the voluntary muscles was absolutely unresponsive — to ordi-
nary mechanical stimuli (see report of autopsy in case of
McElvaine) — within two or three minutes after the last con-
tact was broken.
That there were certain defects of a minor character in
the arrangement and operation of the apparatus at the
first execution by this method will be questioned by no one
who witnessed it; but when it is recalled that, notwith-
standing these defects, unconsciousness was instantly ef-
fected and death was painless — also that less than four
minutes elapsed between the making of the first contact
and the breaking of the last one, when Kemmler was abso-
lutely dead — it will be conceded by unprejudiced minds that
the object to be attained in the infliction of the death penalty,
at least so far as relates to the individual — namely, sud-
den and painless death — was fully realized in Kemmler's
case ; and had the first contact been maintained for a suffi-
cient length of time, in all probability there would have
been no involuntary movement of the body after it was
broken, and no unfavorable criticism of the result could
then have truthfully been made.
Among other criticisms which appeared in the public
press anent the execution of Kemmler was a reported
declaration of the most illustrious electrical expert of the
age, in which he was made to say that a serious mistake
had been committed in not making contact through the
hands instead of the head, the skull and hairy scalp being
poor conducting media.
However logical this criticism may be from the stand-
point of an electrician, it is not sustained by our knowledge
of electro-therapeutics and of the physical properties of
live bone. In what was intended to be an impersonal reply
to this criticism, the writer, in his report to the Governor,
took occasion to call attention to certain facts which are
well known to physiologists and medical electricians —
namely, that the arrest of the heart's action can be as
readily effected by destroying or paralyzing the brain
center which controls such action as by attacking the
heart itself ; hence, by including the brain directly in the
circuit, the action of the heart would probably be quickly
arrested, while at the same time all the vital centers, in-
cluding that of consciousness, would be paralyzed ; also that
the brain itself is very susceptible to the influence of elec-
tricity, and can be readily affected, sometimes to an alarm-
ing extent, by the passage into it through the skull of mild
currents, such as are obtained from medical batteries ; that
the nerve tissues contain an excess of saline moisture, and
hence are among the best of conductors, while the amount
of organic matter contained in live bone is sufficient to
render that substance a fairly good conductor. Further, it
is not difficult to penetrate the hairy scalp by electricity if
the hair be properly moistened, the conductivity of all the
tissues of the body being largely dependent on the amount
of moisture and salinity contained in them.
In each of the five cases following the Kemmler case *
* The head electrode originally suggested in Kemmler's case, but
which, for sonic reason unknown to the writer, was not used, was de-
signed to include the forehead, down to the eyebrows, in the zone of
contact.
508
MacDONALD: THE DEATH PENALTY BY ELECTRICITY. [N. Y. Mud. Jope.,
— namely, Slocum, Smiler, Wood, and Jugigo, executed at
Sing Sing Prison, July 7, 1891, and Loppy at the same place,
December 7, 1891 — one electrode was so applied as to cover
the forehead and temples, and the other, a larger one, the
calf of the right leg, except in the case of Joseph Wood, in
which it was applied to the left leg in consequence of the
existence of an ulcer on the right one. The calf of the leg
was selected because it furnished a broad area of thin skin.
The point of contact of the body electrode is not of mate-
rial importance. It may be applied to the hand, the foot,
the calf of the leg, or to any other indifferent part of the
body.
The electrodes were thoroughly wet with a solution of
salt water before the current was turned on, and were moist-
ened at intervals, when the current was interrupted, with the
same solution thrown on them from a syringe.
The following summary of these executions, except as
relates to Kemmler, is taken from the official reports made
to the warden of the prison, the Hon. W. R. Brown, by Dr.
S. B. Ward, of Albany, N. Y., and the writer, who appeared
as medical advisers for the State :
The electromotive pressure, as shown by the readings
of the voltmeter, taken by Professor L. A. Laudy, of Co-
lumbia College, varied from 1,458 to 1,716 volts, while the
ammeter showed a variation in current of from 2 to 7 am-
peres.
The preliminary preparations — that is, from the time the
prisoner entered the execution room to the closure of the cir-
cuit which rendered him unconscious — occupied, in Kemm-
ler's case, approximately, four minutes ; in Slocum's case,
three minutes and forty seconds ; in Smiler's case, two min-
utes ; in Wood's case, two minutes and forty seconds ; in
Jugigo's case, two minutes and fifteen seconds ; in Loppy's
case, two minutes and thirteen seconds; and in McElvaine's
case, one minute and forty-nine seconds.
In each instance the prisoner walked deliberately to the
chair and quietly submitted to the application of the re-
straining straps and electrodes without the slightest oppo-
sition or show of resistance, and also, save in the cases of
Kemmler and McElvaine, without uttering a word in rela-
' tion to the proceedings. With the single exception referred
t<> (Kemmler's case), there was no exhibition of confusion
or excitement on the part of witnesses, nor was there any-
thing unduly repulsive in the executions themselves ; on the
contrary, everything was done in a quiet, orderly, and dig-
nified manner, in keeping with the solemnity of the occa-
sion. The most striking and constant objective phenomena
observed were instantaneous and complete tonic rigidity of
the muscular system on closure of the circuit and marked
muscular relaxation immediately the contact was broken.
In Kemmler's case there were two contacts, through ver-
tex and lower end of spine, lasting seventeen and seventy
seconds, respectively, the last one being unnecessarily pro-
longed ; in Slocum's case, two contacts — twenty-seven and
twenty-six seconds ; in Smiler's case, four contacts, three of
.ten seconds each and the fourth nineteen seconds ; in
Wood's, three contacts of twenty seconds each ; in Jugigo's,
three contacts of fifteen seconds each ; in Loppy's case, four
contacts of fifteen, eleven, fifteen and a half, and ten and a
half seconds, respectively. (In all of these five cases con-
tact was through the head and leg.) And in McElvaine's case,
two contacts, the first one through the hands* (immersed
to the wrists in liquid electrodes), lasting fifty seconds, and
the last one through the head and leg, lasting thirty-six
seconds.
In Kemmler's case there were chest movements, and
possibly heart-beat, after the first contact (seventeen sec-
onds) ; in Slocum's, chest movements and radial pulsation
after first contact (twenty-seven seconds) ; in Smiler's, no
movement of chest, but radial pulsation after three contacts
(ten seconds each) ; in Wood's, no movement or pulse-beat
whatever; in Jugigo's, a slight fluttering of radial pulse
when final contact was broken, which rapidly ceased.
In all the cases except Kemmler's and McElvaine's con-
tact was broken for the purpose of wetting the electrodes.
From the foregoing it appears that the time consumed
in the preliminary preparations — strapping, adjusting elec-
trodes, etc. — varied from four minutes in the first to less
than a minute and a half in the last instance ; that the
number of contacts varied from two to four, and that the
aggregate length of the contacts in each case varied from
forty-five feo eighty-seven seconds, at the end of which, if
not before, in most instances, both conscious and organic
life were absolutely extinct.
In other words, the length of time which elapsed from
the moment the prisoner entered the execution room until
he was absolutely dead was, in Kemmler's case, eight min-
utes ; in Slocum's, six minutes ; in Smiler's, four minutes ;
in Wood's, four minutes and ten seconds ; in Jugigo's,
three minutes and thirty seconds ; in Loppy's, three min-
utes fifty-three seconds and a half ; and in McElvaine's,
three minutes and fifty-eight seconds.
It appears, therefore, that the time actually consumed
in each of these seven executions, from the moment the
prisoner entered the room until he was absolutely dead,
varied from eight minutes in the longest to three and! a half
in the shortest, whereas executions by hanging usually re-
quire from fifteen to thirty minutes. In fact, in hanging, it
not infrequently happens that the heart continues to beat
for that length of time after the fall of the fatal drop.
Then, too, far more time is consumed in placing the pris-
oner on the gallows, pinioning his limbs, putting on the
black cap, placing the noose about his neck, and carefully
adjusting the knot under his left ear (from whence it some-
times slips at the critical moment, resulting in strangulation
instead of a broken neck), than would be required for ar-
ranging the preliminary details of an electrical execution)
During the preparation of this report the Associated Presa
dispatches contained an account of a hanging in which the
criminal's head was almost completely torn from the body.
* In view of the opinions expressed by electrical experts of the high-
est standing, it had been previously agreed that contact should first lie
made by immersing the hands in two cells, containing tepid salt water,
connected respectively with the opposite poles of the dynamo, and, in the
event of this not causing cessation of the heartbeat, that recourse should
be had to the mode of application through the head and leg employed
in the previous executions at Sing Sing Prison. The apparatus \\ as so
arranged that either mode of application could be instantly employed at
will.
May 7, 1892.]
MacDONALD: THE DEATH PENALTY BY ELECTRICITY.
509
There are abundant reasons for believing that conscious
life is destroyed so rapidly by electricity that the applica-
tion of the current could be repeated several times within
the interval that is known to elapse between the receipt of
an injury or a peripheral sensory impression, and its con-
scious perception by the brain through the medium of the
sensory nerves. In other words, the electrical current
would travel from the point of contact to the brain many
times faster than sensory impressions or nerve currents
would, the rate of velocity of the latter being, roughly
speaking, only, about one hundred and fifty-live feet per
second — a rate which is quite slow in comparison with the
lightning-like velocity of electricity, which travels at the
rate of millions of feet per second.
Thus it will readily be seen that an electrical current of
lethal energy coming in contact with the body so as to in-
clude the brain in the circuit would reach the latter and
produce unconsciousness long, comparatively, before any
sensory impression, at the point of contact or elsewhere,
could be conveyed to and appreciated by that organ,
through the process of nerve-conduction, which, as has been
shown, requires a distinctly appreciable period of time, the
rate of transmission of painful sensations being even slower
than that of ordinary tactile impressions.
x\ striking illustration of the relative slowness of nerve
conduction as compared with electricity was shown in a series
of experiments in instantaneous photography recently con-
ducted by Professor Muybridge, in the following manner :
The lantern was used to make a series of instantaneous
photographs, and in order to make the intervals between the ex-
posures, as well as the periods of exposure, exceedingly short,
the plates were exposed and stopped by means of an electric
current. One very interesting series of pictures made was in-
tended to illustrate the slowness of the brain in receiving im-
pressions. Two women were employed ; one stood in a bath-
tub and the other sat on a raised chair and poured a bucket of
water over the standing woman's head and shoulders. In order
to make the shock more intense, Professor Muybridge had filled
the bucket with ice-water, unknown to the victim, who would
not have awaited the douche so patiently had she known what
its temperature was going to be. One view showed the water
tipped over and falling, yet not quite touching the girl's head.
The next view showed the water splashing from her head and
shoulders, and yet there were no signs of sensation. In the
third picture she was just beginning to respond to the shock,
and the subsequent pictures illustrated the further phases of the
response. The point of special interest, however, is in connec-
tion with the second view. The electric current had in that
case first exposed the plate, and then after a very short intern al
had shut it off again; that is to say, had acted twice with an
interval of time between the two sufficiently long for the sensi-
tive plate to take an impression of the view, and this after the
ice- water had touched the woman's shoulders, and before she
was conscious of it.
Respecting the resistance offered to the current by the
human body, Mr. A. E. Kennelly, of the Edison Laboratory,
at Orange, N. J., and who witnessed the execution of Mc-
Elvaine, in a contribution to the Electrical Engineer for
February 17, 1892, says:
The electrical pressure at the electrodes was determined
from a Cardew voltmeter in circuit with a non-inductive re-
sistance. The current passing through the electrodes was ob-
served from a direct-reading dead-beat ammeter, and the indi-
cations of these carefully calibrated instruments afford reliable
inferences as to the resistance of a human body, under definite
conditions of surface contact, to an alternating current making
some 150 periods per second.
From the official records as already published it would ap-
pear that in the first application the pressure at electrodes was
maintained at approximately 1,600 volts, and the current, which
commenced at 2-0 amperes, steadily increased during the fifty
seconds of contact up to 3-l, indicating a resistance between
electrodes diminishing from the initial value of 800 ohms to a
final value of 516, a reduction during the interval of more than
thirty-five per cent. The electrodes were metal plates in large
wooden receptacles nearly filled with tepid salt water, and in
which the hands of the criminal were immersed. Judging from
the fact that, although the skin of the hands was blistered
over the areas above the water level that had been wetted
by first immersion and then withdrawn, yet the skin that re-
mained immersed was entirely uninjured, it seems reasonable
to suppose that no very large proportion of the whole re-
sistance of the body would reside in the integuments at the
electrodes.
In the second application, forty-three seconds later, the
pressure was observed to be maintained at approximately 1,500
volts, and the current which passed between the forehead and
the calf of the right leg continued at 7-0 amperes during the
thirty-six seconds of contact, indicating a resistance practically
steady at 214 ohms during that time. The electrodes were of
sponge, kept thoroughly wetted with cool salt water and backed
by metallic plates, the area covered by each being about 100
square centimetres. Since no blistering took place immediately
below the head electrode, although some blistering occurred at
the other, it would appear that no large proportion of the total
resistance existed in the contact areas.
The mean activity developed in heat during the first appli-
cation was thus 4,080 watts, and in the second 10,500 watts, or
about 14 E. H. P., this large expenditure of energy accounting
for the considerable post-mortem temperatures that are stated
to have been observed.
The average resistance of the human body between the
hands, immersed to the wrists in dilute solutions of salt or soda,
is often overstated in measurement, owing to the vitiating in-
fluence of polarization on observations taken with feeble cur-
rents in the Wheatstone bridge. Correct readings can, how-
ever, be obtained either by bridge measurement to " immediate
false zero," or by the use of large resistances inserted directly in
the electrode circuit through a galvanometer, so as to employ a
higher pressure without pain to the subject, and so reduce the in-
fluence of the possible 2-5 volts of polarization counter E. M. F.
In either case the mean resistance under these conditions is
about 1,000 ohms.
The inference appears to be drawn that the resistance of the
body between hands to an alternating pressure of 1,500 volts is
only about one half what it is to continuous pressures of 5 volts,
or to alternating pressures of 2 or 3 volts, and. from the obser-
vations above mentioned, it would seem thai the resistance be-
tween forehead and calf is very much lower than between im-
mersed hands. While, in conclusion, the general belief is fur-
ther substantiated that the quantity of current which may pass
through the body from a contact with high pressures will en-
tirely depend upon the area and moisture of the contact sur-
faces, being large with extended and wet surfaces, but, perhaps,
comparatively small for brief contacts on dry and limited sur-
faces of touch.
( To lir concluded. )
510
WEIR AND PAGE: ANEURYSM OF THE ASCENDING AORTA.
[N. Y. Med. Joitb.,
ANEURYSM OF THE ASCENDING AORTA
TREATED BY MAOEWEN'S NEEDLING METHOD
FOR INDUCING A WHITE THROMBUS*
By ROBERT F. WEIR, M. D., and
EMMETT D. PAGE, M. D.
The good results obtained by Macewen, of Glasgow, in
the treatment of internal aneurysms by the induction of
what is termed a white thrombus or the deposition in thick-
ened masses of leucocytes on the internal surface of an
aneurysmally dilated blood-vessel, led me recently to the trial
of this method in a case of aneurysm diagnosticated to be of
the ascending aorta. Macewen reported in the Lancet, No-
vember 22, 1 890, three cases of aneurysm — two of the aorta,
and one probably of the subclavian artery — wherein a con-
solidation and cure of the aneurysmal tumor were effected
in two instances, and in the third, affecting the ascending
aorta, where an autopsy held after the scratching of the inner
surface of the aneurysm — for this is the principle of the treat-
ment— had been resorted to some seven times, with several
days of rest intervening between the sittings. Macewen not
only scratched or irritated in each case with the needle
point the interior of the aneurysm, but left the needle im-
pinging on the opposing wall for periods varying from
twenty-four to forty-eight hours ; this not with the intent of
obtaining coagulation on the needle, as in the older methods
of treatment, but that the wall of the aneurysm might be
more thoroughly roughened. The autopsy of two cases,
the second one being a femoral aneurysm similarly treated,
showed that the deposition of the white laminated fibrin
was greatest where the sac irritation had been most thor-
oughly applied. Feeling the inutility of any other surgical
means, and after submitting the question, in its complete
bearings of novelty and want of corroborative experience, to
the physician in charge, Dr. C. L. Dana, and to the patient's
family, the procedure of Macewen was begun by me June
4, 1891, in a case of thoracic aneurysm, at St. Luke's Hos-
pital, where the patient took a private room, to be more con-
stantly under supervision during the treatment.
The patient was a man of forty- seven years of age, in good
physique, of a somewhat excitable temperament, whose symp-
toms of circulatory disturbance, viz., pain in right arm and side
of chest, and pulsations of heart, dated back some six or eight
months. Ten weeks previously an attack of influenza occurred
during which glycosuria appeared. Four weeks ago the patient
noticed a swelling just below the right clavicle with augmenta-
tion of the cough and the shoulder pains. When seen first by
me, there was a pulsating area over the second and third ribs
near the sternum, rising up beyond the skin level fully an inch,
with a thick wall. The dullness on percussion extended over a
diameter of three inches and a half, stretching upward to the
suprasternal notch. No tumor felt behind clavicle in the neck.
Heart's action regular. Radial pulsations equal. Urine normal.
Considerable pain. Complained sufficiently to require moderate
doses of morphine or codeine at night. Slight irregular tem-
perature elevations, supposed to be malarial, and checked by
quinine, delayed the first insertion of the needles several days.
The skin over the thoracic pulsating mass having been duly
* Read before the Section in General Surgery of the New York
Academy of Medicine, December 14, 1891.
rendered aseptic, and the proper precautions as to surgical
cleanliness of instruments, hands, etc., being resorted to, a slen-
der needle, six inches long and half a millimetre in diameter,
was (June 11th) thrust into the most projecting portion of the
mass through the chest wall into the aneurysm. It struck the
eroded rib at a distance of an inch and a quarter. Its direction
then being changed, it was passed into the aneurysm a distance
of three inches, and gradually increased to four inches before
the resistance showed itself; this opposition was followed by
smart coughing with raising of one or two mouthfuls of blood.
The lung had been punctured, probably through a thin sac wall,
though no resistance had been recognized. The needle was
partially withdrawn and endeavored to be carried over another
portion of the wall without re-entering through the skin, but it
was too slender to permit much change in direction of its point
through the firm tegumentary tissues. A second heavier needle,
one millimetre in diameter — the first one being left in situ — was
introduced and the posterior wall decidedly recognized at a
depth of four inches and a half, whereupon it was scraped de-
cidedly over a circular area of two inches and a half. The posi-
tion of this and the first needle was then changed by withdraw-
ing them nearly to the skin level, and then pushing them in in
a different direction, so that the posterior wall of the aneurysm
was to a fairly satisfactory extent scratched over a space the size
of the palm. This surface of the aneurysm was irregular in depth,
varying from three inches and a half to five inches and a half
from the surface. Left to themselves when touching the poste-
rior wall, only a moderate movement was communicated to the
needles by the aneurysmal wall. After the first or the slenderer
pin had been in the sac eighty minutes, either scratching the wall
or resting against it, it was withdrawn. No more than a drop
or two of blood followed. The second pin, the thicker one, was
removed after a similar sojourn in the sac for fifty minutes, with
the same encouraging result as to the oozing. An antiseptic dress-
ing was applied. The patient had experienced but little pain,
and the only untoward symptom was the previously mentioned
expectoration of blood, which was not repeated. So far the
procedure was tentative to a considerable extent. The size of
the needles had not been mentioned by Macewen, and naturally
the use of the larger needle suggested the possibility of some
haemorrhage, external or subcutaneous. None such occurred.
The thin wall of the sac enforced caution, and it was also recog-
nized that difficulty would be experienced in attacking the lateral
aspects of the aneurysm, and it was felt that unless the various
punctures made should cause the desired deposit of white fibrin
in the bulging anterior, where the most danger to the patient
apparently existed, the treatment elsewhere might be of little
avail, no matter how satisfactorily it might progress. I did not
feel willing, moreover, to leave the needles in place for twenty-
four hours or more, as Macewen has donejand recommends, since
the thinness of the posterior wall had been demonstrated to me.
No reaction followed this first trial.
One week later the needling was repeated, four needles be-
ing introduced through the anterior wall — two being used, of a
diameter of one millimetre and a fifth, at depths of four inches
and a half to five inches, to scrape the posterior wall of the aneu-
rysm, the area reached being at the best a limited one. Two
others were carried through the hour-glass opening made up
mainly by the eroded ribs in such oblique manner as to reach the
lateral aspects of the aneurysm. This, however, could only be
accomplished on the median side, and only to a very moderate
degree. I was tempted to use a curved needle for this purpose,
but the difficulty of managing the point in such a case deterred
me from its employment. The extrathoracic portion of the aneu-
rysm was also scratched by the horizontal insertion of a needle,
though but little was accomplished by this effort. After the
May 7, \W2.\
WEIR AM) PAGE: ANEURYSM 'OF THE AsrEXDLVG AORTA.
511
needling had been continued about an hour, coughing, with ex-
pectoration of blood, to the amount of one ounce, with sharp
pain, stopped further procedure. The removal of the needles
longest in situ was followed by spurts of blood, which finger-
pressure readily checked. Antiseptic dressings renewed.
Half an hour later the patient complained of severe pain in
top of aneurysm and in right arm. This subsided in the course
of an hour. No further reaction followed. Temperature and
pulse continued normal. Though naturally a very nervous man,
his behavior was calm, and ho carried out the injunctions of
quietness, etc., to the letter.
One week later, but little change was visible in the pulsating
mass in the anterior chest wall. If anything, it was more
prominent. Thickened, too, from the repeated punctures made
in it. Since the last needling he has had, he says, less discom-
fort and pain than he had previously experienced.
June 18th. — The insertion of the needles was resorted to for
the third time. The time occupied in this sitting was an hour
and three quarters ; four needles used— longest, five inches and a
half. The summary of the result was that the posterior aspect
of the aneurysm was scratched very satisfactorily over an area
of two inches in diameter, at a depth of four inches and a half.
Median side of aneurysm also scratched, but only with difficulty,
owing to the rib erosion limiting its sweep. Downward — i. e.,
toward heart — a needle five inches and a half long touched noth-
ing. No pain was felt after the needles had been withdrawn.
The patient could feel the scratching readily, and frequently in-
formed me, when in doubt as to whether I had reached the
aneurysmal wall, that "he knew I had got there." Complaint
was made more of the needle punctures and of the traction at
this point in the various movements of circumduction made,
than of the contact of the point of the needle.
He left the hospital three days later, to go to his home in
Brooklyn, with the understanding that if no improvement fol-
lowed in ten to fifteen days the operation should be repeated by
one of my colleagues, as I would then be absent on my summer
vacation.
The case, I learn subsequently, came under the care of
Dr. Atkinson and Dr. Page, of Brooklyn, and from the lat-
ter the concluding notes of the history of the case have been
sent me.
The patient's subsequent condition did not at all im-
prove. The tumor of the chest-wall enlarged steadily, and
increasing pain was experienced, requiring the free use of
anodynes.
The surgical treatment was not resumed at the determi-
nation of the family.
August 21st. — Rupture of the aneurysm took place in-
ternally, causing death in about fifteen minutes afterward.
The autopsy was made by Dr. E. D. Page, assisted by
Dr. Hunt and Dr. Belcher, of Brooklyn. Their notes, with
the specimen, have been kindly furnished to accompany this
report.
They are as follows :
Rigor mortis well marked. Body weight about 155 pounds,
usual weight 180.
Tumor ecchymotic somewhat, but smooth externally. It
extends from the right axilla, two inches to the left of the
median line, and from the clavicle to below the nipple. Cir-
cumference at base, externally, twenty inches. Height above
chest- wall, three inches. Final remnants of a disorganized
blood clot where a thimble-sized tumor existed. This was at
the upper and inner place of introduction of the needle. A clot
had disseminated itself outside the ribs over a space of three
inches and a half to four inches from pressure of aneurysm beneath
it. At this point, too, the wall of the aneurysm was exceedingly
thin and ruptured in dissecting the integument from it. Blood
had evidently escaped from the aneurysm at the time of the
operation into this place, or a vessel of sufficient size to cause
the haemorrhage had been wounded by the needle. No adipose
tissue was found between tumor and integument.
The apex of the heart was an inch and a half to the left, and
three inches below the left nipple.
The liver, upper margin, was crowded down below the
border of the ribs. It was also pushed forward and across the
abdominal cavity to left of median line — i. e., the left border of
liver. It was also very firm in consistence and very anaamic^
Microscopical examination not made.
Diaphragm on right side crowded down to lower rib.
Left lung normal.
Right lung: lobes adherent to each other. Tumor adherent
to large portion of anterior part of lung, and so firmly that
lung tissue was torn in separating them. This lung was
severely encroached upon by the invading aneurysm and caused
the increased number of respirations gradually as it increased
in dimension. The parietal and visceral pleura were slightly
adherent at apex. Otherwise normal.
In the right thoracic cavity was about three pints of clotted
blood, pressing the lung upward and the diaphragm dowuward.
This haemorrhage was the immediate cause of death.
The aneurysm itself was found to be from the anterior part
of the ascending aorta and very near the heart. It was filled
with a post-mortem blood clot, and nowhere was there to be
seen more than a trace of fibrinous deposit. No evidences
of the needling were visible. Everywhere the aneurysmal
walls seemed thin, especially at upper point already mentioned,
and posteriorly where the rupture occurred. In shape it was
that of a flattened spheroid, with the antero-posterior diameter
the lesser. In size it was six inches and a half by eight inches.
The aneurysm, bracing itself against the aorta from which it
sprang and also against the elastic lung, did no damage what-
soever to the posterior walls of the thoracic cavity nor to the
spinal column itself. Both were in perfect condition, and illus-
trate the possible ability of these organs to resist successfully
long-continued pressure.
Anteriorly the third rib was eroded clear through two-
inches from the sternum, the latter also being eroded. Second
rib badly eroded. The intercostal muscles anterior to the aneu-
rysm had also disappeared by a process of absorption from
pressure. The aneurysm, in its relation to the heart, was almost
sessile, and, in fact, the specimen herewith presented shows the
upper part of the heart dilated, so close is it.
The result of the operation, so far as inducing the for-
mation of a white thrombus is concerned, was, unfortunately,
negative. The proximity of the aneurysm to the heart and
the consequent interference of the latter's free action, to-
gether with the attending dilatation, account for the severe
paroxysms of pain following the surgical interference of
July 15th.
The Microscopical Society of Washington held its eighth annual
soiree on Tuesday evening, the 'U\ inst. The programme embraced an
address by the president, Dr. J. Melvin Lamb, on The Field of the
Uicroscope, and the exhibition of fifty-four sets of specimens,
The American Dermatological Association will meet on September
llith at the Pequot House, New London, Conn., instead of at CushingS
Island.
512
WILCOX': AN /EM 1 A.
\S. Y. Med. Jock.,
AMMIA:
ITS TREATMENT WITH A NEW PREPARATION OF IRON*
By REYNOLD W. WILCOX, M. A., M. D.,
PROFESSOR OF CLINICAL MEDICINE IN
THE NEW YORK POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL :
ASSISTANT VISITING PHYSICIAN TO BELLEVUE HOSPITAL.
When one considers the frequency of pathological con-
ditions of the blood, no apology is necessary for presenting
a paper upon this subject. These conditions are found in
all grades and classes of people ; the pampered daughter of
the millionaire is no more exempt than the shop-girl; our
foreign-born suffer equally as the native population.
In the discussion of this question I prefer to follow the
classification of Oppenheimer and Graber :
1. Simple anaemia : where both the corpuscles and haemo-
globin are diminished.
2. Chlorosis: where the corpuscles are normal and haemo-
globin diminished (females).
3. Primary chlorosis or pernicious anaemia : where the
corpuscles are diminished and the haemoglobin is relatively
increased. Perhaps this might be better stated by saying
that the percentage of decrease of corpuscles is greater than
that of haemoglobin, which latter may fall to twenty per
■cent. The symptomatic varieties of anaemia may be due to
many causes :
1. Haemorrhage.
2. Pathological discharges — e. g., prolonged lactation,
sexual excesses, profuse menstruation, suppuration, albumi-
nuria, diabetes, watery diarrhoea.
3. Malignant growths.
4. Toxic and infective processes, such as the fatal cases
of pernicious anaemia, reported by Koran, from carbonic-di-
oxide poisoning, from tea, coffee, tobacco, alcohol, syphilis,
tuberculosis, or myxcedema. Here should also be consid-
ered those cases of auto-infection designated faecal anaemia
by Sir Andrew Clark.
5. Animal parasites.
6. Obstacles to taking food which are mechanical in
their nature.
7. Dyspepsia.
8. Venous stasis in cardiac and pulmonary disease.
9. Impaired sanguinineation in diseases of cytogenic or-
gans, malaria, leucaemia, or Hodgkin's disease.
10. Fever.
jEtiology. — Predisposing causes :
1. Sex : female.
2. Age : infancy and youth, old age.
3. Constitution : so-called irritable weakness.
Exciting causes :
1. Deficient supply of food.
2. Want of light and air.
3. Excess or defect of bodily exercise.
4. Unusual states of temperature ; hot or cold tempera-
tures.
5. Increased expenditure of unoxidized material, physio-
logical discharges ; menstruation or lactation.
* Read before the Section in General Medicine of the New York
Academy of Medicine, April 19, 1892.
6. Psychical influences : depressing emotions.
The symptomatology of anaemia may be divided into the
general : dropsy, loss of body weight, fever.
Alimentary : retching, vomiting, atonic dyspepsia, con-
stipation, sometimes diarrhoea.
Circulatory : palpitation, faintness, praecordial distress,
hiccough.
Respiratory : dyspnoea, slight cough without expectora-
tion.
Integumentary : pallor, hyperidrosis.
Genito-urinary : polyuria, variable menstruation, sexual
torpidity.
Nervous : irritable weakness, morbid hyperaesthesia,
headaches, tinnitus, neuralgia, convulsions, delirium. In
regard to oedema, however, Benezur and Csatasy found that
in the anaemia of Bright's disease the amount of haemoglo-
bin was not consonant with that of oedema.
The physical signs of anaemia are practically two, so far
as the circulatory apparatus is concerned : 1. The bruit de
diable of Bouillaud, or the Normewjerdusch of Skoda, is due
to slackness of the venous wall and a comparative emptiness
of the vessels. This murmur is intensified with deep inspi-
ration and arrested by forced expiration or coughing ; it is
better heard and is more musical when the patient is stand-
ing or sitting than when recumbent. The vibratory sensa-
tion, the fremissement cataire of Laennec, is due to vibra-
tions of the walls of the veins which are imparted to them
by the vibrations of the blood. The muscular contraction
produced by turning the head on its axis strengthens the
bruit ; so also does light pressure with the stethoscope. The
jugular veins can always be compressed by the belly of the
omo-hyoid muscle, so that the presence of the murmur must
be determined by an avoidance of these conditions. I pre-
fer to accept Hamernyk's theory, that these murmurs are
produced by the whirling movement of the blood in the
jugular bulb at the lower end of the internal jugular veins,
and that these veins have a different-sized lumen along their
course and at the termination of the sinus venosus which
explains these eddies.
2. The cardiac anaemic murmurs are due to functional
disorder of papillary muscles, and are ventriculo-systolic.
Balfour believes that these murmurs in the pulmonary area
are really due to mitral regurgitation, which in turn is due
to defective nutrition of cardiac muscle and dilatation of the
ventricular cavity, so that we may say that in the lighter
grades of anaemia the murmur in the neck is heard, while as
it becomes greater that in the second left intercostal space
appears. When this condition becomes extreme we observe
intraventricular murmurs, and these are heard at the apex.
It is interesting to note that in the following recorded cases
as the percentage of haemoglobin increased the murmur at
the apex was the first to disappear, that with further im-
provement that in the second left intercostal space followed,
and that when the percentage approached the normal the
bruit de diable, last of all, vanished.
The composition of the blood has recently received con-
siderable attention. Gorup-Besanez states that the blood
of man contains one part of iron to two hundred and thirty
parts of red blood-globules, quoting the analysis of C.
May 7, 1892. |
WILCOX: ANASMIA.
513
Schmidt. SRhmaltz, in his investigations concerning the
specific gravity of human Wood, found that it varied from
1*059 in the male to 1*056 in the female, the variation
being only three one-hundredths. The ingestion of a thou-
sand cubic eentiinetrcs of a physiological solution of salt had
a very short and feeble influence. The specific gravity may
fall to 1 '030 in anaemia and cancerous cachexia; it varies
according to the amount of haemoglobin it contains. In se-
rious disease of the stomach the mass of the blood itself is
diminished on account of inanition. In phthisis and cardiac
disease its density is increased because of the slowing of the
peripheral circulation. Jones finds a resemblance between
his specific-gravity curves and those of Leichtenstern for
haemoglobin, and explains that the variations of these sub-
stances are closely related to those of specific gravity.
Hence the determination of the haemoglobin by means of
the color is accurate because it is dependent upon the spe-
cific gravity and number of corpuscles.
Meyer and Pernou found that the iron in the liver
cells of a foetus was ten times as great in amount as in a
grown animal, showing that it might be stored there to pro-
vide for future growth. Jacobi injected iron into the blood-
vessels of dogs and rabbits, and found that ten per cent, of
it was excreted by the bowels, liver, and kidneys. Of that
deposited, fifty per cent, was found in the liver, and the
rest in the spleen, the kidneys, the walls of the intestine,
and other organs. It was all removed from the blood,
however, in two or three hours after its administration.
The fact that the excess of iron is stored in the liver may
be looked upon as a physiological, not a pathological pro-
cess.
In estimating the value of a remedy for the increase of
the iron in the haemoglobin, it is necessary that we should
not trust entirely to the physical examination of the heart
and the blood-vessels and the color of the mucous mem-
branes and of the skin, but also should have an exact means
of measuring the luemoglobin in the blood. Daland has
shown conclusively, what I have for some time more than
suspected, that the methods of counting blood-corpuscles,
such as Gowers's, or the use of the Thomas-Zeiss haemacy-
tometer, give such variable results from the same specimen
of blood, not only when examined by different observers,
but also when several portions are examined by the same
observer, that the results are by no means satisfactory.
Besides, it is extremely trying work for the eyes, and I
have for some time abandoned making estimations of the
number of blood-corpuscles. In the haemoglobinometer
made by Reichert, of Vienna, which I show, we have not
only simplicity of operation, but, I believe, accuracy in
ascertaining the amount of haemoglobin contained in the
given specimen of blood.
The technique of this instrument is simple; however,
to insure accuracy of results, certain precautions must be
taken. In the examination of the blood in the cases that
I am narrating to-night the time from 11 a. m. to 1 r. m.
was selected. My light was a gas-jet, four-foot burner,
five feet distant. 1 made use of the same capillary tube
for all examinations. The finger from which the blood is
taken should be cleaned with ether and thoroughly dried.
The cut was made with a sharp-pointed tenotomy knife.
The blood should flow freely, and the work should be done
quickly, so that clots do not form. The finger must not be
squeezed. The capillary tube must be filled at one attempt.
Use water for dilution at the temperature of the body, and
clean the tube at the time of using. Discharge the blood
and water into the cell slowly, so as to avoid bubbles and a
marked meniscus at the edge, filling, however, both divis-
ions of the cell to the same level. The water should be
discharged with a steady current, so as to thoroughly dif-
fuse the blood into the menstruum. Turn the color-wedo-e
from light to dark and note the reading, then turn it from
dark to light and make a second reading, which should cor-
respond with the first. Do not refer to a past record be-
fore an examination. Above all things, the examination
should be made quickly and neatly. In this method of re-
cording our results we are unbiased by any statement of
the patient, and are also independent of any deception in
the estimation of the color of the mucous membranes,
which readily simulates that of health in those cases, by no
means infrequent, where a febrile reaction accompanies
amemia.
In successfully treating anaemia it is necessary to fulfill
the indicatio causalis, thus presupposing a consideration of
the subjects mentioned above. The indicatio morbi brings
up the consideration of food, which should be nourishing
and easily digested, mostly nitrogenous ; exercise in the
open air, the amount to be regulated ; the breaking off of
bad habits ; and the treatment by remedies.
In recent times it has been observed that the haemoglo-
bin of the blood has increased after moderate bleeding.
Dogiel, on the strength of experiments upon dogs, confirms
the deductions of Scholz that moderate bleeding, say with
ten or fifteen leeches, does not alter the arterial blood ten-
sion, but if it is repeated every three or four weeks the pa-
tient gains in weight and the number of blood-corpuscles
increases. Vogt and Schtchberbakoff also found the
haemoglobin to be increased under similar circumstances.
Schubert treated a number of cases of chlorosis by blood-
letting and hot baths. The' venesection was at the rate of
seven to fifteen grains to the pound of body weight for
each bleeding. The patient was kept in bed from twenty-
four to forty-eight hours after the operation, and this treat-
ment was repeated once or twice each year. The treat-
ment with laxatives has at times been followed by so much
success that Hamilton has said that if he were compelled
to treat anaemia by either laxatives or chalybeates he would
use the former. In Sir Andrew Clark's theory that anaemia
arises in a large number of cases from self-infection — in
other words, that a large number of anaemias are of faecal
origin — there is certainly some proportion of truth ; how-
ever, the most rigid and extraordinary antisepsis, which
nowadays can be readily obtained by naphthaline, salicylate
of bismuth, or beta-naphthol, does not seem to meet with
the success that we should expect, although quite recently
Tick has professed to have obtained good results in chlo-
rosis from this method. My own personal experience is
that it will succeed in only a limited number of cases, so'at
I the present time we can say that neither in bloodletting nor
514
WILCOX: A X.EM I A.
[N. Y. Med. Jock.
in laxatives, nor yet in securing intestinal antisepsis, can
we hope to obtain siich brilliant results as by the administra-
tion of iron.
In giving iron we have, up to this time, been hindered
by certain apparently insurmountable difficulties. The or-
ganic salts of iron have had but a limited use, owing to
their comparative inefficiency. The inorganic salts of iron
have hitherto presented many disadvantages. Blaud's
pills, so much lauded and popularized by Niemeyer, cer-
tainly fail in a considerable number of cases. Notwith-
standing the large amount of iron which one can administer
in them, in many instances improvement does not follow
their prolonged and uninterrupted administration. I am
inclined to think that the potash is partly responsible for
this, since it is, as we all know, one of the agents that
promote waste. The tincture of the chloride of iron has
easily held the first place in popularity and efficiency.
Combined with phosphoric acid, when well borne by the
stomach, its therapeusis is unassailable. The formula of
Flint lias been for many years one of my favorites. A
coated tongue, feeble digestion, and constipation are sup-
posed to contra- indicate the use of iron. 1 should rather
say that these conditions called for a previous purgation
and correction of the digestion, preliminary to a course of
ferruginous treatment. On the other hand, I am quite as
strongly opposed to the administration of a laxative at the
same time with iron, such as is frequently found in its
association with aloes, because the metal, being slowly ab-
sorbed, requires a slow passage along the intestine. I be-
lieve that there is no doubt that large doses of iron are less
constipating than small ones, but 1 do not believe that
the final result — namely, the absorption — is so satisfactory.
Iron is absorbed more rapidly in catarrhal conditions of the
alimentary tract, and in those cases tends to accumulate in
the liver. Castellino has found, in his experiments, that
haemoglobin is absorbed rapidly, is always well borne, in-
creases the number of red cells and the specific gravity of
the blood, and improves the general condition. If the ad-
ministration of haemoglobin, however, is stopped before the
normal condition is reached, its effect is only fugitive. In
secondary anaemia it fails completely, in that its effects are
only transitory. It is more rapid in its action than any
other iron preparation. Obviously, the use of this prepara-
tion will be extremely limited The iron found in wines
is too small in amount to be considered, yet I am in the
habit of prescribing wines, and especially Schreiber's
dietetic Tokay, for my patients.
Since, then, we are of the opinion that iron is our sheet-
anchor in the treatment of anaemia, and since all prepara-
tions hitherto used either have been inefficient or have
presented certain disadvantages, we come now to a consid-
eration of a preparation which, I think there is no rea-
sonable doubt, will revolutionize the treatment of amemia,
in that the objections to the strong preparations have been
done awav with. I >r. George W. Weld, of New York, re-
alizing the great injury done to the teeth by the tincture of
the chloride of iron, set about obtaining a preparation
which, while retaining all the therapeutic effects, should
present none of the disadvantages. After years of experi-
mentation, this preparation has been put on the market by
Parke, Davis, & ('<>., under the name of Weld's syrup of
chloride of iron. It was found with the official tincture
that the arid would attack the enamel of the teeth, and,
curiously enough, in Smith's experiments, when two
drachms of the tincture were added to an ounce of water,
tin; destructive energy upon the calcium salts of the teeth
was increased, and it was found that, of iron preparations,
the chloride was the most harmful, the syrup next, and the
wine the least of all. Other preparations of iron, which are
bland, are by no means so valuable as the tincture of the
chloride of iron. I have tested clinically all the albumi-
nates and peptonates of iron, and all are objectionable be-
cause, on the one hand, they are inefficient, frequently re-
quiring administration for many months, and, in the second
place, give rise to extremely bad-smelling flatus. If you
add water to a simple solution of iron chloride, which is
devoid of other acid, you get the basic salts of iron in free
hydrochloric acid. Weld has shown that these basic salts
of iron are not soluble in strong acids, so that they protect
the teeth in the same way that alcohol and syrup do ; when,
however, water is added, these salts are dissolved, and the
acid then attacks the enamel. Thus it is seen that it is the
free hydrochloric acid that is so destructive to the teeth.
In "Weld's iron this excess of acid, which is unnecessary for
perfect solution of the iron salt, is removed, and in no way
does this impair the therapeutic value of the preparation,
because the hydrochloric acid is again added to it from the
gastric fluids. It is easily assimilated ; better tolerated than
the old tincture of the chloride, because it does not produce
nausea; gives rise to no disagreeable eructations; and con-
tains no alcohol save that which is found in the tincture, of
which half an ounce contains only twenty drops. The con-
stipation which is noticeable on the use of all iron prepara-
tions is easily corrected by equal parts of fluid extract of
cascara sagrada and glycerin, the proper dose to be de-
termined by experiment.
Each tiuidounce of Weld's syrup of the chloride of
iron contains forty drops, equaling twenty-four minims, of
the tincture of the chloride of iron of the United States
Pharmacopoeia. It is not pretended that Weld's syrup will
in it stain the teeth; soft-boiled eggs, salads, etc., will of
themselves stain the teeth, but it can be asserted that Weld's
syrup will not injure the enamel of the teeth. On usini;- a
tooth-brush, the surface is always found intact, even after
month-long immersion in this preparation. Weld's syrup
of the chloride of iron is simply the tincture of the chloride
of iron, United States Pharmacopoeia, with the excess of
acid neutralized and a certain amount of syrup of gaultheria
added to improve the taste. The following cases will illus-
trate its usefulness :
Case I. January 15, 1892— H. B. C, United States, aged
twenty-four, single, no occupation. Glycosuric fourteen months
ago. Under Martineau's treatment sugar disappeared from the
urine in three months, and has not returned. Has suffered from
polyuria ; her daily amount of urine sixty to ninety-five ounces.
She complains of dull headache in the afternoon. Suffers back-
ache when walking, has nausea and occasional vomiting, trem-
bling, and pains in limbs. Slight cough without expectoration.
May 7, 18VSS.]
WILCOX:
ANMMIA.
515
dizziness and fainting spells. Dyspnea, which is marked on as-
cending stairs. Her diet lias not been restricted.
Physical Examination. — Pallor, lips bloodless, not (Edema-
tous. Pulse !)2, small and weak. Anaemic murmur in
right side of neck, also in second left intercostal space. Apex
heat weak, otherw ise normal. Liver easily felt at edge of ribs.
\u enlargement of spleen. Urine, ninety-four ounces, free from
albumin, sugar, and casts. Specific gravity, 1*018, acid. Reich-
ert's haemoglobinometer, seventy-eight per cent. Ordered
W eld's iron, two drachms three times daily.
February 18th. — Reichert's haemoglobinometer, eighty-five
per cent.; quantity of urine, fifty ounces, normal. Anaemic mur-
mur has disappeared from second left intercostal space. Im-
provement marked as regards symptoms and faintness. Pulse
good, 82, and of fair volume. Ordered Weld's iron, three
drachms three times daily.
March Hth. — Haemoglobinometer, ninety-one per cent.;
much improvement in headache and backache. No nausea or
vomiting; cough, however, still continues. Less dyspnoea ; pulse
72, of good force ; murmurs have both disappeared ; liver normal ;
urine, sixty-two ounces. Ordered two drachms Weld's iron
three times daily.
April 11th. — Symptoms are entirely relieved. Urine, fifty-
five ounces; specific gravity, 1*017 ; no sugar, albumin, bile, or
casts. Liver normal in size. Reichert's hsemoglobinometer.
ninety-eight per cent. Discharged cured.
Case II. January 19, 1892. — L. D., aged seventeen, single.
Sick one year. Complains of headache, which is frontal, con-
stant, sharp, but not enough to keep awake at night. Some-
times worse in middle of day. Pulse weak. She is languid,
disinclined to exertion, sometimes dizzy, but never faints. No
cough ; formerly palpitation, marked shortness of breath, hands
and feet cold. No appetite, no distress after eating. Bowels
regular every day. Catamenia anticipate two or three days.
Flows four days, not profuse, of good color. No urinary or
bowel symptoms.
Physical Examination. — Pube 78, weak, small, and of low
tension. Tongue pale and flabby ; teeth indent the edges. Bruit
de diable in right side of neck. Ventriculo-systolic murmur in
second left intercostal space. Apex-beat weak, diffused, short-
ened, somewhat irregular in force and rhythm, on exercise.
Reichert's haemoglobinometer, sixty-six per cent. Ordered
Weld's iron, two drachms three times daily.
February J^th. — Headache yesterday; is now fourteen days
over period. Pulse 72, better. Still has anaemic murmurs.
Haemoglobinometer, seventy-six per cent. Ordered Weld's iron,
two drachms three times daily.
February 23d. — Has not felt quite so well during last week
owing to loss of sleep caused by death of father. Pulse now
weaker in force, rhythm is good. Sounds at apex weaker also.
Anaemic murmur not so loud as before; heard in neck and at
second left intercostal space. Period last week as usual. Reich-
ert's haemoglobinometer, eighty-four per cent. Ordered Weld's
iron, two drachms three times daily.
28th. — lias felt very much better since last report. Anaemic
murmurs can not now be heard. Reichert's haemoglobinometer,
ninety-three per cent. Ordered Weld's iron, two drachms three
times daily.
March 15th. — Haemoglobinometer, ninety-seven per cent.
April 3d. — Pulse, G8, good ; lips of excellent color. Hsemo-
globinometer, one hundred and two per cent. Discharged en-
tirely well.
Case III. January 23, 1892.— U. McC, United States, aged
seventeen, sick three weeks. Vomiting constantly, whether
stomach is full or empty. Vomits a whitish matter, never
bloody. Pain in head in both temples; not always present, but
worse on vomiting. Dizziness on going up stairs, also dyspnoea.
Short, dry cough, which is slight; palpitation of heart on walk-
ing; appetite fair. Bowels very constipated, no urinary symp-
toms. Menstruation very irregular for last three months and
continues two clays without pain; discharge pale and scanty.
Sleeps well and is drowsy in day-time. Has pains about heart.
Physical Examination. — Tongue clean, pale, and flabby.
Conjunctivae pearly. Lips pale, no swelling of feet. Pulse. 9Qi
feeble, compressible : slight anaemic murmur in right side of
neck, also in second left intercostal space. Apex beat weak,
with hut little impulse. Reichert's haemoglobinometer, sixty-
three per cent. Ordered Weld's iron, half an ounce three times
daily.
February 7th.— Has felt better, headaches and dizziness
better, shortness of breath less marked Anaemic murmur in
second intercostal space has disappeared Reichert's luemo-
globinometer, seventy-four per cent. Ordered Weld's iron, three
drachms three times daily.
24th. — Has not taken medicine for two days. Nausea has
returned ; heart sounds, however, are better. Reichert's haemo-
globinometer, eighty-eight per cent. Ordered Weld's iron, two
drachms three times daily.
March 3d. — No nausea, no vomiting; dizziness absent; very
little shortness of breath ; pulse, 72, of good volume and regu-
lar; no anaemic murmurs. Ilaemoglobinonieter, ninety-one per
cent. Ordered Weld's iron, one drachm three times daily.
29th. — Haemoglobinometer, ninety-eight per cent. Dis-
charged upon the patient's statement that she feels perfectly
well.
Case IV. January 24, 1892. — C. B., aged eighteen, single,
sick one year. Menstruation at thirteen, always irregular, re-
curring every three to eight weeks, lasting five or six days;
profuse. For the last six months she has had her periods every
fourteen days, lasting from eight to ten days, profuse, but little
leucorrhoea. Headaches at times constant, worse in the morn-
ing. Dizziness, palpitation of the heart, fainting on one occa-
sion, fainting feelings frequently, shortness of breath on ascend-
ing stairs, pain in the stomach almost all the time, poor appe-
tite of late. Pain under the right shoulder. As a rule, food
does not distress her. Bowels move every day. Before each
menstruation there is an attack of diarrhoea. Loss of flesh and
strength.
Physical Examination. — Pulse, 88, broad, weak, irregular
in force and rhythm. Conjunctivae jaundiced, pupils fully di-
lated. Lips pale, tongue clean and pointed. An anaemic mur-
mur in the neck, but none in the second left intercostal space.
At the apex there is a shortened first sound, varying in inten-
sity and irregular in rhythm. Reichert's haemoglobinometer,
fifty-six per cent. Ordered Weld's iron, three drachms three
times daily.
February 14th. — After an interval of sixteen days, she
flowed six days, the first three days as usual, the last three
there was an improvement. Pain during the first day in the
stomach, some headache, but less than formerly. Less pain in
stomach, no diarrhoea. Reichert's haemoglobinometer, seventy-
one per cent. Ordered Weld's iron, two drachms three times
daily.
21st. — Headaches, dizziness, fainting feelings were all im-
proved; appetite good. Reichert's haemoglobinometer, seventy-
nine per cent. Ordered two drachms Weld's iron three time-
daily.
March 12th. — At the last period she flowed for six days;
her head aches very little, the dizziness is better, there is no
palpitation, and no fainting; no shortness of breath and very
little pain in the stomach; food does not distress her; pulse,
72; heart beats stronger than at last report. The murmur in
516
WILCOX:
A X. KM I A.
[N. Y. Med. Jour.,
the neck is less loud. Reichert's haemoglobinometer, eighty-
seven per cent. Ordered Weld's iron, two drachms three times
daily.
22d. — No murmur is now heard, and she has greatly im-
proved in appearance and feelings.
April Jfth. — No headaches; she has slight dizziness and is
restless at night; pulse, 68, good. Reichert's haemoglobinom-
eter, one hundred and three per cent. Discharged well.
Case V. January 26, 1892. — E. EL, Ireland, aged nineteen,
single. Sick five weeks. She was a tea fiend. Vomited after
eating, but not at other times. Pain in stomach before vomit-
ing. The matter vomited is food unchanged. Belches wind.
Bowels irregular, constipated, move two or three times a week,
pain before movement. The head aches in left frontal region,
dizziness, shortness of breath on walking, violent palpitation
on ascending stairs. Menstruation absent for two months, usu-
ally irregular, from five to seven weeks, flows three days, color
good, no pain. She has been losing flesh of late and has poor
appetite.
Physical Examination. — Pulse, 92, weak, compressible,
small. Conjunctivae pearly. Tongue pale, tremulous, flabby.
Anaemic murmur in neck, also in second left intercostal space.
Apex beat and sounds normal. Reichert's haemoglobinometer,
forty-nine per cent. Ordered Weld's iron, three drachms three
times daily.
February 24th. — No vomiting or stomach pain, headache
absent, palpitation and dizziness improved. Anaemic murmur
in neck, also in second left intercostal space. Reichert's hsemo-
globinometer, sixty-five per cent. Ordered Weld's iron, two
drachms three times daily.
March 10th. — Has returned to tea-drinking and has some
vomiting, otherwise improved. Anaemic murmur in second left
intercostal space is now absent. Reichert's hsemoglobinometer,
seventy-eight per cent. Ordered Weld's iron, two drachms
three times daily. Tea was forbidden.
15th. — Considerable improvement; vomiting has completely
disappeared ; murmurs now heard only in neck. Hsemoglobi-
nometer. ninety-one per cent. Ordered Weld's iron, two
drachms three times daily.
April 12th. — This patient has not yet reported, but, judging
from her improvement, she is now well.
Case VI. February 4, 1892— L. O, United States, aged
eighteen, single. Sick two weeks. Two weeks ago she had
cold in chest, cough, expectoration, which was whitish, hard to
raise. Dizziness, shortness of breath. In menstruation consid-
erable pain, but nothing else unusual. Headaches on top of
head, sometimes fainting feelings. Obliged to sit down sud-
denly. Bowels very constipated. Poor appetite. Food dis-
tresses her ; nausea.
Physical Examination. — Pulse, 98, small, feeble, slightly
irregular. Conjunctivae pale, pearly. Mucous membranes anae-
mic. Tongue coated, tremulous, and flabby ; anaemic murmur
in neck and second left intercostal space and roughened respira-
tion. Reichert's hsemoglobinometer, fifty-two per cent. Or-
dered Weld's iron, three drachms three times daily.
18th. — Much improved, but is still weak : shortness of breath
and headache still present, but not so marked. Cough and ex-
pectoration less, appetite much improved ; bowels now regular,
food does not distress her ; pulse, 90, of fair volume, and respi-
ration normal; anaemic murmur in second left intercostal space
less marked. Reichert's hsemoglobinometer, seventy per cent.
Ordered Weld's iron, three drachms three times daily.
March 15th. — Murmur heard only in neck, and that is not
marked ; slight cough, dyspnoea absent. Reichert's hsemo-
globinometer, eighty-two per cent. Ordered Weld's iron, two
drachms three times daily.
April 6th. — Feels perfectly well. Hiemoglobinometer,
ninety-five per cent. Iron to be continued in same dosage for
two weeks. Discharged from observation.
Case VII. February 12, 1892.— S. M. F., United States, aged
thirteen ; sick one year. Complains of headaches, dizziness,
languor for several months ; fair appetite ; sweats easily ; coated
tongue; constipation, sometimes palpitation. Cold does not re-
sult in cough, but tonsils rapidly enlarge. Has not menstru-
ated.
Physical Examination. — Pale, skin soft, easily grasped, blue
veins showing on forehead. Conjunctivae pearly ; lips pale ;
mucous membranes the same. An;emic murmur in neck, also in
second left intercostal space. No pulmonary signs ; abdomen
full. Scapulae prominent. Expansion half an inch in chest,
showing thirty-six inches on expiration; muscles soft. Pulse,
78, weak. Reichert's haemoglobinometer, eighty-three per cent.
Ordered full diet, pulmonary gymnastics, and Weld's iron, one
drachm three times daily.
March 7th. — Great improvement in appearance as regards
muscles, but still anaemic murmurs are present. Abdomen less
protuberant, scapulae less prominent. Reichert's haemoglobi-
nometer, eighty-seventy per cent. Ordered Weld's iron, two
drachms three times daily.
21st. — Chest expansion, two inches in expiration ; its meas-
urement is twenty-nine inches. No murmurs. Cheeks and lips
of good color. Pulse, 72, good. Reichert's haemoglobinometer,
ninety-two per cent. Ordered Weld's iron, two drachms two
times daily.
April 10th. — Chest expansion, two inches in expiration ; its
measurement is twenty-nine inches and a half. Feels very
well. Reichert's haemoglobinometer, ninety-nine per cent. The
iron discontinued.
Case VIII. tebruary 8, 1892. — M. S., France, aged thirty-
two ; sick one month. Always healthy; for the last month
headache in temples constant, sleep interrupted by it. Vomit-
ing of food and mucus for two days ; some pain in stomach ;
poor appetite; bowels regular every day. Of late some dry
cough ; palpitation on exertion ; never dyspnoea. Loss of flesh :
no swelling of feet ; sometime* fainting feelings.
Physical Examination. — Tongue pale and flabby ; mucous
membranes pale : anaemic murmur in neck, also in second left in-
tercostal space ; apex sounds weak ; pulse, 90 and weak. Men-
struation regular, but scanty and pale. Reichert's haemoglobi-
nometer, sixty-six per cent. Ordered Weld's iron, two drachms
three times daily.
22d. — Less headache and vomiting ; palpitation now seldom ;
no fainting; pulse, 88; heart sounds better, though appetite is
still poor; no murmur in second left intercostal space. Reich-
ert's haemoglobinometer, eighty-five per cent. Ordered Weld's
iron, three drachms three times daily.
March 16th. — Her appetite has much improved. Pulse, 72,
good. Reichert's haemoglobinometer, ninety-six per cent. Or-
dered Weld's iron, two drachms three times daily for two weeks,
and then to report if not perfectly well.
Case IX. February 11, 1892. — E. S., United States., aged
nineteen, single; sick six months. Cough not severe, does not
keep her awake at night ; no vomiting; expectoration whitish,
scanty, and easy to raise ; generally only in the morning. Pal-
pitation of heart ; shortness of breath, however, is absent. She
has lost flesh and more strength. Her headaches are coustaut.
She never faints ; has cold hands and feet, but no dizziness; ap-
petite good ; food does not cause distress ; constipation ; has no
menstrual symptoms, except scanty flow and cramps.
Physical Examination. — High-pitched inspiration and ex-
piration at right and left apices ; whispering bronchophony ;
crepitant rales down to upper border of third rib ; rest of chest
May 7, 1892. J
normal; first and second sounds of heart accentuated; anaemic
murmur in neck slight : soft blowing ventriculo-systolic mur-
mur at apex Pulse, 72, weak, but regular. Lips pale, (edema-
tous, mucous membranes pale. Reichert's haemoglobinometer,
seventy-one per cent. Ordered Weld's iron, three drachms
three times daily.
February ■-'■'> t/i. — Cough improved; expectoration yellowish.
No palpitation or shortness of breath. Feet now cold, but not
the hands. Has had DO menstruation since January 15th. Pulse,
66, of better volume. Lips not so pale. Reichert's hsemoglo-
binometer, eighty-five per cent. Ordered Weld's iron, two
drachms three times daily.
March 10th. — Has but little cough and scanty expectoration.
No coldness iif feet. Has menstruated since last report. Color
improved, otherwise no change. No murmurs either in neck or
apex. Reichert's haemoglobinometer, ninety-four per cent. Or-
dered Weld's iron, two drachms three times daily.
2Sd, — Feels first-rate; has no headaches, no coldness of hands
or feet. Pulse, 68, good, inspiration less high-pitched ; no
whispering bronchophony; no rales. Pulmonic second sound
slightly accentuated. Hsemoglobinometer, one hundred and two
per cent. Ordered to stop iron; discharged well.
Case X. February 11, 1892. — M. O'B., United States, aged
seventeen, single ; sick five weeks. Suffered from chorea three
years ago, with repetitions each spring. Constant headaches at
vertex keep her awake at night. Shortness of breath on exertion :
palpitation, which is fluttering, on ascending stairs; also pain
about the waist ; frequent fainting ; dizziness; sometimes ring-
ing in her ears; appetite poor; food distresses after eating-
nausea, hut no vomiting: bowels regular; cold hands and feet.
No disturbance in menstruation, except cramps. The feet swell,
also the face
Physical Examination. — Lips pale: cederaatous. Pulse, 96,
weak and irregular. Anaemic murmur in neck, also ventriculo-
systolic murmur at second left intercostal space and at apex.
Reichert's hsemoglobinometer, fifty -one per cent. Ordered
Weld's iron, three drachms three times daily.
February 25th, — Slight chorea in left side of the face and in
the left arm. Headache better; does not keep awake nights at
present. No pain or palpitation of heart : dizziness on two oc-
casions; feet still cold; has not been unwell for five weeks;
feet do Dot swell, neither does the face. Pulse, 84, more regu-
lar. Murmurs are still present. Reichert's hsemoglobinome-
ter, seventy-two per cent. Ordered Weld's iron, two drachms
three times daily.
March 17th. — Menstruation since last report, but not un-
usual. Shortness of breath improved; no palpitation ; appetite
good ; no distress after eating. Pulse, 72, still weak. Murmur
at the apex very faint. Chorea diminished. Reichert's hsemo-
globinometer, eighty per cent. Ordered Weld's iron, two
drachms three times daily.
30th. — Chorea less marked. Murmurs only in the neck.
Pulse, 68, better force. Hsemoglobinometer, ninety-one per
cent. To continue with Weld's iron for a month.
Case XL February 14, 1892. — A. C, United States, aged
twenty-one, single ; sick for four years. Tubercular family his-
tory. For the last two years she has been subject to colds.
Cough usually not marked., save in the morning ; no expectora-
tion ; appetite poor ; never distressed after eating. She some-
times complains of dizziness and faintness; sometimes dyspnoea
and palpitation, especially on exertion. Four years ago she
had infiltration of the right apex, which was presumably tuber-
cular.
Physical Examination. — Slight dullness over the right apex,
and increased transmission of voice sounds, especially the whis-
pered voice; markedly high-pitched and prolonged inspiration;
517
no rales. Pulse, 92, weak. Pupils dilated ; conjunctivae pearly.
Anaemic bruit in neck on right side ; no heart murmurs. Reich-
ert's haemoglobinometer, fifty-three per cent. Ordered W7 eld's
iron, three drachms three times daily.
March 7th. — No cough, appetite good, no dizziness, no
faintness or shortness of breath, and very little palpitation,,
save on ascending stairs; no headaches. Her food does not
distress her after eating ; bowels regular every day. Reichert's
luemoglobinometer, seventy-one percent. Ordered Weld's iron,
two drachms three times daily.
20th. — Appetite excellent ; feels generally better. Pulse, 68,
good. Lips good color, no anaemic bruit in neck, and all pul-
monary signs have improved markedly. Reichert's haemo-
globinometer, eighty-eight per cent. Ordered Weld's iron, two
drachms three times daily.
April 10th. — Has markedly improved. Pulse, 66, good
force and volume. Hsemoglobinometer, ninety-nine per cent.
Ordered to omit all medication.
Case XII. February 16, 1892.— K. M., United States, aged
nineteen, single. Sick three months. Always well until this.
Complains of shortness of breath on exertion, palpitation of
heart, throbbing in epigastric regioo, and sometimes coldness
of hands and feet; headaches on top of head constant, but
worse on being tired; dizziness; sometimes weak and fainting
spells. She has no cough or expectoration, no swelling of
feet; is regular in menstruation, pain before flow for three
days, flow becoming more scanty and pale; appetite good;
bowels constipated; no distress after eating.
Physical Examination. — Pulse, 102. weak. Skin and con-
junctivae pale. Tongue clean, tremulous, and flabby. Loud
anaemic murmur in right side of neck. Rough blowing murmur
in second left intercostal space. First sounds of heart weak ;
tenderness of liver^ but no enlargement; spleen normal, no
pulmonary signs. Reichert's hsemoglobinometer, forty-six per
cent. Ordered Weld's iron, three drachms three times daily.
March 5th. — No shortness of breath, palpitation improved,
feet still cold ; has bad one attack of headache which lasted
three days; no fainting. Last menstruation was, as usual, of
scanty flow with pain. Her appetite has markedly improved ;.
amende murmur in neck and second intercostal space still pres-
ent, although not so loud. Reichert's luemoglobinometer, sixty-
two per cent. Ordered Weill's iron, three drachms three times
daily.
15th. — Shortness of breath the same, headaches improved,
also palpitation. Pulse, 71, good. Reichert's hsemoglobi-
nometer, seventy-four per cent. Ordered Weld's iron, half an
ounce three times daily.
April 2d. — Has no symptoms excepting occasional head-
aches. Pulse, 68, good. No murmurs. Reichert's haemoglobi-
nometer, ninety-eight per cent. Patient discharged well.
In making an analysis of these cases, we may say that
the cause of the anaemia in Case I was a state of malnutri-
tion following diabetes and arising in the liver. Cases II.
VIII, and XII evidently became anaemic through overwork,
loss of fresh air and sunlight. Case IV is accounted for
by the menorrhagia from which she suffered, and which
was cured during the last week of observation by curetting
of the uterus under ether : her improvement, however, dated
from the commencement of the treatment by iron. Dys-
pepsia evidently was the cause of the amentia in Case III,
which could well be named as one of Sir Andrew ("lark's
faecal anaemias. I believe that the cure was obtained quite
as readily with the administration of iron as it would have
been with beta- nap hthol, and I speak after considerable ex-
WILCOX: ANJEMIA.
518
RAU: THE SARATOGA WATERS.
[N. Y. Med. Jocr.,
perimentation with intestinal antiseptics. Case X devel-
ii]ic(l her usual spring chorea while under treatment, yet the
attack was mild and improved rapidly. Case V was a tea
fiend, and a great portion of the result could he justly as-
signed to the breaking off of the habit. Cases VI, IX, and
XI were of the tubercular diathesis, and Case VII should
he added here, as the condition was one of hypotrophy,
such as has recently been described by Solis-Cohen. Iron,
when change of life, scene, and habit can be obtained, is
certainly a most valuable prophylactic. In all these cases
outdoor exercise was insisted upon, for iron to be of the
most value must be sunned, regular hours for sleep and
meals and a nitrogenous diet prescribed, and the bowels
regulated by cascara sagrada and glycerin.
Conclusions. — 1. In anamiia iron is by far the best
remedy.
2. Of all preparations, the tincture of the chloride is the
must valuable.
3. This preparation is objectionable in that it excites
nausea, disgust, and vomiting, stains and destroys the teeth.
4. These disadvantages are obviated in Weld's syrup of
the chloride of iron.
5. In removing these disadvantages, its therapeutic
efficacy is not in any way impaired.
690 Madison Avenue, April 12, 1892.
THE SARATOGA WATERS:
THEIR (JSBS AND ABUSES*
By LEONARD S. RAU, M. D.
In taking up this subject, I do so in order to try to re-
vive an interest in the medicinal use of these waters rather
than to hope to be able to say anything new about them ;
for they have been used and abused for so many years, and
there has been so much written about them, that it would
be presumptuous on my part to attempt to tell you anything
new. After practicing for four summers at one of the prin-
cipal hotels in Saratoga, I have seen and learned much in
regard to these waters, and, as some of my experiences have
been interesting and instructive, I make this my plea for
reading a paper to you on so old and threadbare a subject.
Let me begin by dividing the principal waters into sev-
eral general classes : First, the cathartic waters, as repre-
sented by the Congress, Hathorn, Empire, Carlsbad, etc.
Next the alkaline waters, such as Vichy, Kissingen, and
Geyser. Then the iron waters, examples of which are the
Columbian and Washington. Besides these may be men-
ti.-ned the High Rock (the oldest of all), the Excelsior, the
Red Spring with its baths, the Favorite, the Patterson, the
White Sulphur, the Hamilton, etc. There are some twenty-
eight in all, and they contain the various salts, iodine, iron,
etc. Careful analyses have been made of each, but I shall
oot trouble you with any of these.
It would seem natural to believe that even a layman
could understand that a combination of all, of many, or even
>>f several of these waters, might bring disastrous results,
* Read before the Metropolitan Medical Society, December 9, 1891.
and yet it has been my privilege to see this very thing done
over and over again. Early in the summer of 1890 the
Kensington Hotel was visited by a large number of school
teachers on their annual excursion. They received im ita-
tions to visit the various springs, and, starting out early in
the morning, they began to drink the waters, and some of
them were not content until they had tasted of all the vari-
ous kinds, so that when night came I was kept busy going
from one patient to another, trying to relieve most violent
colicky pains and endeavoring to control severe diarrhoeas.
Some of the patients told me frankly that they drank any-
where from twenty to twenty-five glasses of water that day.
It is useless to add that fruits, corn, salads, pastries, and
what not were freely indulged in whenever they found a
few moments spare time between their drinks. Seriously
speaking, however, some of the cases suffered intensely ;
several showed marked symptoms of collapse, requiring
considerable stimulation, morphine, atropine, etc. ; and one
case terminated fatally, whether or not as a direct result of
drinking the water I am unable to say, for I could not get
a complete history of the case. I shall take the liberty of
briefly relating as much of the history as I was able to
obtain :
Miss B., aged twenty-five, teacher, sent for me on the
night of the 8th of July, 1890. She had been perfectly
well up to this time. I found that she had been drinking
the waters freely, and that toward evening she was seized
with vomiting and diarrhoea and severe griping pains. I
applied a mustard leaf over the epigastrium and gave a
powder of bismuth, opium, and ginger, which was to be re-
peated hourly until the vomiting and diarrhoea were con-
trolled. She took in all three powders, each containing
half a grain of powdered opium. Next morning, though
weak, she left Saratoga with the rest of the party for Lake
George. A week later I received a letter from New York
stating that she had had no vomiting or diarrhoea after she
took the third powder, but that twenty-four hours after I
had last seen her, while on her way home, she was seized
w ith intense pains in the abdomen. Physicians were sum-
moned. They found her suffering with general peritonitis
and she died on the fifth day. This was certainly a very
sad termination of an excursion.
Many people, some physicians included, consider the
waters worthless and ineffective. My experience just re-
lated may perhaps convince them to the contrary. There
is and can be no doubt that if the waters are properly used
and a regular diet observed — the patients, in other words,
living " Kurgenuiss "—much benefit may be derived from
their use. My friend Dr. Burchard, in a paper on this
subject written some few years ago, strikes the key-note of
the situation by saying : " The trouble is that the people
won't eat porridge instead of birds, especially w hen they
have to pay for birds and not for porridge." Another great
trouble is that the springs are owned by private individuals,
whose principal object, of course, is to make their spring a
financial success. The result is that men are continually
boring for new springs, and every little while they meet
some old spring in their search for a new one, the waters
become mixed, and the old and what was believed to be re-
May 7, 18»2.]
RAU: THE SARATOGA WATERS.
519
liable spring becomes polluted. Of course, the owner soon
rinds out the trouble, but he can not afford to close his
spring while the damage is being repaired, and consequent-
ly the public are the sufferers. This fact was demonstrated
in the summer of 1888, when a number of my patients,
by <»nly drinking one or two glasses of Hathorn water, were
seized with violent cramps and vomiting. Other physicians
had similar experiences, and inquiry showed that the water
had become mixed with the water from another spring.
The damage was, however, quickly repaired. The springs
do not seem to be in the same condition every year, so that
patients often say to me : " Doctor, why is it that last year
one glass of water acted splendidly on me, whereas this
\ ear two or even three glasses seem to have little if any
I effect ? " I can only explain this fact by supposing that the
waters really do change in character, for a time at least.
And now in reference to the question of the springs being-
doctored. It is, of course, next to impossible to obtain any
definite information in regard to this matter. I am willing
to believe that the springs at times are charged with car-
bonic-acid gas. but have no positive evidence to that effect ;
but I do not believe that salts and other ingredients are
added to them.
The fact of the springs changing in character leads me
to speak of the recommending of different waters by physi-
cians living at a distance from the springs. Patients before
leaving the city go to their physician and say : " Doctor, I
am going to Saratoga ; what water shall I drink ? " and he
recommends one in good faith, of course, but in reality
knowing nothing about the condition of the water. To
illustrate this : I called on a medical friend on my return
from the springs one fall, and he asked me which cathartic
water 1 found most satisfactory. I told him the Empire.
Next summer all his patients were drinking Empire ; but it
so happened that this was an off year for Empire, so the
result was unsatisfactory for both physician and patients.
Many people, too, drink the waters because they are so ac-
cessible, and think that on general principles they will do
them good, for it would never do to be in Saratoga and not
drink the waters. Over and over again, while walking on
the piazza or in the corridor of the hotel, I am accosted by
an acquaintance, who stops me and asks in an off-hand way
(of course, he does not expect to pay for this) : " Doctor,
what water do you think I had better drink I " or, " Don't
you think that Congress is a very good cathartic and would
do me good ? " As to his physical condition, of course, I
know nothing, and yet he wants me to recommend medicine
for him. They drink the waters as they please, or as their
friends advise them, and then, when they obtain no benefi-
cial results, the natural inference is that the waters are
worthless. I assure you, gentlemen, that I am not consult-
ed ten times dming a season as to just what waters to
drink, how to drink them, and how to live while drinking
them; and some of my Saratoga colleagues tell the same
story. You all know how different this is in Europe. There
every watering-place has its regularly appointed physicians;
the people come from all over the world and consult one of
these physicians; he lays out a plan of diet and a mode of
living, extending over from three to six weeks, and the pa-
tients cany out these rules conscientiously — in fact, they
have to; they have no alternative. But how is it in Sara-
toga ? The people go there, seldom if ever consult a physi-
cian, immediately begin to drink the waters ad libitum —
the Congress, the Hathorn, or what not — eat everything
on the varied bills of fare, go to the races, indulge in their
favorite mixed drinks, gamble till early morning, and then,
after a couple of weeks, grow weary, or their funds give
out, they leave the place thoroughly disgusted, rather worse
than better, and regretting not having gone to Carlsbad in-
stead. Other people really do get up early, drink their water
conscientiously, but pay little or no attention to diet. There
is no doubt in my mind, and I could cite a number of cases
to illustrate this, that, did the people who come to Saratoga
to drink the waters, drink them as they would do or have
to do abroad, they would obtain just as much benefit there-
from, for there can be no doubt of the cathartic and chola-
gogue action of the Congress, Hathorn, Empire, etc., or
of the antacid and diuretic action of the Vichy, Kissin-
gen, or Geyser. I have obtained most excellent results in
cases of constipation, gastro- duodenitis, hepatic engorge-
ment, gastritis, dyspepsia, etc., by recommending a plan of
treatment somewhat as follows :
Rise at 7 a. m. ; go to the spring (Congress, Carlsbad,
Hathorn, or Empire) ; drink a glass of water hot ; walk for
ten minutes ; another glass of water, hot or cold ; walk for
half an hour to an hour. Breakfast, consisting of milk,
eggs, meat, coffee, or tea diluted. Avoid raw fruit, hot
rolls, or fresh bread. Then go to stool. At 1 1 a. m. one to
two glasses of Vichy (medium) ; walk for half an hour or
so. Dinner at two. Eat no fried meats or fish, no salads,
no corn, no pastry, no raw fruit. Take a rest or a nap till
five, then a walk or a drive. At six, one glass of Vichy.
Supper at 7-30. Light diet — milk, toast, eggs, stewed
fruit. At nine, another glass of Vichy, and retire at ten.
This plan to be kept up for not less than three weeks,
avoiding all mental excitement. If there is a rheumatic
tendency, the Red Spring or magnetic baths three to four
times a week, Vichy with meals and Geyser at night, have
given me satisfactory results. Diabetics and patients with
uric-acid diathesis do extremely well on Vichy or Kissingen
in large quantities. In chlorotic and anaemic patients I
have been much pleased with the effects of Columbian or
Washington (the iron waters), being careful to tell my pa-
tients only to drink these waters from one and a half to
two hours after eating, for, unless these directions are
given, the patients always complain of severe headache
after taking the water. These waters just mentioned I
have found most satisfactory; but there is no doubt of the
efficacy of many of the others, and the paper would be too
long were I to attempt to describe the uses of each of the
twenty-eight springs.
Unfortunately, the great mass of people who visit
these springs annually do so for recreation rather than
health, so that the noise, the excitement, the style, gam-
bling, racing, etc., keep away the invalids, who know that in
the height of the season they can obtain little rest, for, al-
though they may not care to participate in the festivities,
still they feel them to be somewhat contagious, and are not
520
Mc CURDY: AMPUTATION AT THE HIP JOINT.
[N. Y. Med. Jock.
sure that they can resist the various temptations, and so
prefer to stay away. The majority of those drinking the
waters do so as a pastime, obtain little, if any, beneficial
results, an 1 return to their homes firmly convinced that
the waters have lost their efficacy and that ' Saratoga can
no longer be considered a health resort. This view is
being rapidly spread over the country, and unless radical
means are taken to convince people to the contrary, this
resort will soon be a tiling of the past, as a watering-place,
at least. Let me, for one, raise my voice against these
abuses and try to make you gentlemen believe as I do — that
the virtues of the Saratoga waters exist now just as they
always did, only they are not taken advantage of. No one
who knows Saratoga will deny the healthfulness of the
place, with its bracing air, dry climate, and magnificent
trees. Perhaps I can give no better proof of this than by
telling you that at the Kensington Hotel, where many
families with a countless number of children of all a<res
congregate every summer, in the past four summers there
has not been a child ill for five consecutive days. I doubt
whether any physician can furnish better statistics than
that.
Much can be done by physicians to correct this errone-
ous idea of the lost virtues of Saratoga. Let them, instead
of in an off-hand way saying to their patients : " Oh, go
to Saratoga for a few weeks, drink the waters and enjoy
yourselves," tell them to consult a physician when they get
to the springs. Let them give their patients a letter to the
physician, stating the nature of their ailments, etc. The
owners of the springs should either consolidate into a stock
company for mutual benefit and protection, or there should
be some State supervision and each spring should have its
own physician whom patients can consult if they so desire,
and who will see that the spring is in a good condition and
that the patients are taking the waters according to their
physicians' directions. The hotel managers should have
printed bills of fare for people who drink the waters, these
to contain no article of food which ought not to be taken
while drinking the waters.
By some such means as these much, very much, could
be done to change the rapidly developing opinion of the
inefficacy of the Saratoga waters, and thousands who now
cross the ocean every year to obtain relief could obtain it
in their own country without the annoyance of an ocean
voyage, foreign travel, and expense, and, furthermore, they
would tend to bring back Saratoga, the garden-spot of
America, to its former glory and usefulness.
72 West Fifty-fifth Street.
Meetings of State and National Medical Societies for the Month
of June. — State Medical Society of Arkansas, 2d, Little Rock; Oregon
State Medical Society, 2d, Portland ; Rhode Island Medical Society, 2d,
Providence ; American Academy of Medicine, 4th, Detroit ; American
Medical Association, 7th, Detroit; Massachusetts Medical Society, 7th,
Boston ; Maine Medical Association, 8th, Portland ; South Dakota State
Medical Society, 8th, Salem ; Delaware State Medical Society, 14th,
Dover; Minnesota State Medical Society, loth, St. Paul; American As-
sociation of Genito-urinary Surgeons, 20th, Richfield Springs, N. Y. ;
American ( Iphthalmological Society, 20th, New London, Conn. ; New
Hampshire Medical Society, 20th, Concord; Colorado State Medical So-
ciety, 21st, Denver; Medical Society of New Jersey, 28th, Atlantic City.
A MODIFICATION OF
WYETH'S METHOD OF BLOODLESS AMPUTATION
AT THE II 1 1' JOINT.
By STEWART LeROY M< CURDY, M. D.
DENNISON, OHIO,
PROFESSOR OP ORTHOP/EDIC AND CLINICAL SURGERY,
OHIO MEDICAL UNIVERSITY, COLUMBUS, OHIO :
LECTURER ON TOPOGRAPHICAL ANATOMY AND LANDMARKS,
WESTERN PENNSYLVANIA MEDICAL COLLEGE, PITTSBURGH, PA. \
SURGEON, P. C. C. AND 8T. L. RY. CO.
The advance made in amputations at the hip joint, as
suggested by Professor John A. Wyeth, must be considered
one of the principal ones in modern operative surgery. The
operation is descrihed by Wyeth us follows :
The patient being placed in position with the hip of the side
to be operated on well over the corner of the table, the foot is
elevated, and an Esmarch bandage applied to drive the con-
tained blood toward the heart. The bandage should not be
tightly put on over the seat of the disease for fear of driving
septic matter into the circulation. With the rubber bandage
still in position, the needles are next introduced.
Two steel mattress needles, three sixteenths of an inch in
diameter and a foot long, are used. The point of one is inserted
an inch and a half below the anterior superior spine of the ilium
and slightly to the inner side of this prominence, and is made to
traverse the muscles and deep fascia, passing about half way be-
tween the great trochanter and the iliac spine, external to the
neck of the femur and through the substance of the tensor
vagina? femoris, coming out just back of the trochanter. About
four inches of the needle should be concealed by the tissues.
The point of the second needle is entered an inch below the
level of the crotch, internally to the saphenous opening, and
passing through the adductors comes out about an inch and a
half in front of the tuber ischii. No vessels are endangered by
these needles. The points are protected by corks to prevent
injury to the operator's hands.
A piece of strong, white rubber tube, half an inch in diame-
ter and long enough when tightened in position to go five or
six times around the thigh, is now wound very tight around
and above the fixation needles and tied.
The Esmarch bandage is removed, and five inches below the
tourniquet a circular incision is made, and a cuff, which includes
the subcutaneous tissues down to the deep fascia, is dissected off
to the level of the lesser trochanter, at which level the muscles
and vessels are divided squarely and the bone sawed through.
All vessels (including the veins) which can be seen are tied with
catgut, and the smaller bleeding points can be discovered by
slightly loosening the tourniquet, which is then entirely removed.
The remaining portion of the femur is now easily enucleated
by dividing the attached muscles close to the bone and opening
the capsule as soon as it is reached. . . .
One other important point I wish to emphasize — viz., the
advisability in certain cases of doing this operation in two sit-
tings.
In one of my cases the patient was greatly exhausted, and
after dividing the femur at the lesser trochanter and securing
the vessels, fearing the supervention of shock, as indicated by
the pulse, I closed the wTound, which healed by first intention.
At the first dressing (on the seventeenth day), the remaining
portion of the bone was removed by an incision over the tro-
chanter major. The recovery was uninterrupted.
I should prefer to complete the operation at one sitting, but
cases will occur where the danger of shock may be obviated by
stopping short of enucleation, leaving this for a week or two
when reaction and convalescence are assured.
May 7, 1892.]
Mc CURD Y: AMPUTATION AT THE HIP JOINT.
521
In neither of my cases was there any bleeding, and, in fact,
amputation at The hip joint is now- a bloodless operation.
I have some hesitation in even presenting a modification
of an operation devised by so eminent a surgeon, and one
that has been so extensively used by surgeons throughout
the country. It has occurred to me, however, that the dis-
advantage of even having it necessary under extreme cir-
cumstances to subject a patient to a second operation should
be avoided if possible.
Some have been content with what is known as Jordan's
operation, which is performed by making an incision from
over the greater trochanter to the end of the stump and
down to the bone. The head of the bone is then" disarticu-
lated and the soft parts are dissected from the trochanters
and shaft down to a line with the lower edge of the flap.
The head of the bone thus liberated is swung out so as to
admit the assistant's hand into the cavity, pressure being-
made internally upon the femoral with one hand and exter-
nally with the other hand. With the assistant still at his
task of controlling the vessels, the surgeon proceeds to make
the flaps, ligate the femoral, etc.
To perform this operation well, one must have a skillful,
trusty, and, above all, muscular assistant. The task of con-
trolling the femoral artery with the fingers while the hip
joint is opened and the head and neck of the femur are
dissected from the dense soft structures surrounding it,
with the making of the flap and the ligating of the vessels,
is, to say the least, trying.
Pig. i.
An effort has been made to combine what appears to
be the advantages of both the above-described methods,
and at the same time make the operation as bloodless as
Wyeth's and as rapid as Jordan's. As is shown in the ac-
companying drawing, the Wyeth operation is so modified
as to be performed with but one needle instead of two, and
always at one sitting.
First draw a line from the most prominent point of the
greater trochanter to the perimeum. The needle is entered
on this line at a point just internal to the femur, and is
passed directly through the thigh so as to make its exit just
below the tuber ischii. Passed through at this point the
needle will be external to all the important blood-vessels,
and the only haemorrhage possible will be from the smaller
vessels upon the external aspect of the thigh. A figure of 8
is now made by throwing a round rubber tourniquet around
the projecting ends of the needle, over the internal aspect
of the thigh, sufficiently tight to destroy femoral pulsation
beyond the tourniquet. The flaps are now made, which is
followed by disarticulation.
After ligating the blood-vessels, the cord and needle are
removed and the stump is ready for final dressing. The
point of the needle should be guarded, as Wyeth suggests,
with a cork.
The second cut is prepared in view of carrying out the
same idea of a bloodless amputation at the shoulder joint.
Fig. 2.
The steps in such an operation are at once suggested to the
surgeon, after having studied the rules laid down for the
hip operation.
The Death of Dr. Samuel H. Orton, formerly of New York, took
place at South Norwalk, Conn., on April 26th. He was a graduate of
Princeton College and of the College of Physicians and Surgeons of the
class of 1N.V2. lie was prominent as a surgeon in the regular army,
during the late war, at Newark, at New Orleans, at, Fort Schuyler, and
elsewhere. He resigned from the army at the close of the war, and
was appointed examining surgeon of recruits at New York, in which
office he remained until the spring of 1891. lie was in his sixty-third
year at the time of his death.
The Lenox-Medical and Surgical Society. — At the next meeting, on
Monday evening, the Oth inst., Dr. Freeman will read a paper on The
Dispensary Abuse.
522
LEA 1)1 X<1 ARTICLES.
[N. Y. Med. Jo0b.,
THE
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by Edited by
D. Appleton & Co. Frank P. Foster, M. D
NEW YORK, SATURDAY, MAY 7, 1892.
PUERPERAL ECLAMPSIA.
This topic formed the subject of a very interesting discus-
sion at a recent meeting of the Berlin Medical Society. The
discussion followed a paper by Professor Olshausen, who took
a somewhat conservative view of the aetiology and treatment.
He favored the self-intoxication theory, but would not commit
himself as to the nature of the poison further ,than to aay that
it [arose from a hindered functional activity of the kidneys.
One of the speakers advanced the theory that the pathological
factor was pathogenic bacteria, a theory whichjhe said received
support from the investigations of certain French bacteriolo-
gists of the micro-organisms in the urine of eclamptic patients.
Still, he admittedjthat these investigations lacked reliability.
In reference to the erabola of fat found in the lung tissue,
Yirchow stated that they occurred very frequently and in great
abundance. The same condition obtained in crushing injuries
•of bones, in which cases the fat [presumably came from the
crushed marrow. But that could not be the source of the fat
embola in eclampsia, and they did not come from the liver, as
was held by some. He maintained that they arose from the
..adipose tissue — which, he said, gynaecologists were in the habit
of styling connective tissue — of the pelvis, which) was subjected
to traumatism by the child's head during an eclamptic seizure.
The embola, therefore, must be considered as an effect and not
.as a cause. In the many autopsies Yirchow had made, the kid-
neys, in the majority of the cases, had shown only slight
changes, such as were frequently seen in other conditions in
which eclampsia did not occur.
In the matter of treatment. Duhrssen advocated his method
of rapid delivery by incising the cervix, and if need be the
"vagina and perinaeum, and extracting the child with the forceps
or by turning. He regarded incision of the cervix as quite safe
provided the upper part was dilated and the incision made
through the lower, or vaginal, portion only. When the upper
part of the cervix was not sufficiently dilated, he passed a thin-
walled colpeurynter, filled it with air, and forcibly drew it
down, thus dilating the internal os, and then he made the in-
cisions into the lower part. The most recent statistics of puer-
peral eclampsia showed a maternal mortality of fifty per cent.,
and a foetal mortality of twenty-five per cent. Of twenty-six
■cases which he had treated in this manner, all the women had
been saved and only two of the children had died.
Olshausen, while agreeing with Duhrssen as to the advisa-
bility of his method in certain severe cases, considered it too
extreme to be applied in every case. Cases did occur in which
the obstetrician could foretell, after the first or second seizure,
that they would pursue a favorable course and that the uterus
would empty itself without any interference. These cases
could be safely managed by the means hitherto employed, and
without exposing the patient to the risk of what was, after all,
a dangerous procedure. This seems the most reasonable view
to take. Still, to our mind, credit must be given to Duhrsseil
for advocating a method that would have saved many a woman
who has been sacrificed by the delay attending the means
hitherto employed for evacuating the uterus of its contents.
PENSIONS FOR THE CITY HEALTH DEPARTMENT OFFICERS
AND EMPLOYEES.
The recent mortality among the employees of the health de-
partment who were exposed to typhus fever, as well as the past
experience of that department in the death of officers and em-
ployees exposed to contagious diseases in the discharge of their
official duties, has suggested the establishment of a pension
fund for the benefit of their heirs, similar in features to the
plan of the Police Pension Fund. A bill for this purpose that
has been introduced into the Senate provides for the creation
of such a fund, to consist of all fees for searches and transcripts
of records of births, deaths, and marriages kept in the Bureau
of Vital Statistics, all fines and penalties for violations of the
sanitary code and health laws, and such sums as may be an-
nually appropriated by the Board of Estimate and Apportion-
ment from the proceeds of theatrical and excise licenses. The
bill also provides that the board of health shall be the trustee
of this fund, and grant pensions to any physician or employe
of the disinfecting corps or of the hospitals for contagious and
infectious diseases who, while in the performance of his duty or
by reason of its performance, shall have become permanently
disabled, either physically or mentally; such pension not to ex-
ceed one half or be less than one quarter of the annual compen-
sation of such physician or employee. To a widow or minor
children of such physician or employee a pension not to exceed
$300 per annum is to be granted, the pension to lapse if the
widow remarries or when the children come of age. The bill
further provides that any physician or employee may, after
twenty years' continuous service in the department, on his own
request or on a physician's certificate of disability, be retired on
half pay, the latter not to exceed $1,200 per annum, and to be
continued during the life of the pensioner.
While the last clause in the bill is manifestly just — for the
very nature of their occupation is apt to bring on early dis-
ability, like that of a soldier, a sailor, a policeman, or a fireman
— still, at the present time it seems as if it might jeopardize the
success of the remainder of the bill, as creating a new corps of
pensioners.
It is unnecessary here to argue that death or disability in-
curred in the line of such duty is as heroic and as worthy of the
proposed recognition by the State as that in the case of the
policeman or fireman who strives to protect life and property.
Indeed, it is comparable with that of the soldier or sailor who
risks his life to protect his country from the invasion of an
enemy, only in the present case we have the more insidious
enemy, disease.
May 7, 1892. |
MINOR PARAGRAPHS.— ITEMS.— LETTERS TO THE EDITOR.
523
Any medical officer in the army or navy, engaged in such
duty, could feel while discharging it that his widow and chil-
dren would be cared for in case of his death. We believe that
this consideration has nothing to do with the efficiency with
which the duty is discharged, as is shown in the case of those
officers of the Marine-Hospital Service, whose families are not
pensioned, who have died in the discharge of dangerous duty,
as well as by the loss of life among medical volunteers during
the yellow-fever epidemics of 1873, 1878, and 1879. Still, this
fair recognition of the existence of an obligation by the State
might make the mental condition of an official engaged in such
duty less anxious.
It is to be hoped that the present Legislature will enact this
law, and do justice to an efficient class of public servants.
KIN OR PA RA GRA P IIS.
A MEDICAL EDITOR ASSAULTED.
Db. Joseph H. Raymond, editor of the Brooklyn Medical
Journal, made some editorial comments on the results of a libel
suit recently tried in Brooklyn, in the May issue of that journal.
These comments were to the effect that the outcome of the
trial, which was unfavorable to the plaintiff, was acceptable to
the medical profession of Brooklyn, and the editor promised a
later and fuller review of the testimony. These comments were
the occasion of an attempted assault upon the editor with a
whip by Dr. Charles N. Dixon Jones, a son of Dr. Mary Dixon
Jones, the plaintiff in the suit. If Dr. Raymond's opinion of
the tone and judgment of the medical profession was correct,
an assault upon him was the sure way to elevate him into the
position of a martyr ; if his opinion was incorrect, a horsewhip-
ping was not in any wise likely to alter his mind for the better.
There does not seem to be much opportunity for a cowhide in
the argument of medical questions. The accounts, as given in
the daily papers, indicate that Dr. Raymond was very little, if
at all, injured. The notoriety is probably, however, excessively
annoying, and can not be lessened, since he has indicated that
he must prosecute his assailant.
THE ALLEGED DISCOVERY OF A MEASLES BACILLUS.
Alluding to the alleged discovery by Dr. Canon and Dr.
Pielicke, of the Moabit Hospital, Berlin, of a specific bacillus in
the blood and various secretions of measles patients, the Lancet
expresses its hope that the announcement is not another cry of
" Wolf,11 unless it is to be the last one.
ITEMS, ETC.
The Michigan State Medical Society held its twenty-seventh annual
meeting at Flint on Thursday and Friday of this week, under the presi-
dency of Dr. George E. Ranney, of Lansing.
The New York Hospital. — Dr. Frank Hartley has been appointed a
surgeon to the hospital, to succeed Dr. Thomas M. Markoe, who recent-
ly resigned after forty years' service.
Bellevue Hospital Medical College. — Dr. A. Alexander Smith has
been appointed professor of principles and practice of medicine and
clinical medicine in place of Dr. E. G. Janeway, resigned. Dr. Her-
mann M. Biggs has been appointed professor of materia medica and
therapeutics, pathological anatomy, and clinical medicine in place of
Dr. Smith, and has been nominated attending physician to Bellevue
Hospital in place of Dr. Janeway. Dr. Henry M. Silver has been ap-
pointed demonstrator of anatomy in place of Dr. Biggs.
A Correction. — In Dr. Sachs's and Dr. Armstrong's article on Mor-
van's disease, the word " painful " in the sentence before the last on
page 486, should be painless.
Changes of Address— Dr. H. J. Boldt, to No. 51 West Fifty-second
Street; Dr. S. J. Meltzer, to No. 66 East 124th Street.
Army Intelligence. — Official List of Changes in the Stations and
Duties of Officers serving in the Medical Department, United Stales
Army, from April 17 to April 30, 1892 :
Phillips, John L., Captain and Assistant Surgeon, is granted leave of
absence for one month, to take effect on the final adjournment of
the board of officers convened by Par. 1, S. 0. 32, c. s. Headquar-
ters Department of Missouri.
De Loffre, Augustus A., Captain and Assistant Surgeon, is granted
leave of absence for fourteen days on surgeon's certificate of disa-
bility, with authority to enter the Army and Navy General Hospi-
tal, Hot Springs, Arkansas, for treatment.
Janeway, John H., Major and Surgeon, is relieved from the further
operation of so much of special orders as directs him, in addition
to his other duties, to perforin the duties of post surgeon at Frank-
ford Arsenal, Pennsylvania.
By direction of the Secretary of War, Par. 13, S. 0. 74, March 29
1892, A. G. 0., removing the suspension of the orders changing the
stations of Appel, Aaron H., Captain, and Cabell, Julian M., First
Lieutenant and Assistant Surgeon, is revoked.
Rafferty, Ogden, First Lieutenant and Assistant Surgeon, is granted
leave of absence for one month, to take effect on or about May 1
1892.
Snyder, Henry D., First Lieutenant and Assistant Surgeon, granted
leave of absence for one month and fifteen days, to take effect when
his services can be spared by his post commander.
Munday, Benjamin, Captain and Assistant Surgeon, is granted an ex-
tension of one month to leave of absence granted in S. 0. 40, Depart-
ment of Dakota, March 19, 1892. S. 0. 98, A. G. 0., April 26, 1892.
Society Meetings for the Coming Week :
Monday, May 9th : New York Academy of Medicine (Section in Gen
eral Surgery) ; New York Ophthalmologic^ Society (private) ; New-
York Medico-historical Society (private); New York Academy of
Sciences (Section in Chemistry and Technology) ; Lenox Medical and
Surgical Society (private); Boston Society for Medical Improve-
ment ; Gynaecological Society of Boston ; Burlington, Vt, Medical
and Surgical Club; Norwalk, Conn., Medical Society (private)-
Baltimore Medical Association.
Tuesday, May 10th: Nebraska State Medical Society (first day
Omaha) ; New York Medical Union (private) ; Medical Societies of
the Counties of Albany (semi-annual), Greene (annual — Cairo), and
Rensselaer, N. Y. ; Kings County, N. Y., Medical Association ; New -
ark, X. J., and Trenton (private), X. J., Medical Associations ; Cam-
den (annual — Camden), Morris (annual), and Sussex (annual) County,
X. J., Medical Societies; Norfolk, Mass., District Medical Society
(election — Hyde Park); Franklin County, Vt., Medical Association
(annual) ; Baltimore Gynaecological and Obstetrical Society.
Wednesday, May 11th: Nebraska State Medical Society (second day);
New York Surgical Society; New York Pathological Society; Metro-
politan Medical Society (private); American Microscopical Society
of the City of New York ; Medical Society of the County of Albany ;
Pittsfield, Mass., Medical Association (private) ; Franklin (annual
Greenfield), Hampshire (annual — Northampton), and Worcester
(annual — Worcester), Mass., District Medical Societies ; Philadelphia
County Medical Society.
Thursday, May 12th: Indiana State Medical Society (first day In-
dianapolis); Xebraska State Medical Society (third day) ; New York
Academy of Medicine (Section in Paediatrics) ; New York Academy
of Medicine (Section in Genito-urinary Surgery); Society of Medical
Jurisprudence and State Medicine; Brooklyn Pathological Society
Medical Society of the County of Cayuga, N. Y. ; South Boston
Mass., Medical Club (private); Pathological Society of Philadelphia.
PROCEEDINGS OF SOCIETIES.
[N. Y. Med. Jour.,
Friday, May 13th: Indiana State Medical Society (second day); York-
ville Medical Association (private); German Medical Society of
Brooklyn ; Medical Society of the Town of Saugerties, X. Y.
Saturday, May l^th : Indiana State Medical Society (third day) ; Ob-
stetrical Society of Boston (private).
|1rocccbings of Societies.
NEW YORK ACADEMY OF MEDICINE.
SECTION IN GENERAL MEDICINE.
Meeting of April 19, 1892.
Dr. A. A. Smitii in the Chair.
Anaemia; its Treatment with a New Preparation of
Iron. — Dr. Reynold W. Wilcox read a paper with this title.
(See page 512.)
Dr. George W. Weld said that the preparation was practi-
cally non-alcoholic ; the only alcohol in the syrup, so called,
was the alcohol contained in ordinary tincture of chloride of
iron, each half-ounce containing twenty drops. Regarding the
name of syrup of chloride of iron, when one came to taste it,
one would discover that it w as not a syrup in the sense of
the other syrups, which, as everybody knew, were apt to de-
range the stomach. In regard to its acidity, it was acid in re-
action, and necessarily so to hold the basic salt of the iron in
solution, for the moment any solution of iron was brought to a
neutral point there would be precipitation of the basic salt,
which in this case would be the hydrated oxide. The syrup
was not acid enough to destroy the enamel of the teeth or to
cause nausea or vomiting. Strictly speaking, there were five
ingredients in the preparation — iron, saccharine matter, alcohol,
oil of gaultheria, and an alkali used to neutralize the free hy-
drochloric acid. The oil of gaultheria and the hydrochloric
acid were present in a very small percentage. Practically, then,
there were only three ingredients — the alcohol, the iron, and
the syrup. Some six or eight years before, in experimenting
with tincture of chloride of iron, the speaker had placed a
tooth in the tincture, and, on taking it out, after three hours,
been very much surprised that the enamel was not destroyed in
the slightest degree, because he had heard a great deal about the
injurious effects of this particular preparation. He had thought
it very strange, and had concluded there must be some mistake,
but, in order to make sure, he had left it in for twenty-four
hours, and on taking it out had again found that the enamel was
not at all injured. Then his attention was called to an old ex-
periment— that of putting zinc into strong sulphuric acid, when
the zinc was not harmed in the least, but the moment water
was added there was an immediate and powerful effect of the
sulphuric acid. He then added some water to the tincture of
chloride of iron and put the tooth into it. The enamel was
entirely destroyed. [The speaker showed a number of teeth
that had been immersed in solutions of tincture of chloride
of iron of various strengths, which strikingly illustrated the de-
structive action upon the enamel.]
Dr. A. II. Elliott said that his interest in this subject was
purely from a chemical standpoint. Some six or seven years
before Dr. Weld had got him interested in his endeavors to
counteract the injurious action of tincture of chloride of iron
upon the teeth, and, in order to get a thoroughly good idea of
what he was working upon, he had made an examination of a
lot of enamel of teeth, in order to see the kind of material that
was being acted upon by tincture of chloride of iron. Then his
attention was called to the fact that acids generally acted very
rapidly upon this enamel ; in fact, as near as he could remember,
one of the first experiments of the kind had been with a five-per-
cent, solution of acetic acid — pretty good vinegar. In that case
the teeth were attacked to such an extent that about five or six
per cent, of the enamel was dissolved by this simple acid.
Other acids would destroy enamel as well, the effect varying
with the strength, provided, of course, there was no grease or
alkali on the teeth to protect them. Then Dr. Weld had called
the speaker's attention to the fact that he had concluded that he
could add Vichy water to the tincture of chloride of iron, and
thus counteract the acidity. Although this had rather amused
him as a chemist, nevertheless he bad done it, and had found out
afterward by making experiments that he could neutralize the
free hydrochloric acid in the tincture of chloride of iron by
adding bicarbonate of sodium, which Dr. Weld was practically
doing by the addition of Vichy water. By adding too much
bicarbonate of sodium the point of neutrality would be passed,
and the solution would then, of course, become distinctly alka-
line. This naturally would not do, as precipitates would be
thrown down, and the preparation he made entirely useless. It
became necessary, therefore, to add the bicarbonate of sodium
very carefully so that only the free hydrochloric acid would be
neutralized, but the solution still be acid in reaction, id order to
hold the salt of iron in suspension. The difficulty that Dr.
Weld had met with in using Vichy water, or, rather, the diffi-
culties, as there were two, had been, first, that he did not know
the strength of the tinctnre of chloride of iron, for, although
the druggists said it was made according to the United States
Pharmacopoeia, we all knew that there were variations in the
amount of the free acid. In the second place, he did not know
the strength of the Vichy water, so he could never tell just how
much Vichy water to add to the tincture of chloride of iron,
unless he had the Vichy water analyzed every time. So that
this method of counteracting the corrosive action of the tincture
of chloride of iron was not always successful, although it could
be used in a number of cases, and he did use it in that way.
The speaker had then thought that, if one could use the bi-
carbonate of sodium carefully and find out how much to add to
a stipulated amount of tincture of the chloride of iron, the
free hydrochloric acid could be neutralized, and yet the prepa-
ration still retain its acidity. This saturation point had been
found and syrup of gaultheria added. The speaker still had a
preparation of tincture of chloride of iron that had been treated
by this method several months before, and there was not the
slightest evidence of precipitation of any of the ingredients of
the solution, whereas preparations of tincture of chloride of iron
treated with Vichy water would precipitate if kept for any
length of time.
He had obtained from various places in the city a number of
samples of tincture of chloride ot iron from pharmacists who were
reliable. The actual amount of the solid chloride of iron averaged
from 8*6 to 14-7 percent.; so one could imagine what the prepa-
rations were. According to the United States Pharmacopoeia,
tincture of chloride of iron should contain about thirteen per
cent, of the dry chloride. The acid over and above that neces-
sary for the solution of the iron in it — for it must be remem-
bered that metallic iron required a certain amount of hydro-
chloric acid to clear it — averaged from nothing in one to a
sample which contained ten per cent, more than was necessary.
A sample of syrup of chloride of iron obtained in the open
market had been handed to him, and he had found no free acid
in it, but more bicarbonate of sodium than appeared to be neces-
sary. This had caused a curious chemical phenomenon to take
place in the syrup — namely, the hydrochloric acid had acted on
a portion, with the result that sodium chloride had been formed.
May 7, I892.J
BOOK NOTICES.
525
But this had resulted in this one preparation of the syrup, some-
thing that had "been entirely unlooked for, hut that added to the
efficacy of the syrup, for in this preparation there were the
bicarbonate of the sesquioxide of iron and the protocbloride of
iron — a very curious and happy outcome, from a chemical stand-
point.
[)r. J. C. Smith had used Reichert's haemoglobinometer for
several months at the same time with Gowers's, and was posi-
tive that the first-named instrument is not only more accurate
iu results, but also far easier of manipulation.
Dr. A. S. Dana spoke of a patient who, on March 2d, had
been suddenly attacked with a severe chill, followed by very
Acute pleuritic pain in the left side. At the end of two weeks
■a purulent collection broke into the bronchial tubes, and large
quantities of pus were evacuated. The patient was very much
emaciated, and his anaemic condition became extreme, with
■severe cough, profuse night-sweats, and a very irritable stomach.
He was immediately put on the use of tablespoon ful doses of
syrup of chloride of iron every four hours, and the dose was in-
creased to three tablespoonfuls, with gratifying results. The
cough was relieved to a great extent, the anaemic condition was
rapidly improving, the stomach took kindly to the iron, and the
patient was on the road to rapid recovery. He had been taking
during the preceding two weeks an amount averaging seven
ounces and a half of the syrup every twenty four hours, with-
out any stomach irritation. The speaker mentioned also the
case of a child, three months old, that had pronounced diar-
rhoea, milk passing through with the stools in an apparently un-
digested condition. The abdomen was much distended, and
there were nausea and vomiting. After using the usual reme-
dies with no apparent effect, the speaker had resorted to Weld's
syrup of chloride of iron, giving teaspoonful doses every two
hours. The improvement was marked, almost from the begin-
ning, the nausea and vomiting were checked, the tympanites
subsided, and the complexion of the child entirely changed for
the better. In a number of other cases he had had unusual suc-
cess with the same syrup.
Dr. C. E. Quimby called attention to a preparation of ozone,
and said he believed it was now possible to make a permanent
solution of ozone in a neutral menstruum.
i'looh Notices.
Diseases of the Urinary Apparatus. Phlegmasia Affections.
By John W. S. Gouley, M. D., Surgeon to Bellevue Hospi-
tal. New York : I). Appleton & Co., 1892. Pp. xiii to 342.
[Price, $1.50.]
Most of this work having appeared in the Journal during
the past six months, it will not be necessary to make any ex-
tended review of it for our readers. The old students from
Bellevue Hospital especially, with the profession in general, will
be glad to welcome Dr. Gouley 's work upon the diseases of the
urinary apparatus. It is not issued as a treatise on genito-urin-
ary diseases at large, but is chiefly concerned with the phleg-
masic affections, of which it is a good exposition, and well worth
reading.
The Medical Annual and Practitioners' Index: A Work of
Reference for Medical Practitioners, 1892. Tenth Year.
Bristol : John Wright & Co. Pp. lii to bT>7.
The yearly editions of this work have become so familiar to
the medical profession that a review, properly speaking, would
be a waste of space and time. It is pleasant to note, however,
that the editors have a progressive spirit which annually adds
new features to the work. The Dictionary of New Remedies
has been improved this year by the introduction of the chemis-
try of the new synthetic drugs and a dose table of the latest
medicinal remedies. This part of the work has been in charge
of Dr. Percy Wilde, and is thoroughly' and concisely treated.
For those who have access to few medical journals this book is
invaluable in giving the latest views and methods of treatment
of diseases, by the leaders of medical thought.
Bacteriological Diagnosis: 'Iabular Aids for Use in Practical
Work. By James Eisenberg, Ph. D., M. D., Vienna. Trans-
lated and augmented, with the Permission of the Author,
from the Second German Edition, by Norval II. Pierce
M. D., Surgeon to the Outdoor Department of Michael Reese
Hospital. Philadelphia and London: The F. A. Davis Co.
1892.
This volume considers the subject of micro-organisms in
three divisions — non-pathogenic bacteria, pathogenic bacteria,
and fungi. The first are subdivided into bacteria that liquefy
gelatin and those that do not, and the second into those that
may be cultivated outside the animal body and those that can
not. The tabulation that is followed in the ca^e of all micro-
organisms insures their description under the headings of place
found; form and arrangement; motility; growth on gelatin,
agar-agar, potatoes, and blood-serum ; temperature for the best
growth; rapidity of growth; spore formation ; aerobiosis; gas
production; gelatin reaction; and color production.
The name of the micro-organism is followed by that of its
discoverer and the title of the journal or book in which it was
originally described.
In an appendix there is a description of the technique used in
the cultivation and staining of bacteria that will be verv useful
in laboratory work.
There is no book in the English language that gives the in-
formation this does so concisely and yet comprehensively • and
it needs but to be seen to appreciate that it is the most service-
able work we have for reference and use in the bacteriological
laboratory. The translator has performed his work satisfactorily.
A Practical Manual of Diseases of the Skin. By George H.
Rohe, M. D., Professor of Materia Medica, Therapeutics, and
Hygiene, and formerly Professor of Dermatology in the Col-
lege of Physicians and Surgeons, Baltimore. Assisted hv J.
Williams Lord, A. B., M. D., Lecturer on Dermatology and
Bandaging in the College of Physicians and Surgeons, Balti-
more. Philadelphia and London: The F. A. Davis Co., 1892.
Pp. viii to 303. [No. 13 in the Physicians'1 and Students'
Ready-Reference Series.]
This little book was never intended for a systematic treatise.
It is a book for the student or the busy practitioner whose time
is too limited to allow him to go over the complete systems of
dermatology in looking up the diagnosis of an ordinary case.
Its descriptions are brief, but clear and intelligible. The chief
diagnostic points of the different diseases are made prominent,
and the most accepted methods of treating them are laid down
without any theorizing. In his list of conditions for epilation
by electrolysis the author forgets to mention the one important
factor in the case — viz., a patient's willingness to stand the pain.
The indiscriminate way in which the needlo electrode is recom-
mended to be inserted into the skin may lead some to believe
that, it is a perfectly painless procedure, but they will find out.
their error very soon. It requires considerable pride to undergo
the pain necessary for this treatment. This, with a few other
626
BOOK NOTICES. — REPORTS ON THE PROGRESS Ob MEDICINE. [N. Y. Med. Join.,
sucli irregularities, almost necessary in a work of its size, consti-
tute all there is in it to criticise. It is a thoroughly commend-
able little reference book.
Psycho- Therajieutics, or Treatment by Hypnotism and Sugges-
tion. By 0. Lloyd Tuckey, M. D., Member of the Medico-
psychological Association, etc. Third Edition, revised and
enlarged. London: Bailliere, Tindall, & Cox, 1891. [Price,
$2.]
In less than three years this work has gone through three
editions, an evidence of the interest the profession takes in this
subject and of the popularity of the volume.
The present book is larger than its predecessors, as the
author has incorporated such criticisms and reports as have
been published since the appearance of the last edition, with a
view of throwing all the light possible on the theory of psycho-
therapeutics.
While there is a strong sentiment throughout the book re-
garding the value of hypnotism as a therapeutical agent, yet it
is urged that the same discrimination should be exercised in its
application as in that of any other remedial agent; and the
frank acknowledgment of personal failures, as well as the
reference to those reported by others, shows the fairness and
impartiality with which the subject is considered.
The volume is commended to any one desiring a satisfactory
work on hypnotism.
Leu tumeurs de la vexsie. Par J. Ai.bakkan, Chef de elinique
des maladies des voies urinaires a la Faculte de medeeine de
Paris (hopital Xecker). 75 figures et 9 planches. Paris : G.
Steinheil, 1892. [Prix, 18 francs.]
Professor Guyon prefaces this work with a reference to the
fact that tumors of the bladder have virtually been scientifically
studied only during the past fifteen years, and remarks that the
accumulation of material, the discoveries in pathology, and es-
pecially the advent of cystoscopy, have made a new history of
the subject desirable. The fact that the author was his u>so-
ciate for four consecutive yrears is a sufficient guarantee of the
character of the material that he has had access to.
The history of the subject is divided into the ancient, up to
187-i, when Billroth proposed the hypogastric incision for the
removal of vesical neoplasms; and the modern, subsequent to
that date. After considering the structure and development of
the normal mucous membrane of the bladder, the subject of
classification is presented. Tumors are divided into primary, or
those originating in the bladder, and secondary, or those devel-
oping by propagation from contiguous structures or by generali-
zation.
The primary tumors are subdivided into those of the epi-
thelial, those of the connective, and those of the muscular tis-
sue, following Bard's theory of cellular specificity.
The tumors originating trom the epithelium are subdivided
into an atavic group, of an allantoidian type, in which the epi-
thelial cells resemble those of the intestine of allantoidian origin
and the epithelium of the villosities of the chorion ; a vesical
adult group that is subdivided into a variety having a common
epithelial layer, one having an epithelial layer in which the
polygonal cells have a large nucleus surrounded by clear proto-
plasm, and one of a glandular type; and epithelioma, including
the lobulated or tubulated, cylindroma, carcinoid and reticulated
growths, and myo-epithelioma.
Tumors originating from the connective tissue are divided
into an atavic group, including sarcoma, myxoma, and fibro-
myxoma; and an adult group, fibroma. As an adjunct to the
connective-tissue tumors, we have angeioma.
The muscular tissue tumors include the myomata, while the
heterotopic tumors embrace dermoid cysts, dermoid or horny
epithelioma, chondroma, and rhabdomyoma. As an adjunct to
this group there is the hydatid cyst.
The pathological anatomy is clearly described and the text
is illustrated by colored woodcuts. The a'tiology, pathgeny,
and symptomatology are well described.
The cystoscopes of Nitze and Leiter, the megaloscope of
Boisseau du Kocher, the urethro-cystoscope of Grunfeld. and the
panelectroscope are described, and their advantages and disad-
vantages properly portrayed. The chapter on diagnosis is very
comprehensive. Under the head of treatment the various
operations for opening the bladder are mentioned, the question
of suture is considered, and sections are devoted to resection and
total extirpation of the bladder. There is a table of two hun-
dred and twenty collected cases.
The volume is well printed, and, besides the illustrations in
the text, there are nine large phototypes of cystic tumors. The
work is a valuable contribution to the literature of an impor-
tant subject.
licports on tbc progress of Hleuirinc.
GENERAL SURGERY.
By MATTHIAS L. FOSTER, M. D.
What is a " Felon " 1— Burrell (Box/. M< </. and Surg. -lour.. Feb. 4.
1892) is convinced that the term " felon " is very loosely applied to a
variety of inflammatory diseases of the finger, and suggests that this term
should be abolished mid an anatomical classification of the inflammatory
affections of the finger be adopted. The classification he proposes is :
1, dermatitis; 2, paronychia; 3, cellulitis of the finger; 4, suppurative
thecitis ; 5, periosteitis or osteitis of the phalanges. While he feels
sure that most practitioners distinguish these various affections, he
maintains that the distinction is frequently not made in name, and that the
common text-books on surgery neglect to clinically distinguish them.
The treatment of these various conditions differs. Dermatitis requires
local applications ; paronychia, an incision through the nail or its removal,
with a proper dressing afterward ; cellulitis, a limited incision into the
pulp of the finger with evacuation of the pus ; suppurative thecitis, an
incision through the sheath of the tendon, evacuation of the pus, anti-
sepsis, and immobilization of the fingers, hand, and arm ; periosteitis or
osteitis, an incision down through the periosteum at the earliest moment.
These affections run into one another, and it is at times impossible to
make a clear distinction between them, but the distinction is needed, for
an incision down to the periosteum is worse than useless in dermatitis,
and not necessary in any except in periosteitis or osteitis where such an
incision is imperatively demanded.
Symmetrical Congenital Defects in the Anterior Pillars of the
Fauces. — Toeplitz reports (Arch, of Ofol., January, 1892) the observa-
tion of two symmetrical openings in the palato-glossal arches of a young
man, the right one being slightly larger and somewhat more remote from
the margin of the anterior pillar. The margins of the openings were
smooth, without a trace of cicatrization. They were elliptical in form,
about half an inch long by three sixteenths of an inch wide, and led
from the cavity of the mouth into the space usually occupied by the ton-
sils, which in this case were absent. More marked on the right side
than on the left, a quarter of an inch below the margin of the opening,
was a slight indication of what might be considered a radiated scar, but
to the observer it rather resembled radiated folds. Dr. Toeplitz state:-
that he has been able to find very few similar cases recorded in the lit-
erature of the subject.
Acute Orchitis following Influenza. — The latest addition to the mul-
titudinous sequeke attributed to influenza is made by Harris (Lancet,
Jan. 2, 1892) in the form of acute orchitis. The patient, aged sixty-
seven, came under treatment complaining of " pains all over," especially
in the back, head, and back of eyes, slight cough, temperature 103-2°,
May 7, 1892.]
REPORTS ON THE PROGRESS OF MEDICINE.
527
pulse 120, tongue slightly furred, bowels open. Five days later he com-
plained of pain, tenderness, heat, swelling, and redness of the left tes-
ticle. This occurred during an epidemic of influenza. The patient had
not left his bed and had no trouble with his urine, and there appeared
to be nothing to account for the inflammation of the testicle except the
theory that it was a sequela to that disease. Briscoe (ibid., Jan. 23,
1892) reports a similar case.
Intussusception. — Barker (Lancet, Jan. 9, 1892) suggests the follow-
ing procedure in cases of intussusception which can not be reached from
below, and which are found, on opening the abdomen, to be so tightly
strangulated that reduction, even if feasible, could end only in disaster,
instead of forming an artificial anus or resecting the whole mass of dam-
aged bowel directly and suturing the divided ends together :
" At the point at which the intussuscipiens receives the intussuscep-
tum the two portions of the bowel are at once united by a continuous
circular suture of fine silk taking up the serous and muscular coats of
each, and carried on to the mesentery. A longitudinal incision is then
made for about two inches through all the coats of the intussuscipiens
on its free margin. This gives access to the sausage-like intussuscep-
tum within. The latter is then drawn out through this incision and is
cut across close to its upper end ; or, if too long to be first drawn out,
it may be cut across in situ. A few stout silk sutures are, however,
passed through all the walls of the stump as the mass is gradually cut
off, and are tied tightly so as to keep the serous surfaces in contact and
control all bleeding from the vessels entering it at its mesenteric attach-
ment. The stump is now cleansed, dried, and dusted with iodoform,
and is allowed to drop back through the incision into the lumen of the
intussuscipiens. Then the longitudinal incision in the latter is closed
by a continuous suture from end to end. Toilet of the surrounding parts
and closure of the abdominal wound complete the operation."
Mr. Barker has performed this operation twice, each time on a pa-
tient in a desperate condition, and in neither case did the operation avert
a fatal residt. Nevertheless, he professes to have demonstrated that the
operation is quite feasible, that it can be performed in a reasonable time
and without much difficulty, and that he is impressed with the feeling
that, under less unfavorable conditions and with an increased experience
of details, this method will prove very successful.
Anthrax successfully treated by Excision of the Pustule. — Lowe
(Lancet, Jan. 23, 1892) reports two cases in which excision of the
focus of inoculation arrested the progress of anthrax. In one the pust-
ule was situated on the neck, in the other on the cheek. It seems
strange that such an operation should cheek the disease, but one fact
is established — viz. : that theoretical considerations should never deter
any one from operating, not only during the early stages, but at what-
ever period of the disease the cases present themselves.
Suprapubic Dislocation of the Head of the Femur. — Nash reports
(ibid.) a very unusual and remarkable form of dislocation, of the head
of the femur which differed very materially from the ordinary pubic
dislocation, in which the head of the bone lies on the pubic bone or
beneath the anterior-inferior spine of the ilium.
A boy, eleven years of age, was running behind and pushing a
swinging boat when he slipped under it. On its return the boat struck
his right knee, dislocating the hip. On admission to the hospital there
was a contusion over the front of the right knee. The right leg was
everted, abducted, and shortened to the extent of two inches and a half
or three inches. The head of the bone could be seen and felt lying
half way between the umbilicus and Poupart's ligament. Both tro-
chanters could easily be felt on rotating the limb. There was consider-
able effusion into the soft tissues around the joint. The femoral artery
could be felt pulsating on the inner side of the small trochanter.
Methylene was given and reduction attempted by means of pulleys and
manipulation, but the head of the bone could not by any means be
brought below the pelvic brim. The patient was then put into bed w ith
an extension applied ; an attack of acute rheumatism supervened, so that
over two months elapsed before an operation could be performed. Then
methylene was given and an incision was made down to the neck of the
femur, the head was exposed, and all the ligamentous and muscular
attachments to the neck and great trochanter divided. The tip of the
great trochanter was found to be separated and a large amount of peri-
osteum Stripped off the back of the femur. Connecting the shaft with
the acetabulum was a mass of bone formed by the periosteum which
had been stripped off. The head of the bone was resected, as traction .
still failed to effect reduction. Six months later the hip was quite
stiff and there was about two inches of shortening present.
Mr. Nash states that he has not been able to find any record of a
similar dislocation.
Echinococcus of the Orbit. — Olga A. Mashkovtzeva (Med. Obozrenie;
Brit. Med. Jour., January 23, 1892) relates the of ;i pale and very
emaciated Tartar girl, two years of age, who was brought to her on ac-
count of eve disease of three months' standing. The affection had
been steadily growing worse, the child becoming ever more restless,
fretful, and sleepless. There was very marked exopthalmia of the
right eye, with swelling of the eyelids, oedema, and congestion of the
ocular conjunctiva ; the globe was dislocated forward and inward, was
immovably fixed, atrophied, and degenerated; and the cornea was rep-
resented solely by a grayish spot of the size of a lentil. The whole ex-
ternal portion of the orbit was filled with an immovable tumor, homo-
geneous in its consistence, and indistinctly fluctuating. A malignant
neoplasm, growing from either the eyeball or the optic nerve, was sus-
.pected and the eye was extirpated. The child bore the operation well,
and her general condition rapidly improved. The tumor was found to
be an echinococcus cyst of the size of a small hen's egg, containing
booklets, but no secondary cysts, and occupying the site of the ex-
ternal rectus, the lacrymal gland, and the adjacent cellular tissue, all of
which were entirely absent. The hydatid was surrounded by a dense
fibrous capsule. The whole eyeball was transformed into an equally
dense pigmented mass.
Pneumonotomy and Pneumonectomy. — Willard (Univ. Med. Mag.,
February, 1892) has been conducting some experiments on dogs re-
garding these operations, which he reports, together with a digest of
the literature on the subject, and presents the following conclusions :
His experiments in thoracotomy and in bronchotomy show that the
entrance of air into the pleural cavity is a far more serious matter as
regards the collapse of the lung and of the patient when the lung tissue
is normal than when it is diseased or already crippled.
Incision into the substance of the lung with removal of a portion is
well borne in dogs. Haemorrhage, though free, is not fatal, and can be
arrested by packing.
Adhesion of the parietal and visceral layers can readily be obtained
by sutures, and the resulting pleurisy is slight.
Surgically, these experiments point out that similar adhesive inflam-
mation can be secured and thus permit safe incision into tubercular or
other diseased lung tissue without infection of the pleural cavity.
A lung can be drawn into the wound made by excision of the ribs
and so sutured to the edges of the opening that the pleural cavity can
be excluded.
Pneumonectomy, performed for gangrene or for abscess of the lung,
otters better results than is possible in cases not treated surgically.
Abscess of the Brain from Aural Disease. — Korner (Arch. f. Ohren-
heilkwn.de ; Ctrlbl.f. Chir., 1892, No. 3) arrives at the following conclu-
sions, after a consideration of the reports of a hundred cases of intra-
cranial abscess due to aural disease, nine operations, and ninety-one
autopsies :
1. Abscess of the cerebrum was found in sixty-two cases, of the
cerebellum in thirty-two, in both at the same time in six. Children
under ten years of age seldom suffer from cerebellar abscess, on ac-
count of the great distance of the posterior fossa of the skull from the
auditory meatus. Men are about twice as liable to abscess of the brain
as women. The right side is affected more frequently than the left.
2. Regarding the extension of the disease from the temporal bone
to the brain, he concludes that, contrary to the generally received opin-
ion, in a very large portion of the abscesses of the brain which result
from suppurative otitis and develop near the seat of the primary lesion
a demonstrable continuity with the same can lie found. Therefor.', in
order to avoid later trouble after an apparently brilliant residt, besides
emptying the abscess, the diseased bone should be sought and removed.
3. Abscesses of the brain dependent on disease of the petrous bone
lie in the immediately neighboring portions of the brain, in the temporal
lobe, or in the half of the cerebellum on the same side. In seven of the
hundred cases this seemed to be contradicted, ami Korner acknowledges
528
MISCELLANY.
[N. Y. Med. Joub.,
it to he not proved, for to prove it it would be necessary to have data
regarding each case, showing that a disease of the temporal hone was
present, which could cause abscess of the brain, that no pyaemia was
present, and excluding any general tuberculosis or suppurative inflam-
mation of the air passages.
4. The information in regard to incapsulation and quality of the
pus was deficient. In one case the odorless condition of an abscess
which resulted from a foetid otitis was mentioned.
5. As complications, thrombosis of the venous sinus was found sev-
enteen times on the right side, five times on the left ; in the ninety-one
autopsies, suppurative meningitis was found seventeen times, rupture
into the lateral ventricle ten times, into the fourth ventricle once. The
frequency of the complications does not permit the conclusion that
these abscesses were inoperable in their early stages.
ti. In regard to the diagnosis between otitic abscesses in the tempo-
ral lobe and the cerebellum these points must be borne in mind: 1, Tin-
age: cerebral abscesses are three times as frequent as cerebellar in
children under ten ; 2, the seat of the primary bone lesion ; 3, labyrinth
disease does not certainly indicate cerebellar abscess; 4, location of
painful area by percussion; 5, pain, vertigo, and optic neuritis are un-
certain signs ; 6, disturbances of speech occur only in cerebral affec-
tions, but are seldom met with on account of the preponderance of
right-sided abscesses.
Surgical Treatment of the Gall-bladder. — Ignatow (Chirurgit-
tcheski Westnik ; Qtrtbl.f. Chir., 1892, No. 9), after an extensive con-
sideration of this subject, draws the following conclusions :
Operative interference is always indicated by intense pain associated
with symptoms more or less plain of closure of the ductus cysticus or
eholedochus.
Cholecystotomy must be considered the typical operation, because it
has the greatest range of application.
The so-called normal cholecystotomy is attended with the least
mortality.
In all obscure cases, where the walls of the gall-bladder have under-
gone more or less marked pathological changes, especially in cholecysti-
tis ulcerosa and empyema of the gall-bladder, normal cholecystotomy is
indicated as the least dangerous operation.
Cholecystectomy can not be recognized as a radical treatment for
gall stone, and is, therefore, to be confined to cases of malignant disease
of the walls of the gall-bladder, and cases of impassable stricture of the
ductus cysticus.
The so-called ideal cholecystotomy is indicated in recent cases with
only slight changes in the walls of the gall-bladder.
Choleeystenterostomy is the only applicable operation, and in many
cases, in the absence of malignant growths, a radical one, for the cure
of unremovable stricture of the ductus eholedochus.
Intestinal Occlusion. — Pernice (Riforma med. ; Deutsche med.
Zeitwng, Jan. 25, 1892) has conducted a series of experiments on dogs,
in which he completely occluded the intestinal canal at various points.
The following is a partial resume of his results:
Death resulted from stenosis of the duodenum in from four to six
days, and from stenosis of the ileum in about ten days.
The only positive diagnosis that can be made with regard to locality-
is between stenosis of the large and of the small intestine.
The symptoms of stenosis of the small intestine are about the same
as those of stenosis of the pylorus, but they become less marked the
greater the distance of the obstruction from the stomach. These symp-
toms are dejection, aversion to food, thirst, vomiting, which occurred from
half an hour to two hours after ingestion into the stomach, and sometimes
without tin-, particularly of bile, and especially severe in stenosis of the
duodenum, rapid and weak pulse, subnormal temperature, emaciation,
constipation, and lessened excretion of urine, rarely anuria. In the
urine, indican was always present, sometimes bile pigment was found,
rarely traces of albumin, once signs of spermatorrhoea. The changes in
the blood consisted of a considerable increase of the red and white
blood-corpuscles with increase of haemoglobin during the first few days,
and then a gradual decrease until death.
In stenosis of the lower colon, constipation and tenesmus were con-
stant, rarely associated with vomiting. The animals remained lively
and took nourishment. Their weight diminished but slightly, there
were no changes in pulse or temperature, while in the blood only an in-
crease in the white and a Btight decrease in the red blood-corpuscle- wof
observed.
After death the principal anatomical changes found were emacia-
tion, dryness of the tissues, enlargement of the alimentary canal above
the obstruction with atrophy of the part below, great hyperamia of the
liver, and thrombosis of the veins, also haemorrhages by diapedesis, a
thickened condition of the circumportal connective tissue, atrophy of the
liver cells, formation of pigment, sometimes biliary engorgement, fatty
degeneration of the cells, and atrophy of the acini.
P i s c c 1 1 a n p .
The Physiology and Pathology of the Mammalian Heart. — In the
I'riieeediiu/s of (lie Royal Society, No. 31 Hi, Dr. C. S. Roy and Mr. J. G.
Adami, of the University of Cambridge, give the following abstract of
a communication of theirs :
Our communication begins by stating that we have sought to study
the action of the mammalian heart in conditions (unexcised and intact)
as nearly approaching the normal as we were able to make compatible
with the employment of exact methods of research. This is followed
by a general consideration of the difficulties attendant upon such a
Study, and of the means by which these difficulties may be overcome.
Under the heading of Methods we describe a cardiometer which we
employed to measure the contraction volume and the "output," as well
as the changes in the volume of the heart other than those due to its
rhythmic contractions and expansions. A description is also given of
the method of employing it, together with a statement as to the degree
of the accuracy with which, according to our experience, the instru-
ment supplies information regarding the changes in the volume of the
heart. We then describe an automatic counter, which we emploved for
measuring out and recording the output of the heart, as obtained by the
cardiometer.
This is followed by a description of our myoca rdioyraph, which we
made use of to record the contractions and expansions of any part or
parts of the ventricular and auricular walls without interfering with the
movements of the heart. In most cases we employed this instrument
to obtain simultaneous records of the contractions of one auricle and
one ventricle. We state also our doubts as to the value of observations
made on the heart by " button " cardiographs.
Section III begins by a consideration of the relationship between
the circumference of a hollow spherical muscle and its cubic contents,
this being illustrated by a diagram, and by one or two concrete ex-
amples with regard to the bearing of this subject upon the physiology
of the ventricles.
We then state the relation between the internal circumference of a
hollow spherical muscle and the resistance to contraction of its walls.
Reference is also made to the elastic resistance which the heart wall
itself offers to contraction, and the bearing of this upon the production
of negative pressure within its cavity under certain conditions.
We then consider briefly the effect on the ventricular contractions
of changes in the blood pressure within the systemic and pulmonary
arteries, pointing out how much the heart has in common with the
voluntary muscles of the body, and explaining why the amount of
residual blood is liable to changes, concluding with a few remarks upon
" failure of the heart."
In Section IV we enter upon a study of the effects of the vagus
nerve upon the heart. We begin with the changes in the contraction
volume, and point out that, at first sight, our curves seem to show that,
other things being equal, the volume of blood expelled at each systole
varies in inverse ratio to the rapidity of heart beat. We show, how-
ever, that this general law does not hold good for vagus slowing (if,
indeed, it be exact for slowing of any kind), which is found to he ac-
companied by a lowering of the output ; that, with moderate slowing,
this diminution of the output may be as much as thirty or thirty-five
per cent.
May 7, 1892.]
MISCELLANY.
529
We then speak of the increase in the amount of residual blood in
the heart which is produced by vagus excitation, showing that this
docs not necessarily indicate any weakening of the ventricular con-
tractions.
We next analyze myocardiographic records of the action of the
vagus upon the heart, showing that the auricular contractions are
weakened or arrested, and noting that the influence of the vagus upon
the force of the auricular contractions bears no constant proportion to
the vagus slowing. By strong vagus excitation or by muscarin the
auricles may be completely arrested, it may be, for hours. This com-
plete arrest is, in some cases, led up to by progressive weakening, but
sometimes arrest occurs immediately after fairly strong beats, or with
fairly strong beats presenting themselves at times during the arrest.
These latter cases may be explained by weakening of the excitations
which reach the auricles from the sinus, although they are possibly due
to diminished excitability of the auricles.
On coming to the effect of the vagi upon the ventricles we find that
the distention of the heart during vagus actions is due to the ventri-
cles being more expanded, both in diastole and in systole. We point
out that the increased volume of the heart at the end of systole is a
necessary result of the increased contraction volume, and combat the
conclusions of those who ascribe it to weakening of the ventricular
contractions, pointing out that the greatly increased contraction vol-
ume increases to a corresponding extent the work done at each con-
traction. We give detailed reasons for concluding that this suffices to
explain the apparent diminution of the ventricular contractions.
We then examine the influence of the vagus upon the tonus of the
relaxed ventricles, and point out that the great distention during vagus
action is due entirely to increased intraventricular pressure during dias-
tole, and not, as has been asserted by some, to any change in the elas-
ticity of the relaxed ventricular wall.
Next, we consider the cause of the rise of venous (systemic and
pulmonary) pressure, and find that this is due not to any increase in
the amount of blood entering the veins in a given time or to contrac-
tion of their walls, but that it is to be ascribed to the diminished in-
flow into the ventricles.
The cause of this diminished inflow into the ventricles leading to
corresponding diminution of the output is twofold — namely, weaken-
ing or arrest of the auricles, and, secondly, the elastic resistance of the
ventricular wall to distention. We show that this explanation must
apply to both sides of the heart, and that observed facts correspond
with it.
We then consider the after-effects of vagus excitation, and show
that the temporary increase in the output which is sometimes present
may be explained by a temporary increase in the force of the auricular
contractions, and by the venous pressure taking some little time to fall
after the vagus excitation has ceased.
After this, we examine the influence of the vagus upon the heart
rhythm, and show that, when the vagus excitation reaches a certain
degree (varying in different animals), the ventricles begin to beat inde-
pendently of the sinus and auricles ; that this rhythm, which is at first
slow and irregular, gradually becomes fairly rapid and almost com-
pletely regular.
This rhythm, we show, must be looked upon as the same as that
which, as Wooldridge and Tigerstedt observed, makes its appearance
when the ventricles are severed from the auricles. We point out,
however, that the independent ventricular rhythm of vagus action is
characterized by the slowness with which it establishes itself.
This characteristic is due to the lowering of the excitability of the
ventricles produced by vagus action, and we adduce a considerable
number of facts showing that the vagus does lower the excitability of
the ventricles, and that, by means of muscarin and by discontinuous
stimulation of the vagus, it is possible to isolate the influence of the
vagus on the rhythm and force of the auricles from its influence upon
the excitability of the ventricles. The power of the vagus to stop the
ventricles temporarily can only be explained by this diminution of
their excitability.
We show that, with a certain degree of vagus excitation, irregu-
larity of the ventricles necessarily results, in consequence of the sinus
and the ideo- ventricular rhythms interfering with one another; that
this is the common cause of irregularity ; and that irregularity may also
be caused by the auricles not responding to all the impulses which
reach them from the sinus.
We explain that, in rare instances, direct excitation of the vagus
may so lower the excitability of the ventricle that the contractions may
not extend over the whole of their walls, and may in this way produce
the apparent weakening which is sometimes met with.
In Section V we pass on to study the effect of direct excitation of
the nervi augmenlores (accelerantes) upon the heart, and show that
the acceleration of the rhythm may be extremely slight if the heart be
beating fast, and that the acceleration and augmentation of force of
the heart bear no constant proportion to one another. The aug-
mentor nerves increase the diastolic expansion of the auricles and also
increase their systolic contraction ; but these two effects do not go hand
in hand.
Excitation of the augmentors increases the output of the heart,
owing to the increased force and frequence of the auricular contrac-
tions, the result of this being that the pressures in the systemic
and pulmonary arteries rise, while the systemic and pulmonary venous
pressures fall. If there be but little quickening, the contraction vol-
ume of the ventricles is increased.
The augmentors, on direct stimulation, cause a slight increase in
the diastolic expansion of the ventricles, which is passive in nature and
due to the increased force of the auricular contraction. The force of
the ventricular contractions is increased ; they contract more com-
pletely, diminishing the amount of residual blood, in spite of the fact
that the arterial pressure is usually somewhat raised.
There are certain nerve fibers other than the nervi ani/mentores
proper which pass from the stellate ganglion to the heart, sometimes
by the annulus of Yieussens to the inferior cervical ganglion, but some-
times as separate branches passing directly to the heart from the
ganglion stellatum or the annulus. On peripheral excitation of the cut
nerves there is marked weakening of the contractions, both of the
auricles and of the ventricles, usually with some degree of slowing,
this being sometimes followed on cessation of the excitation by a very
well marked increase in the force and frequence of the auricular and
ventricular contractions. They may be vaso-constrictors for the coro-
nary vessels, although we give no proof of this.
There are nerve fibers which descend to the heart by the vago-sym-
pathetics, which, on excitation under certain conditions, increase the
force and frequence of beat of the auricles and ventricles, and which
may be vaso-dilators for the coronary vessels.
Reflex excitation of the vagus produces results which are the same
as those of direct excitation of the nerve, and the curves are more
typical and satisfactory than those obtained on direct excitation of the
nerve.
Excitation of a mixed nerve like the sciatic usually produces effects
on the heart similar in kind to those due to direct excitation of the
augmentors, but the phenomena are complicated by the greater rise of
the pressure in the systemic arteries. Sometimes the increase in force
of the ventricle more than counterbalances this increased resistance to
contraction, and the amount of residual blood in the left ventricle is re-
duced ; in other cases the increase in force of the ventricular contrac-
tions is not sufficient to counterbalance the increased resistance, and
the residual blood in the left ventricle is increased.
In Section IX we show that excitation of the central end of a mixed
nerve like the sciatic or splanchnic usually affects both the augmentor
and vagus centers in the medulla, and that, in nearly all cases, the aug-
mentor center is the more strongly excited of the two, so that aug-
mentor effects show themselves during the excitation, but are succeeded
by vagus action on ceasing to excite the nerve. In many cases aug-
mentor effects alone show themselves. When excited reflexly the aug-
mentor center ceases to act earlier than the vagus; the opposite, there-
fore, to what takes place with direct excitation. In rare cases the ex-
citation of the vagus center may be stronger than that of the augmentor
from the first. Although, in the absence of any augmentor action, the
vagus does not reduce the force of the ventricular systole, it does un-
mistakably have the power of inhibiting the strengthening influence
which the augmentors exert upon the ventricular contractions.
In Section X, upon the part played by the vagus in the economy, we
530
MIS<' ELLA NY.
[N. Y. Med. Jocib.,
show that vagus excitation relieves the heart of w irk, an 1 therefore of
waste, to as great an extent as is compatible with a continuation of the
circulation, and conclude that the vagus acts as a protective nerve to
the heart, reducing the work thrown upon that organ when from fatigue
or other cause such relief is required by it. The presence of fibers in
the sciatic and other mixed nerves which cause reflex excitation of the
vagus would seem to indicate that this nerve may be used by other
parts of the body to diminish the output of the heart ami lower the
blood-pressure, thereby reducing the activity of the circulation as a
whole. The influence of the blood-pressure in the systemic arteries on
the degree of vagus activity and the readiness with which the vagus
center is called into play by raising the intercranial pressure indicate
that the vagus mechanism is specially employed in lowering the circula-
tion so as to limit cerebral congestion. The vagus acts chiefly in the
interests of the heart and central nervous system.
The power of the vagus over the heart is limited, and the ideo-ven-
tricular mechanism, which comes into play when the vagus action ex-
ceeds a certain limit, must be looked upon as the means by which arrest
of the circulation and death is prevented, whenever from any cause the
nerve exerts a maximum influence. The power of the vagus to lower
the excitability of the ventricles makes their temporary arrest possible,
but this reduction of the excitability of the ventricles can not be kept
up, no matter how strong the stimuli applied to the nerve, for a period
long enough to endanger the economy.
In Section XI we show that the function of the augmentor in the
economy is to increase the work and tissue waste of the heart as part
of the mechanism by which the nervous system governs the circulation,
and that the augmentor mechanism sacrifices the heart in order to in-
crease the output of the organ and enable the ventricles to pump out
their contents against a heightened arterial pressure. Such excessive
action of the heart is limited by the vagus, which, as we have seen,
readily steps in so soon as the call for an increased supply of blood has
ceased. It may do so earlier, presumably because the increased blood-
pressure or the fatigue of the heart calls for vagus intervention.
In Section XII we consider the mode of interaction of the vagi and
augmentores; we point out that when the vagi are paralyzed by section
or atropine the augmentores have no control over the cardiac rhythm,
and that therefore they can only act by inhibiting the influence of the
vagi on the rhythmic center of the heart. When neither nerve is acting
on the auricles they contract with a certain force, which is increased by
the augmentores and diminished or inhibited by the vagi. The force
of the ventricular contractions is increased by augmentor action : this
increase can be inhibited by vagus excitation, which latter has other-
wise no power to reduce the strength of ventricular contractions.
The force of the heart's contractions is influenced by other factors
than the vagi, augmentores, and other nerves. The pressure of the
blood in the coronary arteries is one of the most important of these
factors. If this be lowered, the contractions of both auricles and ven-
tricles diminish in strength, while a rise of pressure in the systemic
arteries causes an increase in the force of the heart's contractions, so
that the force of the heart's contractions is to a certain extent regu-
lated automatically by changes in the blood-pressure in the aorta, which
is one of the variable quantities affecting the work of the left ventricle.
Change of the volume of blood in the body affects greatly the con-
traction volume and output of the heart. Injections into the veins of
a volume of detibrinated blood equal to one tenth of the total blood in
the body may double the output. It is important to note here that there
is no increase in the strength of the ventricular contractions ; increase
in the work, therefore, of the ventricles due to increase in the output
has no tendency to automatically increase the force of the ventricular
contractions, as is the case with rise of pressure in the systemic arteries.
We refer to the bearing of this in cases of plethora.
Increase of the watery constituents of the blood increases the con-
traction volume and output to the same extent (though only tempo-
rarily) as does transfusion of blood, but acts more unfavorably on the
heart, seeing that the work done by the ventricles is increased, while
the nutritive value of the blood supplied to the coronaries is dimin-
ished.
The increased output of the heart both in plethora and in hydnemia
js due to rise of pressure in the systemic veins increasing the volume
of blood which enters the right ventricle during diastole. We refer to
the bearing of these facts upon the treatment of chlorosis and heart dis-
ease.
In Section XIV we consider the limits of the power of the heart to
perform the work thrown upon it, and show that in strictly physiologi-
cal conditions, and in spite of the beautiful mechanism by which the
force of the ventricular contraction is regulated, the heart, like the
voluntary muscles of the body, is liable to fatigue when the work
thrown upon it greatly exceeds that required to maintain the circula-
tion under ordinary circumstances. We take as example the increased
work thrown upon the organ during active muscular exertion, and show
thai exertion and endurance of fatigue are limited mainly by the lim-
ited power of the heart to continue supplying the increased amount of
blood which is required by the acting voluntary muscles. We show
that those luxuries which arc forbidden or limited in " training," and
which are known to hinder prolonged exertion — such as water, alcohol,
tobacco, caffeine — all directly weaken the force of the heart's contrac-
tions, anil, in the case of water, place the organ under a disadvantage ;
also that fatigue of the heart leads to dilatation of the organ.
On comparing the power of fatigued ventricles to carry on increased
work, as compared with well-nourished unfatigued ventricles, it is found
that not only is the strengthening effect of the augmentor nerves upon
the individual contractions less in the former case, but also that, the
fatigued and therefore dilated heart is per se unfavorably placed for
meeting increase in the work thrown upon it. An explanation is given
of the reason why in heart disease failure takes place during exertion.
The part played by the vagus in protecting the diseased heart from
harmful overwork is referred to, and it is shown that irregularity of
the heart in disease may be explained by the mode in which this nerve,
when acting powerfully, releases the ventricles from the control of the
rhythmic center in the sinus. The chief forms of rhythmic and arryth-
mic irregularity are considered, and it is shown that these correspond
with the forms of irregularity which can lie produced by vagus action.
The irregular heart expends more energy, and its tissues thetefore are
more wasted, for a given amount of work than the heart which is beat-
ing regularly.
The effect upon the heart of imperfect aeration of the blood is, first
of all, to produce powerful vagus action from the medullary center ;
this is usually, though not always, accompanied in curarized animals by
diminution of the output of the heart. But reasons are given for as-
suming that the output would be increased in uncurarized animals,
owing to the high venous pressure which results from struggling. Be-
sides the vagus action, it can be shown that asphyxia causes progressive
weakening both of the auricles and of the ventricles, and attention is
drawn to the fact that the considerable rise of pressure in the systemic
arteries in asphyxia is accompanied by vagus effect? upon the heart, and
not by augmentor action, as is the ease, so far as we know, in all other
instances in which the vaso-constrictor center is excited in the normal
individual.
It is noted that the change in the heart and circulation which takes
place during asphyxia points to the conclusion that, when the total
amount of oxygen in the blood is lowered, it is for the benefit of the
economy that those organs, such as the central nervous system, whose
continuous blood supply is a vital necessity, should be richly furnished
with blood by constriction of the vessels of the spleen, kidney, and di-
gestive system, whose blood supply can be cut off temporarily without
danger to life, and also that the heart should carry on the circulation
in a manner involving as little waste as possible of its own substance.
This, as we have seen, is the function of the vagus nerve to bring
about.
Epidemic Neuroparesis is the name given by Dr. B. W. Richardson,
of London (Asclepind, ix, 33), to influenza. In all essentials, he says,
the svmptoms start from a catarrh, and are attended, as might be ex-
pected from their rapidity, with more or less of febrile disturbance.
They are, in brief, symptoms of a neuroparesis, w ith pyrexia.
From the first the symptoms are nervous in character. The pain,
the heaviness of spirit, the languor, are all characteristic of organic nerv-
ous shock. The local symptoms in the pulmonary organs are of the
same type. The dullness preceding crepitation ; the irregular extension
May 7, 1892. J
MISCELLANY.
531
of the pulmonary lesions, in patches, over the lung ; the invasion of
both lungs at "different points ; and, in some instances, the sudden con-
gestion of the structure of both pulmonary organs — these signs all point
to nervous failure as distinct from acute sthenic pneumonia, as we com-
monly understand that affection. The character of the expectoration
also is special. The well-known rusty expectoration of ordinary pneu-
monia is not presented in distinctive manner, nor does the urine follow
the same changes in relation to the chlorides. There is also another
condition which markedly distinguishes the pneumonic paresis from the
specific sthenic inflammatory pneumonia — I mean the quickness of the
changes, not only from bad to worse, but from bad to recovery. I was
called to a patient late one night in consequence of the danger arising
from a sudden and extreme congestion of both lungs, from their bases
to a point three inches above the apex of each scapula. The resistance
to the circulation was extreme, and under the resistance the febrile ex-
citement was considerable, while, from the imperfect aeration of the
blood, the cerebral oxidation was vehemently disturbed. It seemed as
if death were inevitable, and so it would have been if the commanding
influence had continued to exert its sway ; a few hours, in fact, would
have been sufficient to bring life to an end. It was like a process of
rapid destruction of respiratory function. But twenty-four hours later
all the general symptoms were relieved in the fullest degree, and the
respiratory murmur was so clear that, if my own ear had not heard the
difference, I fear I should have distrusted the evidence that might have
been brought before me in regard to the modification that took place in
so short a period. This was a rather extreme case, and I doubt not that
during the late widespread epidemic multitudes like it in the way of
rapid intensity of symptoms and comparative rapidity of relief — leaps
into and out of danger from pulmonary lesion — have been observed.
But this is not the feature of ordinary sthenic pneumonia. It is the
feature of a sudden paresis from some temporary nervous shock and
nervous failure.
There has been another peculiarity in this epidemic relating to the
bronchial complication and the bronchial discharge. There has usually
been some excess of bronchial secretion in advanced stages of the affec-
tion, but not of secretion of the same tenacious character, and in the
same excess, as in common broncho-pneumonia. Hydrops bronehialis
has not, in my observation, been a prevailing cause of death, neither has
it been, except actually in articulo, a troublesome symptom. The term
" simple acute bronchitis " could not be applied readily to the cases of
most marked character coming under the epidemic ; and, when bronchial
symptoms have appeared, it has been surprising to see with what rapid-
ity they have disappeared as the influence at the root of the mischief
has passed away.
The symptoms in sequence, what some have called the secondary
symptoms, have borne out remarkably the idea of the nervous origin of
the disease. The cerebral attacks are either dependent on the pulmo-
nary disturbance, or are due to the same influence, interfering with the
nervous governance of the cerebral circulation, as that which interferes
with the pulmonic circulation. But the cerebral lesion is more continu-
ous, as is common to cerebral and nervous injury ; hence the often pro-
longed stretch of nervous symptoms which follows a fairly (puck recov-
ery from the acute stage of the disease. At one time I thought that
possibly there was formed in the blood, under the perverted oxidation
that is in progress, a new substance of toxic character ; and this, in-
deed, may be the fact. The carbon of the blood can not be naturally
oxidized, and therefore the nervous oxidation in the great centers will
be perverted. This will, of necessity, lead to disturbed cerebral func-
tion, to delirium, to water pressure, and to the coma which is so often a
prominent symptom of the later stages in fatal seizures. This central
nervous failure would lead in its turn to the congestion of other vital
organs, like the liver and kidneys, that are under nervous control, and
depend on nervous supply for their natural activity. Thus the mischief
of the neuroparesis, commencing in the pulmonic circuit, extends to the
whole system ; and in observing the symptoms we are practically watch-
ing development of phenomena, precisely as when we are watching the
development of amcsthetie symptoms under the administration, by inha-
lation, of a narcotic vapor or gas, like nitrous oxide, ether or chloro-
form. And the perfection of our art should be to place the patient
under such conditions that the influence causing the symptoms shall be
neutralized, and the body be so circumstanced that the natural acts shall
swing round into their usual course.
A Case exemplifying Gross Negligence. — Mr. Lorenzo D. Bulette, of
the Philadelphia bar, contributes the following article to the April num-
ber of the hitcrtiiifioiiiil MiiTiad Mai/iizinc :
It may be of interest to the physician to know that the act of leav-
ing his horse standing unfastened, or if unfastened then unattended, in
a populous place, while making a professional visit, constitutes gross
negligence, for which he will be responsible to the person who suffers
injury thereby ; and this too in face of the fact that the known quali-
ties and habits of the animal are such as to induce the belief of perfect
safety in so doing. Evidence of the quiet and gentle character of the
animal, or to the effect that he was accustomed to stand without being
tied, must, in such case, be disregarded by the jury in reaching their
verdict.
This is the law as it was laid down in Overington vs. Dunn,* which
was an action for damages for an injury caused in the following man-
ner, as appears from the evidence at the trial :
The defendant was a practicing physician, who, on the day the in-
jury occurred, had left his horse and gig in a lane about ten yards from
the door of the house in which his patient was. He did not secure his
horse in the ordinary way, or leave any person in charge of it. The
position of the defendant, while attending his patient, was such that he
could see the horse from the place where he stood. But, while the de-
fendant was engaged in the examination of his patient, the horse, un-
perceived, passed out of the lane into the street leading down through
the built-up portion of the city, and, while going at a considerable rate
of speed, came in contact with the horse of the plaintiff, which was in
a team attached to a wagon. The shaft of the defendant's gig entered
the plaintiff's horse, causing an injury from which the animal died.
The defendant's evidence showed, and it was received in this in-
stance without objection, that the horse was well broken, that he was
kind and tractable, and that he was accustomed to stand for hours
together without being tied. Further evidence, on the part of the de-
fendant, gave a description of the place in which he left his horse.
The house was in the suburbs, and built upon a lane or court about
thirty feet wide. Across the lane where it opened into the street there
was a large gate, which the defendant found open and left it so. Owing
to obstructions, he was unable to drive quite up to the door of the
house, but he drove as near to it as the circumstances of the place
would allow. It also appeared that, owing to these obstructions, it was
impossible for the horse to get from the place at which he was left
without backing for quite a distance.
The judge before whom the cause was tried charged the jury that
negligence was a question of fact for their consideration, but that, in
deciding it, they ought not to take into view the peculiar qualities of the
defendant's horse ; they should rather consider and decide whether the
care taken by the defendant would be sufficient in the case of any
horse, whatever his known character and disposition. And this, on ap-
peal, was affirmed to be the law.
Negligence is the omission to exercise that degree of care which the
law requires; and it can occur only in cases where there is legal obliga-
tion to observe care. If no care be taken where the law requires it,
the negligence is gross. If some care be taken, but less than the law
requires, the negligence is greater or less according to the degree of
deviation from the legal requirement.
It is sometimes supposed that, where little or no danger is to be ap-
prehended from the omission of care, the obligation to exercise can1 is
proportionally less or does not exist at all ; and such appears to be the
view of the defendant in this case. But Ids idea confounds the fact
of negligence with the danger or risk attending it. They are, however,
entirely distinct. Cause and effect are not more so. A grossly negli-
gent act, as the law would term it, may, in fact, be attended with very
slight risk, while, on the other hand, an act perfectly proper, anil per-
formed with extraordinary care, may, from causes not foreseen and for
which the agent may not be responsible, be followed by disastrous
results.
* 1 Miles, 89.
532
MISCELLANY.
[N. Y. Med. Jocr.
In this case there was no evidence of any care used l»y the defend-
ant to restrain his horse at the time he left him. On the contrary, it is
express that he left his horse at large. In the eye of the law his negli-
gence was gross ; it could not be greater. He, no doubt, thought that
there was no risk attending his neglect. It may be conceded that most
persons, as his counsel asserted, would have done as the defendant did,
but the event proved that it was unsafe. It was an error of judgment ;
and the law makes him responsible for the consequences.
The New York Academy of Medicine. — The programme for the
meeting of Thursday evening, the 5th inst., included a paper on The Re-
action of Ether with Urine, by Dr. Andrew H. Smith, and one entitled
Practical Hints on the Examination of Urine, by Dr. K. A. Witthaus.
At the next meeting of the Section in General Surgery, on Monday-
evening, the 9th inst., Dr. W. B. Coley will read a paper on Hydrocele
in the Female, with a Report of Fourteen Cases, and Dr. John Ridlon
will read one on Fracture of the Neck of the Femur ; a Report of
Twelve Cases treated by the Thomas Hip Splint.
At the next meeting of the Section in Genito-urinary Surgery, on
Thursday evening, the 12th inst., Dr. R. W. Taylor will report A Pecul-
iar Case of Urinary Fever, Dr. Charles Heitzman will read a paper on
Pus in the Urine — how to discover its Source, and Dr. Samuel Alex-
ander will read one on Blood in the Urine — how to discover its Source.
At the next meeting of the Section in Pediatrics, on Thursday even-
ing, the 12th inst., there will be a discussion on Summer Diarrhoea in
Children.
Mortality in Cities in the United States. — The following table
represents the mortality in the cities named, as reported to Dr. Walter
Wyman, Surgeon-General of the Marine-Hospital Service, and pub-
lished in the Abstract of Sanitary Reports for April 29th:
Philadelphia. Pa.
Boston. Mass..
San Francisco, Cal.
Cincinnati, Ohio. . .
New Orleans
New Orleans
La.
La.
Detroit. Mich
Milwaukee. Wis. .
Minneapolis, Minn,
Lorisville, Ky
Roc hester, N. Y
Providence, R. I. . .
Toledo, Ohio
Nashville, Tenn . . .
Fall River, Mass . .
Portland. Me
Binghamton, N.'Y.
Mobile. Ala
Galveston. Texas...
Auburn, N. Y
S
1
go
• 5
" g
S *
I""
*o
f-
Apr. 23.
1,515,301
9111
Mar. 26.
1,099,850
469
Apr. 2.
1.099,850
507
Apr. 9.
1,099,850
548
Apr. 16.
1,099,850
452
Apr. 23.
1,099,850
t;:.
Apr. il.
1 .046,9(14
495
Apr. lfi.
1,046,964
442
Apr. 23.
806,343
3s6,
Apr. Hi.
451,770
163
Apr. 23.
451.770
158
Apr. 28.
44S.477
222
Apr. 23.
434.439
193
Apr. 16.
298,997
118
Apr. 22.
996,908
ins
Apr. 23.
261,353
100
Apr. 2.
242,039
149
Apr. il.
242.039
132
Apr. lti.
242,039
154
Apr. 23.
238,617
10(1
Apr. Hi.
205,876
113
Apr. 23.
205,876
107
Apr. 23.
204,468
so
Apr. Hi.
164.738
60
Apr. 23.
161.129
59
Apr. 23.
133.896
56
Apr. 23.
132,116
53
Apr. 22.
81.434
36
Apr. 23.
76.168
27
Apr. 22.
74,398
.28
Apr. 23.
36,425
14
Apr. 23.
35,005
11
Apr. 23.
31.076
24
Apr. 8.
29,084
11
Apr. 15.
29,084
8
Apr. 23.
25,858
13
Apr. Pi.
16,159
4
Apr. 16.
11.750
5
DEATHS FROM-
lio
1 s
CSS
2 27 36 23
16 9 22 1
IS 7 11 4
21 12 18 5
11 8 16 3
13 ltl 12 3
5 17 21 5
13 8 18 31
2 14 21 3
116..
12 4 1
2 7 16 . .
311 8 3
Some of the Dangers of washing out the Stomach. — The April
number of the Practitioner contains an article by Dr. W. Soltau Fen-
wick which concludes as follows :
At the present day every imaginable symptom that can in any way
be connected with the digestive organs is immediately considered as an
indication for the use of lavage, and we find that not only are chlorosis,
atonic dyspepsia, and the gastric crises of ataxia subjected to this treat-
ment, but even cases of reflex vomiting are supposed by some to neces-
sitate the employment of the douche. But it is obvious that in those
cases where the treatment fails to do good it is extremely likely to do
harm, since, as Leube pointed out, it has the effect of removing those
products of digestion whose manufacture has caused the stomach a con-
siderable amount of labor. And for my own part I fail to understand
how washing out the organ in a case where the normal amount of secre-
tion proves insufficient can possibly increase its digestive powers; or
the lavage of the stomach prevent the occurrence of symptoms which
are wholly dependent on organic disea.se in another organ remotely situ-
ated. In one case of tabes dorsalis, accompanied by exceedingly severe
gastric crises, I had the stomach washed out every dav for some weeka
and the state of digestion carefully watched ; but beyond the fact that
the symptoms of the disease grew steadily worse, I could detect no ma-
terial alteration in the condition of the patient. In like manner, the
few cases of atonic dyspepsia and chlorosis which I have treated by
lavage have, without exception, proved exceedingly rebellious and only
improved when subjected to the more ordinary course of medical treat-
ment. I would therefore conclude by saying that although lavage is an
invaluable remedy in certain cases of gastric disease, its indiscriminate
employment in every case of disorder of digestion will prove a curse
rather than a benefit, and will eventually throw discredit upon the whole
method of treatment.
To Contributors and Correspondents. — The attention of all who purpose
favoring us with communications is respectfully called to the follow-
ing :
Authors of articles intended for publication under the liead of " original
contributions " are respectfully informed that, in accepting such arti-
cles, we always do so with the understanding that the following condi-
tions are to be observed: (i) when a manuscript is sent to this jour-
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All communications intended for the editor should be addressed to him
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All communications relating to the business of the journal should be ad-
dressed to the publishers.
THE NEW YORK MEDICAL JOURNAL, May 14, 1892.
Original Communmtticms.
ON THE SCOPE OF OETHOP^EDICS.
By F. BEELY, M.D.,
BERLIN.
In the introduction or preface of treatises upon ortho-
paedic surgery, authors usually give a concise definition of
this specialty and a short enumeration of the diseases which
come under the head of this department. In some essays
that have appeared within the past few years the necessity
for so doing has been emphasized. Dr. N. M. Shaffer, for
example, delivered an address before the International Medi-
cal Congress at Berlin in 1890 entitled, What is Orthopaedic
Surgery ? Dr. Gibney also read a paper before the Ameri-
can Orthopaedic Association, at its fifth annual meeting at
Washington, in 1891, called Orthopaedic Surgery; its Defi-
nition and Scope,* and Dr. Shaffer's reply was published in
the New York Medical Journal for November 14, 1891.
There seems to be no definite agreement as to the true defi-
nition of this specialty. Authors in different countries vary
very materially in their views upon this subject. Shaffer,
for example, says : " Orthopaedic surgery is that department
of surgery which includes the prevention, the mechanical
treatment and the operative treatment of chronic or pro-
gressive deformities, for the proper treatment of which
special forms of apparatus or special mechanical dressings
are necessary." Dr. Gibney, whose paper is essentially a
critique upon Dr. Shaffer's address, agrees with him in the
main, but he does not think that the scope of orthopaedics
should be limited from the standpoint of mechanico-therapy.
Acknowledging Shaffer's definition to be to a great extent
the true one, Gibney omits, however, the qualifying phrase
of the definition, which says : " For the proper treatment of
which special forms of apparatus, etc., are necessary." Dr. L.
A. de Saint-Germain, in his Chirurgie orthopedique, defines
the problem thus : " Le redressement, la rectification, des
difformites." But we find in his book sections on obesity,
malformations of the ears and of the teeth, hypertrophy of
the tongue, hare-lip, na;vi, strabismus, etc. Dr. E. H. Brad-
ford and Dr. R. W. Lovett, in their treatise on Orthopaedic
Surgery, 1890, without giving the definition, say: "Ortho-
paedic surgery should include the prevention as well as the
cure of deformity." Besides Pott's disease, club-foot, lat-
eral curvature, bow-legs, the diseases of the joints, etc., they
include spondylolisthesis, congenital dislocation of the hip,
webbed fingers and toes, and cerebral paralysis, but omit to
cite the deformities resulting from fractures, dislocations,
and burns. Dr. Schreiber, in his General and Special Or-
thopaedic Surgery (Allgemeine and speciele orthopddische Chi-
rurgie, 1888), calls orthopaedics " the science of the de-
formities of the human body." Dr. Iloffa, in his treatise,
limits its sphere to those deformities of the body which ap-
pear as deviations of posture and stature of the skeleton.
The purport of these two books is very similar. Iloffa in-
* N. Y. Med. Jour., Nov. 7, 1891.
eludes prothesis under orthopaedics, which means the manu-
facturing of all apparatus and bandages. Both authors de-
vote special chapters to the treatment of orthopaedic diseases
following fracture or dislocation of bones, traumatic lesions
and burns of the soft parts, and inflammation of the soft
parts. There are numerous other examples, but the foregoing
quotations may be sufficient. It is impossible in so short an
article to indicate the various definitions given by different
authors. The question therefore arises, Is it necessary or
even advisable to confine or limit the realm of orthopaedic
surgery ? Possibly it would be best to leave it ail to grad-
ual development. Should we not rather hold fast to the
present opinion, and, without regard to principles, study
from the various sources those diseases the treatment of
which is generally accepted by orthopaedists ?
It may be of some interest to glance into the history of
orthopaedic surgery — viz., as to how it originally developed
— thus trying to gain further insight into its nature, and
become familiar with methods which may lead us to accord
to it proper rank among the specialties. General medicine
has been divided into specialties, because it has been im-
possible for one man to acquire a proficiency in all. This
separation lias been due to different circumstances. It was
necessary that either one particular organ or a restricted
region of the body should be studied — for example, the
nose, throat, or larynx ; or a specified system of tissue
which the specialist should select as his province — as
that of the skin, the nerves, etc. ; or therapeutical meas-
ures the application of which required special dexterity ;
or else appliances, like massage, gymnastics, and electro-
therapeutics. The department of the last named is, of
course, not limited. One is at first uncertain as to which
category of specialties orthopaedy belongs. From the
many definitions attempted, it appears that great effort has
been made to secure for it a firmly planted position in the
department of surgery. The fact that scientific authors
and practitioners desire to do so seems evident. On an
anatomic-physiological basis, a scientific system may be
more clearly erected. Pathological anatomy, symptoma-
tology, diagnosis, and therapeutics are more clearly allied
to it, while it is difficult to find a systematic scientific-
classification from the therapeutical point of view. The
practitioner, to whom the scientific point of view is not of
much importance, desires to appear to the public not so
much as practicing therapeutical methods as that of be-
ing an authority upon the treatment of a special class of
diseases, so that he need have no fear of being supplanted
in order that his patient may have change of treatment.
We can not admit that this view of the subject is the right
one, as it is not consistent or in accordance with historical
development, as least so far as Germany is concerned, and
I think that German conditions are especially suitable as
illustrating this point, as Germany has had for so long a
time the advantage of a thoroughly instructed medical pro-
fession of the highest scientific order. If we glance at
the history of orthopedic surgery in Germany, as sketched
by Iloffa, our attention is especially drawn to the names of
Heine (1770-1838) and to Ilessing. Iloffa says of the
534
BEELY: ON THE SCOPE OF ORTHOPAEDICS.
[N. Y. Med. Joub.,
former : The name of Heine takes the first rank among
the founders of orthopaedia.
Johann Georg Heine, of Wiirtemburg : "His estab-
lishment was the prototype of all others " ; and, regarding
the latter (Hessing), we are indebted to him, a skillful me-
chanic, for the knowledge of all kinds of splint-capsule ap-
paratus, and various apparatus for supporting the spine.
Heine was in early life an apprentice to a cutler and after-
ward to a manufacturer of surgical instruments. Neither
of these men belonged to the medical profession, neverthe-
less they greatly advanced orthopaedic surgery, and have be-
come famous beyond the confines of Germany. Their repu-
tation was due to their skillfulness in the use of mechanical
instruments. Heine devoted himself exclusively to the ap-
plication of orthopaedic apparatus, and scorned to make use
of gymnastic exercises or subcutaneous tenotomy, invented
at that time by Stromeyer. He equally despised the aid
of medicine administered internally (see Bibliograj)hisches
Lexicon, by Goult). Both of these men have proved that
eminence and success, not surpassed even by the most cele-
brated contemporary surgeons, may be acquired by the
adoption solely of mechanical methods. It is not to be
wondered at that Heine, as he had been deprived of the ad-
vantage of medical instruction, and also on account of his
eccentric therapeutical theories, should have made many
mistakes, especially as he often ventured upon the treatment
of diseases when the proper mechanical instruments could
not be procured. On account of his general success he be-
came extremely arrogant, and he practiced general medicine
irrespective of all professional ethics. These shortcomings,
however, did not detract from his real merit, save that he
did not during his lifetime receive full credit for his valua-
ble services. Hoffa continues : " He steadfastly adhered to
his conviction that in orthopaedy mechanical methods should
alone be adopted. Many of his disciples and imitators
have practiced his teachings, and thus great reproach rests
upon Heine for having delivered orthopaedy into the hands
of the manufacturers of instruments. The medical profes-
sion, consequently, became averse to treating deformities,
and so gradually, up to the present time, the majority of
them prefer to relegate their patients to the department of
the bandagist."
Upon this point I differ with Hoffa. Heine, I think;
was on the right track. Members of the profession who do
not appreciate the value of mechanical apparatus are to be
blamed for this decadence, for they leave to the bandagist
the most important department of therapeutics. Mechanical
treatment is, and ever will be, the very essence of ortho-
paedy. Upon that it stands or falls. If mechanical treat-
ment be left out, orthopaedy becomes either operative sur-
gery or gymnastics and massage. The orthopaedist must,
of course, take personal supervision of the mechanical treat-
ment, and not simply prescribe the apparatus as the practi-
tioner prescribes his medicine. The apparatus should be
made under his special direction, and he must assume the
entire responsibility of its application and use. Under
these conditions alone can he hope for continual develop-
ment and progress. What would be thought of a surgeon
who restricted his practice to diagnosis and prescription,
and turned his patient over to the nurse for mechanical
treatment ? What the patient demands of the surgeon he
should require of the orthopaedician. From the difficulty of
defining the line between orthopaedy and surgery there arose,
according to Hoffa, the term " orthopaedic surgery." As I
have expressed my opinion to the effect that mechanical
treatment is the essence of orthopaedy, I should therefore
prefer to have it called mechanico- therapy. The last term
would be the more significant, but in Germany this term is
used for " cures by motion " or gymnastics and massage.
General surgery, then, would be divided into mechanical
surgery and operative surgery. As there are some physi-
cians who prescribe only internal medicine and do not per-
form surgical operations, so there are others who practice
both internal and external treatment with equal skillfulness.
Some surgeons undertake operative work only, others me-
chanical only, while many others practice both combined.
An entire separation could be practicable only in large cities.
The consideration from this standpoint leads to the ques-
tion, What diseases belong to the department of orthopaedy
and which of them belong to general surgery ? Unfortu-
nately, I do not know to what extent Heine carried his ex-
periments. As to Hessing, we know that besides treating
deformities, he also treated joint diseases, some cases of
dorsalis, and also fractures successfully. We have seen,
therefore, that from the above-mentioned illustrations the
criterion of orthopaedy is the mechanical treatment ; and
the representatives of orthopaedic surgery, and other phy-
sicians who have had equal advantages show a predilection
for solving mechanical problems. By this means patients
may be supplied with apparatus from the technical and
therapeutic point of view. The orthopaedician should un-
doubtedly be placed upon equal footing with other special-
ists, in order that the sufferings of mankind may be allevi-
ated. He may lay claim to the treatment of fractures, as
well as to mechanical treatment of spondylitis ; he may
undertake the treatment of hernia as well as curvature.
This should be taught in the universities, and it would then
lead to a higher estimation of, and to more rapid progress
in, mechanical surgery. Young doctors would then have
the opportunity of studying the mechanical as well as the
operative treatment of deformities, and would be glad to
avail themselves of it, as they have hitherto been unabl
to do, notwithstanding that the professors have had the
desire for imparting the knowledge. The number of opera-
tions in the treatment of deformities would be greatly di-
minished, as there are, as a matter of fact, very few that
could not be avoided, if relatively simple mechanical means
could be correctly and promptly administered. Nearly
every osteoclasis or osteotomy in genu valgum or rhachitic
curvature of the lower part of the thigh ; almost every
bloody operation in pes equino-varus ; in fact, nearly every
violent redressment of angular ankylosis of joint disease,
has been necessarily performed because of incompetent
knowledge of mechanical treatment.
Resorcin, in five- to ten-grain doses, dissolved in plenty of water
and flavored with orange-peel syrup, is reported to relieve the nausea
and depression following the excessive use of alcoholic stimulants. —
British mid Colonial Druggist.
May 14, 1892. J MacDONALD: THE DEATH
.THE INFLICTION OF THE
DEATH PENALTY BY MEANS OF ELECTRICITY.
BEING A REPORT OF SEVEN CASES.
With Remarks on the Methods of Application and the
Gross and Microscopical Effects of Electrical Currents of Lethal Energy
on the Human Subject.
By CARLOS F. MacDONALD, M. D.,
PRESIDENT OF THE NEW YORK STATE COMMISSION IN LUNACY ;
PROFESSOR OF MENTAL DISEASES IN THE BELLEVUE HOSPITAL MEDICAL COLLEGE;
LECTURER ON INSANITY IN THE ALBANY MEDICAL COLLEGE.
(Concluded from page 509.)
Autopsies.
William Kemmler. — The autopsy, held about three
hours post mortem, was by verbal direction of the warden
officially in charge of the writer, and was performed by Dr.
E. C. Spitzka, Dr. George F. Shrady, and Dr. W. T. Jen-
kins, of New York, and Dr. C. M. Daniels and Dr. George
E. Fell, of Buffalo, N. Y. Notes were taken by Dr. Shrady,
from which the following is compiled :
Body fairly well nourished. Rigor mortis marked, particular-
ly in the muscles of the jaw, neck, and thorax, and gradually ex-
tending from above downward, involving the feet and legs last.
Post-mortem discoloration existed over lower portion (posterior
and lateral aspects of trunk) of body, and extended up as far as
the anterior axillary line, also on the pendent surfaces of the
upper and lower extremities. The upper extremities were part-
ly flexed and rotated outward, the nails showing post-mortem
lividity. There was a seminal discharge, which, on microscopic
examination, was found to contain a large quantity of dead
spermatozoa. There was marked post-mortem discoloration of
the forehead, about an inch in width, corresponding with the
position of the strap, beginning at the hair on the left side and
extending to the hair line on the right side. A corresponding
discoloration from the pressure of the chin strap was also noted.
There was an oval depression of the scalp upon the vertex, due
to the pressure of the electrode, beginning at the anterior hair
line and measuring four inches in its long and three inches and a
half in its short diameter. Anterior to the posterior portion of
the depression and in the immediate line there was a vesication
an inch and a half in length, very superficial in character, eres-
centic in shape, and upon which the hair appeared to be slightly
scorched. On the small of the back, corresponding to the level
of the fourth sacral vertebra below and second above, four inches
and a half in vertical diameter and four inches and a half in
transverse diameter, was a burn, presenting four concentric
zones, of which the outermost had a pale area, corresponding
to that of the rubber cap of the electrode, and one fourth of an
inch in diameter.
Succeeding this was a vesication, partial below and complete
above, about an inch in diameter above and one third of an inch
below.
Then followed another zone, which was in its upper third
a complete eschar, black in appearance, and in its lower part
showed desiccation of a greenish-brown color. The last or in-
ner zone showed a number of vesicles, chiefly peripheral, and
below the center was a black eschar, half an inch in its vertical
and five eighths of an inch in its transverse diameter. Above
was a tongue-shaped, pale area, with a lateral projection to the
left of the median line, extending about two inches, and an up-
per projection in the dorsal furrow, which was more sharply
pointed, and which on its periphery showed a reddened por-
tion, with here and there vesication. In addition, the back
showed a number of depressions produced by the folds of the
PENALTY BY ELECTRICITY. 535
shirt and suspenders, such as are commonly found in dead bodies
lying on the back.
On incising the skin over the sternum, the blood which es-
caped was unusually dark and fluid, and remained so on exposure.
The muscles of the thorax were of the usual color. " Tardieu
spots" were noticed on the posterior border of the lower lobe
of the left lung. When placed in water, more than half of the
lung floated above the surface, showing a marked emphysema-
tous condition. The bronchi were normal in appearance, and
contained mucus and air bubbles. The right lung was adherent
throughout to the diaphragm. In the middle lobe of this lung
there were numerous well-marked '' Tardieu spots." The heart
weighed five ounces and three quarters; its valves and sub-
stance were normal in appearance, and its ventricles were emp-
ty. The stomach contained a pint of undigested food. The
blood from the cut surface of the liver was of a dark-crimson
hue. The gall-bladder was distended with bile. The spleen
was normal in size and appearance. The left kidney weighed
three ounces and a half, and the right three ounces ; both were
markedly congested. There was no vermicular action of the
intestines on exposure to the air or on irritation. The bladder
was contracted.
The scalp, on being removed, showed the outer aspect of the
vertex of the skull to be in a desiccated condition, correspond-
ing with the site of the electrode as previously noted, but of a
larger area, being four by four inches, the zone of the scalp
being only two and a half by tRree inches, the long diameter
being aDtero-posterior. On removal of the skull-cap, the dura
was normal in texture, somewhat dull in color, particularly over
the area corresponding with the zone of contact. In the pre-
Rolandic region the meningeal vessels, measuring along the con-
vexity antero-posteriorly four inches on the left side and three
on the right, were filled with carbonized blood. On the internal
aspect of the calvarium the meningeal vessels in the dura and in
their contents appeared to be black and carbonized. The car-
bonized vessels were so brittle that their ends were torn off
with the calvarium and presented a broken, crummy appear-
ance. This carbonization was limited in an abrupt manner.
The other meningeal vessels in the region corresponding to the
outer burn, previously described, contained blood of a dark-
crimson hue. In the narrowest portion of this region was seen,
a little posteriorly, in the median line, a dark discoloration send-
ing out a right lateral prolongation three fourths of an inch in
the direction of the longitudinal sinus, and in width seven
eighths of an inch. Over the left cerebral hemisphere, one
third of an inch to the left of the median line, there was a deep
carbonized spot corresponding with the desiccated portion of
the calvaria. The pia and gyri were of a pale-buff color; the
rest of the cerebral cortex was normal in appearance. While
observing this ana?mic area it was noticed that its blood-vessels
began to fill. The pia and arachnoid on the convexity of the
brain were perfectly no.-^al. An interesting fact was observed
on handling the pons and medulla, in that they were found to
be warm. By a thermometer inserted in the fourth ventricle,
the temperature was noted at 97° F. The area of this tempera-
ture corresponded with an area of temperature on the back of
the neck which was noted at 99° F., three hours post mortem,
the temperature of the room being 83° F. The smaller vessels
of the pia were ectatic. Capillary hemorrhages were noted on
the floor of the fourth ventricle, also in the third r< utricle and the
anterior portion of the lateral ventricle. The circumvusrvlar
spaces appeared to he distended irith serum and Hood. The brain
cortex in the area of contact was sensibly hardened to one sixth
of its depth, where there was a broken line of vascularity. The
vessels over the corpus striatum showed enlargements in differ-
ent ports of their ramifications. The pons was slightly softened.
536
MacDONALD : THE DEATH PENALTY BY ELECTRICITY.
[N. Y. Med. Joub.,
The spinal cord was removed entire, but showed no gross ap-
pearances of pathological condition. Portions of the brain and
spinal cord were preserved for purposes of hardening and micro-
scopical examination. The blood taken immediately after death
showed, under the microscope, a markedly granular condition,
almost suggesting an electrolytic dissolution of the red cor-
puscles.
A preliminary microscopical examination of portions of
the brain and spinal cord, including specimens from all the
cerebral lobes of both sides, segments of the cervical, dor-
sal, and lumbar regions of the spinal cord, with the con-
nected nerve groups, was subsequently made by Dr. Spitzka,
who states as follows :
The brain, spinal cord, and peripheral nerves appeared
structurally healthy in every portion examined, except in the
area corresponding to the discolored (anaemic through extreme
contraction of vascular channels) area of the Rolandic and pre-
Rolandic regions, the ventricular surfaces, and the pons and
medulla oblongata. The latter, which had been the seat of a
remarkable post-mortem preservation of a temperature ap-
proaching that of the normal human body, were distinctly softer
than the observer has been accustomed to find these parts in
autopsies on persons of Kemmler's age. and performed so soon
after death. The haemorrhagic spots in the fourth ventricle,
which were strongly marked, were not accompanied by signs of
parenchymatous rupture of larger vessels. Hence they may be
regarded as having the same significance as the " taches de Tar-
diev " found on the surfaces of other organs — notably, the heart
and lungs.
The peculiar softened vesicular zone of tissue underlying
the outermost layer of the cerebral cortex being very fragile,
will require extreme care in hardening and manipulation to en-
able me to obtain reliable specimens. It is noteworthy that
this "destruction line" runs parallel to the free surface of the
brain and does not "dip" with the sulci.
Examination of the fresh specimen revealed the existence
of vacuoles (probably gas bubbles) in the ganglion cells and in
the parenchyma of the " destruction line." From the fact that
no haemorrhages had occurred in this softened area, it is a just
inference that it was produced afterlife had become entirely ex-
tinct, for the continuance of a blood circulation in a softened
brain area is incompatible with the bloodless appearance al-
ready noted and the absence of capillary haemorrhages in this
very district while they were present in those remote from the
site of the electrode.
A more minute analysis will be completed, but can not be
reported until some future time.
That the " cooked " appearance of the muscular tissue
of the back beneath the site of the electrode, and the desic-
cation of the skull and so-called " carbonized " state of the
blood-vessels on the internal aspect of the calvaria over
the area corresponding to the zone of contact, were due to
the unduly prolonged second contact, together with failure
to properly moisten the electrodes, there can be no ques-
tion, no such results having been observed in any of the
subsequent cases, the surface lesion in these latter being
limited to superficial vesication of the skin at the points of
application of the electrodes, as will presently appear.
All of the subsequent autopsies, including the micro-
scopical examinations, were made by Dr. Ira Van Gieson,
of the Pathological Laboratory of the College of Physicians
and Surgeons, and are here described substantially in I Jr.
Van Gieson's language.
Sch ichioh Jugigo. — The post-mortem examination in this ca<e
was held four hours after death. The pupils were alike and
moderately contracted. The body was well nourished and un-
usually well developed. The anterior epithelial cells of the
cornea had desquamated from the central portion by the action
of heat. There was a bulging forward of the sclera of the left
eye at the left sclero-corneal junction. Conjunctiva anaemic.
The scalp and skin covering the neck had a dull, purplish hue.
The skin of the anterior surface of the body was not discolored
or ecchymosed. At the flexure of both elbows were a number
of symmetrical linear ecchymoses, which were more marked on
the right side. Also a curved, narrow ecchymotic line just be-
low the outside of the right nipple. These probably were
caused by the straps. At the posterior surface of the right
knee-joint, and on the posterior and inner and upper surface of
the calf, the epidermis was raised, wrinkled, and folded. At
the flexure of the knee joint the epidermis had been torn away
to the extent of about an inch in diameter. The right lower
extremity was flexed and bent more to the median line than
its fellow. There is a slight discharge of thin, milky fluid
from the urethra and some still remaining in the canal. A
sample of this fluid was taken for microscopical examination.
Post-mortem rigidity well marked except in the arms, where it
was only slight. The whole posterior surface of neck, trunk,
arms, and lower extremities was of a dull, purplish hue. There
were a few slight blisters on both temples, and both cheeks and
eyelids. There were raised whitish streaks on both sides of the
neck, just below the angle of the jaw.
The trunk was opened by a straight incision from the top of
the sternum to the pubes. The fat was an inch thick over the
abdomen. Muscles red and firm. Diaphragm at left side was
found at the level of the sixth intercostal space, and on the
right side at the fifth intercostal space. Portions of small in-
testine were taken for microscopical examination.
Examination of heart : Auricles and ventricles flaccid and in
diastole and filled with fluid blood. The larger vessels were
tied and the heart removed. The left ventricle was well filled
with fluid blood but no clots. The auricles were the same.
The blood was of the same color in the left ventricle as in the
right. Valves normal. On opening the vessels, a large quan-
tity of dark-colored liquid blood escaped, half filling the pleural
cavity. There were no pleural adhesions. Lungs perfectly
healthy, but slightly congested.
The spleen was found to be of normal size, the capsule
smooth, pulp firm, and uniformly filled with blood, and the ar-
rangement of the Malpighian bodies and splenic connective tis-
sue entirely normal.
The pancreas was perfectly normal and a portion removed
for microscopical examination.
Liver entirely normal, and a portion was also removed for
microscopical examination.
The gall-bladder was filled with bile.
Left kidney : The capsule was non-adherent. It was rather
large and the cortex of normal thickness. The kidney was
uniformly injected and the markings in the cortex were normal
as to number and arrangement. The right kidney was in the
same condition.
The stomach was empty, the mucous membrane pale ; the
rugae were well marked and perfectly healthy.
The intestines were healthy. The small intestines were filled
with semi-fluid fieces. The large intestines showed the same
condition.
The urinary bladder was normal and half full.
May 14, 1892.]
MacDOXALD: THE DEATH PENALTY BY ELECTRICITY.
537
Examination of brain: The brain was exposed by a straight
incision of scalp over the vertex from ear to ear, and saw cuts
through the skull at a slight angle and at the level of the eye-
brow-. The scalp showed several old sears, and was slightly
less adherent under those portions where the electrode was at-
tached. The skull was symmetrical. The dura mater was
normal and the vessels moderately dilated. The longitudinal
sinus was found to he normal and contained some fluid blood.
The brain was removed in the usual way. The pia mater was
uniformly thin and transparent ; the vessels in a medium state
of congestion ; subpial fluid small in amount. The blood was
everywhere fluid in the meshes of the pia mater. There was
no apparent difference in that portion which the electrode
covered. The vessels at the base were perfectly normal. The
ventricles contained a small amount of clear fluid. The roof
and floor of the lateral ventricles were normal. Trie ependy-
ma was smooth and transparent. White substance firm.
Gray matter normal in every respect. Floor of the fourth
ventricle at the upper half contained some dilated vessels, and
on the left side there were a number of minute, radiating pe-
techial spots from one to two millimetres in diameter. (See
Fig. 1.)
The spinal cord was exposed in the usual'manner. The ex-
ternal appearance of both cord and membranes was entirely
normal, and the vessels containing, if anything, even less blood
than usual, due, probably, to the short time that had elapsed be-
tween the occurrence of death and the holding of the autopsy.
Sections half an inch apart showed nothing abnormal. A por-
tion of both sciatic nerves was taken for microscopical exami-
nation.
Owing to the great length of time necessary to make this
autopsy as completely and minutely as was done, and the sub-
sequent careful microscopical examinations, it was not consid-
ered necessary to examine the brain and spinal cord in the
other cases, especially as nothing of any importance had been
observed in these organs in this case.
Harris A. Smiler. — Posterior surface of the body was of the
same color, and also showed the same blisters as in the case of
Jugigo. The left leg showed the same state of contraction.
The body was opened by the long, straight incision, as in the
case of Jugigo. The diaphragm was found at the left side at
the sixth intercostal space and on the right side at the fifth
intercostal space. The left lung was slightly adherent at the
apex. The heart was rather small. The lett ventricle was
somewhat firmer than the right, which latter was a little flabby.
The auricles were distended with fluid blood. The right ventri-
cle was empty and collapsed. The apex of the left lung was
small and shrunken and retracted, and contained a few small,
scattered, dense, tubercular nodules, some of which were calci-
fied. Otherwise the lung was normal and resembled the pre-
ceding case. Right lung shows the same set of changes, but not
so marked. Small ecchymotic spots (Tardieu's spots) were ob-
served under the pericardium on surface of left ventricle. The
walls of the ventricles were of normal thickness. There were
signs of an old endocarditis below the aortic valves. All the
valves were healthy.
The spleen was small and the pulp soft and normal.
The pancreas was normal.
The liver was normal both in size and texture.
The left kidney was greatly hypertrophied and the capsule
non-adherent. The cortex was somewhat thickened and the
markings distinct and regular ; moderately congested. The
right kidney was small, two and a half by three quarters of an
inch in size, and weighed forty-eight grammes— less than an ounce
and three quarters. The tissue was normal, but the kidney was
apparently congenitally small.
Intestines. — Descending colon was filled with gas; ascend-
>ng colon and small intestine pallid and contained semi-fluid ma-
terial.
Stomach contained undigested food, potatoes, etc. Mucous
membrane pale and coated with a thin layer of slimy mucus.
Bladder distended with urine. Walls and mucous membrane
normal.
Examination of brain and cord deemed unnecessary. The
blood was fluid everywhere and darker than normal.
Joseph Wood. — Autopsy held at 1.25 p.m.
Body presented same appearance as in preceding cases.
There was the same contraction of the legs and the same gen-
eral appearance as in the others. Same condition of epithelium
of cornea.
Median incision made as in other cases. Diaphragm attached
to fifth intercostal space on both sides. There were half a dozen
scattered petechial points found under the pericardium, half a
millimetre in diameter. On the anterior surface of both ven-
tricles and on the posterior surface of the left ventricle were five
scattered similar points. On the posterior surface of the right
ventricle were three similar small points and one larger, three
millimetres and a half in diameter.
Heart normal in size and condition of ventricles the same as
in the case of Smiler. Both lungs were free from adhesions.
The right lung, bronchi, pulmonary vessels, and lung tissue were
normal, but somewhat more pigmented than usual. The sub-
stance of the lung was dry and dark pink in color. Heart mus-
cles pale and firm and of normal thickness. All the valves were
normal.
Spleen was normal in size and dark red in color, and showed
two thickened white patches on capsule. The pulp was firm.
The pancreas was normal.
The liver was normal in every respect.
Both kidneys normal in every respect.
Nothing abnormal was found in the intestines.
The gall-bladder was distended with normal bile.
The urinary bladder was of normal thickness, but the mucous
membrane was considerably congested.
The brain and cord were not examined.
James J. Slocum. — Autopsy held at 1.45 p.m. There were
the same blisters and external appearances as in the others.
There was also the same appearance of cornea. Median incision
was made as in the other cases.
Heart. — Petechial spots scattered about as in the other cases,
and were also observed under the pulmonary pleura. The left
ventricle was firmly contracted, while the right was flabby.
Both auricles, especially the right one, were filled with fluid
blood. The left lung was free from adhesions. The upper lobe
of right lung was slightly adherent. The left lung was in the
same condition as the others, but slightly (edematous. The right
lung was in the same condition. There was a well-marked large
group of petechial spots at the center of anterior surface of left
ventricle.
The spleen was of normal size, with the pulp soft, of dark-
red color and somewhat congested.
Pancreas was normal both on the surface and on section.
The gall-bladder was half full of bile and the common duct
patulous.
The liver was normal in every respect.
The left kidney was very much congested, but normal in all
other respects.
The right kidney was in a similar condition.
A careful examination of the intestines showed nothing ab-
normal.
The bladder was collapsed and normal.
The trachea was normal.
538
MacDONALD : THE DEATH PENALTY BY ELECTRICITY. [N. Y. Med. Jooh.,
Microscopical Examination.
The practical results of the microscopical examination are,
that the passage of the electric current through the body is at-
tended with no recognizable changes in its tissues or organs, ex-
cepting the local thermic changes in the skin at the points of
application of the electrodes and some minute petechial spot3 on
several of the organs.
Such a summary of the examination, however, seems insuffi-
cient without adding that it was determined by most exhaustive
and modern investigation, and as there are apparently no re-
corded examinations of similar cases in medical literature, it
seems not inappropriate to give the detailed report subjoined,
showing in what way and to what extent the tissues were ex-
amined.
Specimens were taken from all four of the subjects, but the
material from the Japanese criminal was especially selected for
minute study, as it could be obtained the soonest after death.
Notes about the technical preparation of tissues are added
at the conclusion of the report
The Examination of the Cells in General. — For this purpose
the ciliated cells of the trachea, the liver cells, and the ganglion
cells were studied especially with the oil-immersion lens. The
physical properties of the protoplasm are in no way changed.
The arrangement of the protoplasm, its volume, consistency, its
behavior with light and staining reagents, are not at all different
from the ordinary cell body. The same may be said of the con-
stituent elements of the nucleus. None of the cells in any of
the tissues examined show any signs of mechanical violence, such
as tearing, fracture, or disintegration of the protoplasm. Neither
does there appear to be any chemical change in the nucleus or
cell body, as far as can be determined with micro-chemical
methods. (The cells thus studied were prepared with solutions
of corrosive sublimate, and also osmic acid.)
The Blood. — The blood cells are not damaged in any way by
the current. The red cells have their normal size and shape.
The white cells are uniformly spherical and have the usual ar-
rangement of the nuclei. The blood was very perfectly pre-
served, even the blood plaques being unchanged.
The stomach, small intestine, and kidney are unchanged,
with the exception of a slight amount of post-mortem degenera-
tion in the parenchyma cells. The stomach shows the appear-
ances of functional activity.
The liver and pancreas and spleen show no changes.
The Muscular System. — The smooth muscles, studied from
the gastro-intestinal tracts and the heait muscle fibers, are un-
changed.
In sections of the eyelid lying directly beneath the electrode
the voluntary muscle fibers are normal.
The blood-vessels are not altered. The lungs and genital
organs were not examined microscopically. The fluid ejaculated
from the urethra in the case of the Japanese criminal does hot
show spermatozoa.
The central nervous system was examined with especial care.
It has recently been determined that, during periods of muscular
fatigue or prolonged muscular exertion, certain of the motor-
ganglion cells are diminished in volume, which is recovered
again during periods of muscular repose. Speaking roughly,
this shrinkage of the ganglion cells during muscular fatigue
represents a sort of mechanical equivalent of the work done by
the muscles. Hodge (Am. Jour, of Psychology, May, 1888, 1889,
and 1891), in inducing experimentally the effects of fatigue in
ganglion cells by the prolonged action of weak electrical cur-
rents, found that the ganglion cells suffered a vacuolation,
shrinkage in the volume of the cell body, and a still greater
reduction in the size of the nucleus. This diminution of the
ganglion cell was tangible enough and could be measured, and
in some cases in Hodge's experiments with the current on cats
the nucleus shrank to 43-9 per cent, of its original bulk.
Although it could hardly be expected that there would be
time enough for the ganglion cells of these criminals to show
traces of the intense muscular contractions, yet the ganglion
cells of the central convolutions and the anterior spinal cornua
were very carefully examined to see if there would be any
shrinkage coincident with the expenditure of so great an amount
of muscular energy as was manifested during the contacts.
The ganglion cells in these regions, however, as far as can
be determined by careful comparison with sections from the
same regions in other ordinary healthy subjects, seem to be nor-
mal in size, or at least do not show any striking reduction in
volume. A slight shrinkage may be present, but it would be
almost impossible to determine it from the lack of a normal
standard to make measurements with. Concerning this sus-
pected change in the ganglion cells, then, it may be said that if
there is any shrinkage at all, it is of very limited extent.
At the autopsy some minute petechial spots were found on
the [floor of the fourth ventricle (Fig. 1).* Microscopically,
these spots are small masses of extravasated red blood-cells,
situated, for the most part, in the perivascular spaces just be-
neath the ependyma.
The diagrams show the distribution and character of those
haemorrhages well enough, so that we may omit detailed de-
scription of them. A few of the extravasations are more deeply
situated and have a more significant position with regard to
the important nuclear groups in the medulla. Fig. 2a shows
one of the haemorrhages just on the outskirts of the senary
vagus, and other smaller ones close to the hypoglossal nuclei.
The extravasation near the vagus is confined by the perivascular
space of the median lateral artery of the medulla, which takes
the course of the dotted line x, y, in Fig. 2.
These haemorrhages look as if due to the passage of blood
along the perivascular spaces, and out into the tissues after
rupture of a small vein or capillary, but whether any especial
significance should be attached to these haemorrhages, or wheth-
er they are caused directly by the current, or by intense muscu-
lar tension, or by manipulation in removing the brain, are ques-
tions extremely difficult to decide about.
The Peripheral Nerves. — The sciatic nerves from both sides
were examined without finding any change or difference be-
tween the sciatic of the electrode side and its fellow.
The delicate structures of the retina lying so close to the
electrode are not altered.
The skin beneath the electrode is but slightly changed. The
epidermis is absent or raised up from the corium and has a
dried-up appearance. The corium, structurally, is nearly nor-
mal ; the connective-tissue nuclei are not shrunken and stain
well, but the connective-tissue bundles and fibers seemed changed
chemically and behave abnormally with certain staining re-
agents. The sweat glands are degenerated to a considerable
extent ; they have a desiccated appearance.
It would then appear from this examination that, beyond
the scalding effects of the electrodes, electric currents passed
through the body in this way produce no change in the body
except minute petechia?, and it is doubtful if these are not some
indirect or secondary consequence of the current. The results
of the microscopical examination of the two remaining subjects
— Loppy and McElvaine — are corroborative in every way of
this examination.
It seems proper to add that the central nervous system of
only one of these four cases was removed, because nothing was
* The plates are from drawings by Dr. Van Gieson.
May 14, 1892.]
MacDONALD:
THE DEATH PENALTY BY ELECTRICITY.
539
found in it which would receive any further elucidation from
the examination of the other three cases.
Methods of the Preparation of the Specimens.
The Blood. — Two drops from a glass rod dipped in the
freshly cut right ventricle were received in a one-per-cent.
aqueous osmic-acid solution.
The sciatic nerves were prepared in the same medium by
gently pulling short fasciculi out of their lamellar sheaths, al-
lowing the acid to penetrate.
The Central Nervous System. — Thin shavings of the con-
volutions and of the cervical spinal cord were placed in alco-
holic and aqueous solutions of corrosive sublimate of different
strength for periods of time varying from an hour to several
days. Exceedingly small portions of the gray matter were also
hardened in Fleming's osmic-acid mixture and in one-per-cent.
osmic-acid solution for half an hour. All of the specimens were
subsequently hardened in eighty per cent., and then in strong
alcohol.
Still other portions of the convolutions were scraped gently
with a sharp razor, so that the gray matter was reduced to a
thick pulpy broth on the edge of the razor. This pulp was then
shaken into exceedingly fine fragments in osmic acid and subli-
mate solutions, so that the fixation of the ganglion cells would be
as nearly as possible uniform and instantaneous. (Incidentally,
attention may be called to this method as giving very good re-
sults for ganglion cells, and being much better than the ordi-
nary methods of hardening the cortex in blocks, no matter how
small.)
The medulla and portions of the cord were also hardened in
Muller's fluid in the usual way. The trachea, thoracic and ab-
dominal viscera were prepared in sublimate solution, and also
with strong alcohol in the ordinary way. Portions of the spleen,
pancreas, and liver were also injected interstitially with osmic-
acid solution. The eyeball, eyelid, and singed portions of the
integument beneath the electrodes, were prepared with Muller's
fluid.
All of these variously hardened portions of the tissues
were imbedded in celloidin and sections stained appro-
priately with several different methods, such as Weigert's
method, double staining with hsematoxylon and eosin, and
also with the picro-acid fuchsin method.
Martin D. Loppy. — Autopsy held as soon as practicable after
breaking of the last current. Subject somewhat below the
medium stature. Body well nourished. Muscular system well
developed. Eigor mortis almost completely, if not entirely, ab-
sent, except in the right leg, where there is sufficient muscular
rigidity to hold the leg slightly adducted and flexed at the knee
joint. The mouth and nostrils are perfectly natural, and show
no traces of the extrusion of fluids or frothy material. About
a drachm of viscid fluid, wetting the skin of the pubic region,
has escaped from the urethra.
There are no discolorations, contusions, or other marks on
the skin, except in two places — viz., (1) at the flexure of the
right knee, where the lower electrode was applied, and (2) upon
the cheeks, corresponding to the position of one of the restrain-
ing straps. The unexposed surfaces of the skin are everywhere
else smooth, white, rather thin, and delicate in structure, and
show no settling of blood in the dependent portions of the
body.
At the flexure (or back part of the knee joint), where the
lower electrode was applied, there is a diffuse reddish discolora-
tion of the skin about three inches and a half by five inches in
diameter. This region of the skin shows a very moderate, su-
perficial, irregular separation of the thin outer scarf skin or
epidermis from the true and thicker skin beneath. The epi-
dermis or scarf skin in this region is raised up and corrugated,
and it can be easily rubbed off with slight force, When the
whole thickness of the skin is cut through with a knife, it can
be seen that this change is quite superficial, affecting the outer
scarf skin only, and does not damage the corium or true skin
beneath to any appreciable extent.
The corium or true thicker skin underlying the electrode re-
gion is soft, pliable, not desiccated, and seems to be normal in
every way, except that it is somewhat congested, which pro-
duces the reddish discoloration in this region.
The layer of fat beneath the skin in the electrode region is
in no way changed or damaged.
The head electrode has left no traces upon the skin. The
forehead and scalp beneath the electrode are perfectly white and
natural, and there are absolutely none of the superficial altera-
tions referred to above at the knee joint.
There is redness and swelling of both cheeks just beneath
the eyes, which is very moderate in extent and not enough to
make any distortion of the face. This was occasioned by press-
ure against one of the leather restraining straps during the pe-
riods of muscular activity when the current was applied.
The right eye had been lost some time previously during life.
The eyelids are closed ; skin of eyelids intact. Anterior cor-
neal epithelium of the left eye cloudy, but not detached. The
eyeball is perfectly natural ; it has the proper tension and con-
tour.
The interior of the mouth is normal. The tongue and the
teeth show no signs whatsoever of injury.
The body was opened in the usual way. The abdominal or-
gans were critically examined first, then the thoracic viscera,
and finally the brain and upper portion of the spinal cord.
The stomach is normal ; it is much contracted, rather small;
mucosa pallid ; fundus smooth ; pyloric extremity folded.
The small intestine is normal, contracted, upper portion
nearly empty, lower portion partially filled with semi-fluid faecal
matter.
The spleen contains, just beneath the normal capsule, several
larger and smaller haamorrhagic spots, from one millimetre to
three millimetres in diameter, such as are not infrequently found
after death from a variety of causes. The substance of the spleen
is normal.
The pancreas is normal in size and texture.
The liver is normal in size, and uniformly filled with blood;
cut surface smooth, stroma and parenchyma unchanged. Gall-
Madder normal; partially filled with bile.
The kidneys are of medium size ; capsules non-adherent ;
vessels well filled|; the cortex is normal in thickness, and has its
constituent elements properly arranged.
The suprarenal capsules are unchanged.
The urinary bladder shows no abnormities ; it is much con-
tracted and its mucosa pallid.
Heart. — The left ventricle is firmly contracted and empty ;
both auricles and the left ventricle are flaccid. The right ven-
tricle contains a little fluid blood. Two small thickened patches
of old endocarditis are at the base of the aortic valve. The
heart muscle is firm and normal.
The diaphragm stands at the level of the sixth intercostal
space on the left side, and at the sixth rib on the right side.
The lungs are non-adherent, pale, normal in size, texture,
and consistence.
The trachea, irsophagus, and aorta are normal.
The vocal cords are in cadaveric position.
Brain and Spinal Cord. — The brain was removed in the or-
dinarily practiced method, and the scalp, pericranium, and skull
show no effects of the head electrode. Skull braehycephalic.
540
MacDONALD: THE DEATH PENALTY BY ELECTRICITY. [N. Y. Med. Joub.,
Dnra mater of convexity normal. Longitudinal sinus normal;
contains a little fluid blood. Pia mater not thickened, but con-
tains a number of nebulous stria? and opacities uniformly scat-
tered over the whole convexity. There was considerable sub-
pial fluid. Both this change in the pia mater and the increased
subpial fluid are referable to some pre-existing condition, and
are such as are not infrequently found in persons having the
age and intemperate habits of this subject.
Convolutions of the brain have the normal topographical
distribution ; substance of brain normal, both as to the condi-
tions of the blood-vessels and the character of both the gray
and white matter. Vessels at base normal. Lateral ventricles
contain a slight amount of clear fluid. Ependyma of all ventri-
cles unchanged. Floor of fourth ventricle normal.
The right optic nerve — corresponding to the lost eye — is
atrophied, having about half of its ordinary thickness. The
medulla, pons, and basal ganglia show no abnormities. (These
were referred to Dr. Brill for microscopical examination.)
There is an old healed fracture extending across the right
orbital process of the frontal bone, one centimetre from the
median line, which extends backward and outward nearly to
the apex of the petrous portion of the temporal bone for a dis-
tance of about five centimetres. The dura mater along the track
of this old fracture is slightly thickened (to the extent of three
millimetres) and adherent to the bone.
The superior portion of the spinal cord shows no changes in
its coverings, vessels, or substance.
The rhuscles were critically examined to determine if there
were any signs of violence induced by the current or the con-
traction it caused, aDd with a negative result. The muscles of
the chest, abdomen, and calf were normal, bright red, firm, and
show not the slightest tearing or rupture.
Remarks. — In looking carefully over the details of this au-
topsy and comparing this report with that of the four previous
cases of infliction of the death penalty by electricity, the fol-
lowing points may be noted :
1. The passage of an electrical current of the pressure em-
ployed in these cases (of approximately from 1,400 to 1,700
volts) and in this manner does not do any damage to any of the
internal organs, tissues, or muscles. None of these parts are
lacerated or changed in volume; neither are there any gross
chemical or morphological changes or alteration of their finer
structural features.
2. The local thermic effects of the electrodes are limited to
the outer scarf skin. The true skin beneath is not damaged to
any appreciable extent. The epidermis or scarf skin may be
separated from the deeper skin, and resembles in this way an
ordinary blister from which the fluid has escaped. The blisters
about the knee in this case are like the ordinary familiar water
blisters on the hands trom friction, or the blisters which physi-
cians often have occasion to produce in their treatment of dis-
ease. Where the skin has been exposed to the weather, and is
tougher and more resistant, as on the forehead and scalp, the
blistering does not take place, whereas in the more sensitive
delicate skin ot unexposed surfaces, as at the fold of the knee
joint or the calf, the superficial blistering is more readily in-
duced. Compared witli the four previous executions, the
changes in the skin induced by the local thermic action of the
electrode are even still less in degree in this case, and may be
pronounced altogether trivial.
3. The occurrence and distribution of the minute hsemor-
rhagic spots (described more completely in the previous cases)
are not a uniform or constant feature in these cases, and as they
are found after death from the greatest variety of causes, they
can not properly be regarded as positively characteristic of
death by this method.
4. The attitude of the body on the autopsy table is peculiar
and very uniform. When the electrodes are applied at the knee
flexure, the leg is invariably slightly flexed at the knee and a
trifle adducted.
Charles McElraine. — Approximately two to three minutes
after the breaking of the last current the reflex action of the
voluntary muscles was tested as follows:
1. The patellar reflex was tried in the usual way without any
response from the muscles either in the knee of the electrode
side, which was rigid, or the knee of the other side, which was
relaxed.
2. The cornea was touched with the finger without eliciting
any exertion from the muscles of the eyelids.
3. The nipples were pinched with a forceps, and the sur-
rounding skin was scratched and lightly scarified with fine scis-
sors ; but this did not induce any motion of the muscle groups,
or even any fine fibrillary twitching of the individual fibers of
the subjacent muscles.
4. One of the muscles of the abdomen (the rectus) was ex-
posed, but showed no activity when cut or irritated with the
knife. Voluntary muscle reflexes to ordinary stimuli were ab-
sent. The activity of smooth or involuntary muscle was not
interfered with; thus peristalsis of the intestines and the cre-
masteric reflex could be excited.
After these tests the autopsy was made immediately.
I. External Appearances of the Body. — The subject is a trifle
below the medium stature, well nourished, has no deformities,
and has well-developed muscular system. The lips are pallid,
but the nostrils and interior of the mouth are perfectly natural.
The left eyelid is quite firmly closed, while the other lid is
partly open. The delicate membrane coating the front of the
cornea has not been disturbed by the head electrode. The
pupils are about midway open, nearly uniform, and measure
about two millimetres and a half in diameter. The eyeballs are
natural. There is no distortion of the face, such as muscular
contractions or marks of violence, to mar the countenance.
Rigor mortis is marked only where the current was applied ;
the electrode leg is flexed at the knee joint at an angle of about
90°, and is a trifle adducted. The arms, which received the first
contact, are less flexed than the knee joint, and the fingers are
almost completely closed in the palm of the hand.
There are no evidences of a seminal emission.
The skin is everywhere perfectly natural, except at the
points of application of the electrodes, and here there are some
superficial changes in the outer layers of the skin. In these
places, at the back part of the right knee joint and on the upper
surface of the wrists (where the first contact was made), the
thin outer scarf skin is wrinkled and raised up or partially de-
tached from the true or deeper skin beneath.
These superficial patches on the skin in the electrode regions
are not extensive and do not measure more than two to two
inches and a half in diameter. In order to see if these patches
involved the skin beyond the outer layers, the whole skin was cut
through with the knife and looked at critically. It was then
seen that the deeper layers of the skin were but very little in-
volved. The deeper or true skin is in places in these patches
a little drier than it ought to be, and this is all. The layer of fat
beneath the slightly superficially damaged patches on the skin is
perfectly normal in every way.
II. Examination of the Thoracic and Abdominal Organs.
— There is very little to be said about the examination of these
organs other than that they were subjected to a thoroughly
detailed systematic scrutiny, and nothing abnormal was found
either about their shape, consistency, or texture, except the left
ventricle of the heart was firmly contracted, while the right
ventricle was flaccid. Valves and heart muscle normal.
May 14, 1892.J
MacDONALD: THE DEATH PENALTY BY ELECTRICITY.
541
The left kidney (measuring 6x13 centimetres in diameter)
contained a number of larger and smaller cavities (the largest
one centimetre and a half in diameter) near the region of the
pelvis, some of which contain calculi. Such a condition of the
kidney is due to an old chronic previous process, and is to be
expected in persons who develop calculi in the kidney.
All of the viscera and organs of the thorax and abdomen
were examined.
III. The Central Nervous System. — The brain is brachyce-
phalic and is perfectly normal as to its coverings, in the disposi-
tion and structure of its blood-vessels, in the arrangement of
the convolutions, fissures, and sulci, and in the texture and rela-
tive distribution of the gray and white matter. The fourth
ventricle and its floor are normal. The superior portion of the
spinal cord is normal. (The brain was not completely dissected,
in order that it might be transported to Professor Donaldson, of
Clarke University.) The brain with the pia weighed, on scales
weighing to half a gramme, 1,442 grammes. The dura mater
weighed 52 grammes.
IV. The Muscular System. — The muscles are red and firm
and show no signs of tearing, rupture, or haamorrhage.
Conclusion. — As might naturally have been expected,
the adoption and successful inauguration of this new
method of capital punishment has not been accomplished
without encountering vigorous opposition, amounting in
some instances to violent and apparently malicious denun-
ciation of the acts and motives of those who were called
upon to act as principals in carrying out a law the estab-
lishment of which must eventually be regarded as an im-
portant advance in criminal jurisprudence in the direction
of a higher civilization. But even to-day, despite the wide
publication of unofficial reports, proclaiming the method a
failure and apparently designed to invest it with an air of
repulsion, brutality, and horror, it is conceded by substan-
tially all unprejudiced individuals who have witnessed these
executions, or who are reliably informed as to the facts re-
lating thereto, as well as by a large and increasing propor-
tion of the daily press, that the intent of the law to effect
sudden and painless death has been fully attained in each
instance. That a method of judicially inflicting the pen-
alty of death in punishment of the crime of murder will
ever be devised which in its operation shall be divested
of that sense of awe and dread usually experienced, espe-
cially by laymen, when in the presence of death, is not to
be expected ; and even were it possible, the wisdom of
such a method might well be questioned, so long as the
welfare and protection of society require the infliction of
such a penalty to deter men from committing murder.
It should be borne in mind that up to the time of
Kemmler's execution there was no recorded instance of
death having been deliberately effected on the human sub-
ject by this method, the only knowledge on the subject be-
ing derived from experiments on lower animals and from
observations in cases of death from accidental contact with
live electric wires and from such deductions as could logic-
ally be made from technical knowledge of electro-motive
force ; hence the first execution by electricity was neces-
sarily to some extent experimental and attended with possi-
ble elements of uncertainty, owing in part to crudeness in
the law and in part to certain minor defects in the arrange-
ment and operation of the apparatus and to the inexperience
of those in charge. In spite of these defects, however, the
important fact remains that the prisoner was instantly ren-
dered unconscious and death was painless.
Of the nearly one hundred physicians, many of whom
are eminent members of their profession, who have wit-
nessed one or more of these executions, only two have dis-
sented in any essential particular from the conclusion that
this mode of inflicting the death penalty destroys conscious
and organic life, both aggregate and segregate, with a sud-
denness and thoroughness that is not attained by any other
known method. One of these gentlemen, a distinguished
surgeon and an ardent opponent of capital punishment in
any form, witnessed the Kemmler execution, and while con-
curring in the general opinion that unconsciousness was in-
stantly produced by the first contact, still thought there was
a possibility that resuscitation might have been accom-
plished by means of hypodermic injections of brandy —
that is, after the first contact. The other dissenting physi-
cian, who is an advocate of the execution of criminals by
means of suffocation with toxic gases, witnessed the execu-
tion of McElvaine. He also agreed that unconsciousness
was instantly procuced by the first contact, but thought
that the second shock was required to effect absolute death.
There is no reason to doubt the sincerity of either of these
gentlemen.
Dr. Van Gieson, in his official report of the McElvaine
autopsy, in speaking of the rapid abolition of reflex action
of the voluntary muscles, says :
This tends to show how superlatively complete and far^
reaching the effects of the currents are in abolishing life, not
only in the concrete form, but also in the integral activities of
the body which in other forms of sudden and violent death is
liable to persist for a time after life is extinct. From observa-
tions at this execution, as well as at the subsequent examination
of the body, the current appears at first not only to extinguish
life in the ordinary sense of the word, so far as consciousness,
feeling, and volition are concerned, with overwhelming sudden-
ness, but reaches beyond this and destroys the energies of the
individual component parts of the body so that they can not be'
raised into activity by artificial mechanical stimulation, as is usu-
ally the case in sudden violent death.
The experience thus far had has demonstrated that the
only reasonable objection to so-called " electrocution " — at
least so far as the individual is concerned — as compared
with other modes of inflicting the death penalty, lies in the
fact that the application of a current of lethal energy re-
sults in the generation of heat at the point of contact, and,,
if sufficiently prolonged, is attended with vesication of the
skin at that point, owing to the temperature of the moist-
ure on the electrodes becoming elevated to the boiling point,
while if the sponges are allowed to dry out, local burning
may occur. This occurs, however, if at all, toward the end
of the contact and long, comparatively, after conscious life
is extinct; hence the objection is, after all, merely a senti-
mental one. Furthermore, it may reasonably be assumed
that a method of avoiding this local thermal effect will soon
be determined.
Finally, as compared with hanging, in which death is
frequently produced by strangulation, with every indication
of conscious suffering for an appreciable time on the part
542
JEXKS: ELECTRICAL EXECUTION.
[N. Y. Med. Jouk.,
of the victim, execution by electricity is infinitely prefera-
ble, both as regards the suddenness with which death is ef-
fected and the expedition with which all the immediate pre-
liminary details may be arranged. By the latter method
the fatal stroke renders the subject unconscious in an in-
finitesimal fraction of a second — so small as to be beyond
the power of the human mind to estimate it — while, at the
same time, it destroys both conscious and organic life in a
shorter space of time than is possible by any other known
method. In other words, it is the surest, quickest, most
efficient, and least painful method of inflicting the death
penalty that has yet been devised.
334 Fifth Avenue.
ELECTRICAL EXECUTION *
By W. J. JENKS.
Professor Lacdy has expressed the feeling which I
experienced regarding the possibility of accidental inter-
ruption of the current at a critical moment during an elec-
trical execution, and I think it important that any such pos-
sibility should be guarded against as further experience may
dictate, principally, in two ways — first, by making the appa-
ratus, engine, belting, dynamo, and circuit of ample capacity,
and partially loading it by operating a considerable number
•of lamps or otherwise, so that when the sudden strain is put
upon it by the completion of the circuit through the body,
the additional load may be a small percentage of the total
output at that moment or of the total capacity ; second, by
reducing, as far as is feasible, the energy applied.
Dr. Morton's remarks have very greatly instructed and
interested me. If he will permit me, however, I should like
to call the attention of the gentlemen present to a few con-
siderations and a few methods of expression which may
point the way to a clearer appreciation of just what occurs
to the body of the man upon whom the hand of justice is
ilaid in the application of the extreme penalty which human
power can inflict, in the form of instantaneous electrical
death.
Dr. Morton has to-night truly said that it is not the
mere voltage that kills. Perhaps a desirable form of ex-
pression is that it is the expenditure of that voltage at a
•certain rate for a certain time.
But the indefinite ideas that prevail on this subject
•are well illustrated by an incident which is a matter of
public record. Not long ago a gentleman who has a wide
reputation as an instructor and a man of science made
.some remarks on this point in testimony before the Board
of Aldermen of the city of Boston. In the course of his
examination the following record was made by the stenog-
rapher :
" Q. Now, when such a current (alternating) is applied to
the human body, it has a tendency to disintegrate all of the
tissues of the human body, and is necessarily fatal ?
u A. It depends on how much there is of it. I have taken
alternating currents, and every one knows that they are used in
■connection with medical treatment.
* Remarks made, by invitation, in the discussion of Dr. MacDonald's
paper.
" Q. What voltage?
" A. Oh, millions of volts. I have taken the current from
an ordinary little medical machine — well, I will be very con-
servative and say, to the extent of half a million volts.
" Q. But a small quantity of electricity?
" A. Small in quantity; yes, sir.
" Q. It would be like taking a stream of water so small that
you could hardly see it, and projecting it with great force?
" A. It would be projecting it backward and forward ; it is
really vibration."
Now, while at a first reading of these expressions they
may appear to agree with Dr. Morton's proposition, it is
difficult to imagine more misleading statements. If there
is any medical electrical machine in existence that will
resist the j>ressure 0f 500,000 volts tending to break down
its insulation, the fact that it could produce that electro-
motive force would by no means prove that any such press-
ure was expended in the body of a person who might use
it. It does not require much power to produce a differ-
ence of potential of 500,000 volts, but it would require an
enormous power to maintain that pressure if given an op-
portunity to expend itself in a human body, for, assuming a
resistance of 200 ohms, we should find a fall of potential of
2,500 volts for every ohm, or, as we usually express it, a
current of 2,500 amperes.
To apply a pressure of 1,000 volts, alternating from two
hundred to three hundred times a second, and maintain
that pressure for an appreciable time against the resistance
of the human body, does not probably greatly increase that
resistance at the instant of contact. Or, if it has such an ef-
fect, the maintenance of the so-called current reduces the
effective resistance so speedily that we get the expenditure,
from 1,000 volts (to say nothing of 500,000 volts), of such
tremendous energy as snuffs out the life of the criminal more
quickly, as the graphic language of Dr. MacDonald's paper
has explained, than neural impression can be carried from
the point of contact to the seat of sensation in the brain.
The energy that kills is therefore the product of three
factors — (1) the electrical pressure or electro-motive force
that is applied to the surfaces of the body, or, in more ac-
curate technical language, the effective difference of poten-
tial (in volts) between the electrodes, shown by the Cardew
voltmeter ; (2) the rate of expenditure of this potential in
each unit of resistance in the body, or the number of volts
fall of potential to the ohm (amperes) shown by the amme-
ter ; (3) the time (seconds) shown by the stop-watch. The
volt-amperes (watts) give the rate at which the work of de-
struction is going on ; the volt-ampere-seconds (joules) are
the measure of energy expended or heat developed in the
body during the time of contact.
None of these factors are well settled as yet in their re-
lation to the energy actually required to cause instant and
painless death. By " death " I mean now, not alone cessa-
tion of consciousness of a perfectly healthy human being in
an interval too brief for thought to measure, and the estab-
lishment of conditions which produce gradual and final ex-
penditure of the stored nervous energy of the brain and the
subordinate centers of distribution of vital force — such as
the pneumogastric nerve and the spinal column — 1 mean,
THE NEW YORK MEDICAL JOURNAL, MAY 14, 1892.
DR. MacDONALD'S ARTICLE ON
THE INFLICTION OF THE DEATH PENALTY BY MEANS OF ELECTRICITY.
Fig. I shows the construction of the "death chair," the method of applying the current through
the hands in the case of McElvaine, and the attitude of the subject before receiving the contact.
Figs. 2, 3, and 4 show the character and distribution of the petechial spots in the floor of the
fourth ventricle in the case of Schichiok Jugigo.
THE NEW YORK MEDICAL JOURNAL, MAY 14, 1892.
MR. JENKS'S ARTICLE ON
Fio. 1.
Figure 1.
Assumed distribution of resistance, and expenditure of energy
which would result from such distribution, illustrative of possible
conditions of second contact in McElvaine's electrocution. Total
potential, 1,500 volts ; average current, 7 amperes. Total resistance
indicated by volt and ampere readings, 215 ohms. Width of chan-
nel through the body illustrates assumed comparative conductiv-
ity. Total watts expended (1,500 x 7) = 10,500 = 14 H. P. Onlv
490
10 500 = ^ Per cen'- °f total energy is by this assumption ex-
pended upon the large channels of blood, the heart and lungs, and
the nerves between the neck and hips.
C. — Surface contact and adjacent tissues say within six inches
of electrode on the leg: HO ohms, 5G0 volts drop, 3,920 watts.
C to B. — Knee to trunk: 45 ohms, 315 volts drop. 2.205 watts.
B to A. — Heart and trunk generally: 10 ohms, 70 volts drop,
490 watts.
A. — Surface contact of head electrode and adjacent tissues : 80
ohms, 560 volts drop, 3,920 watts.
Figure 2.
Assumed distribution of resistance and expenditure of energy
illustrative of possible conditions of first contact in McElvaine's
electrocution. Total potential. 1.600 volts; average current, 2-5
amperes. Total resistance, 640 ohms. Width of channel through
body illustrates comparative conductivity. Total watts expended
(1,600 x 2-5) = 4.000 = 5J H. P. Onlv 135 = = 3 per cent, of
• 4,000 1
total energy is here expended upon the large channels of blood
and the nerves between the shoulders and the heart and lungs.
1) to E. — Heart and trunk generally: 20 ohms, 50 volts drop,
125 watts.
C to D. — Elbow to shoulder : 50 ohms. 125 volts drop, 312 watts.
B to ('.— Wrist to elbow : 250 ohms. 625 volts drop, 1,562 watts.
A.— Salt-water contact: 10 ohms, 25 volts drop, 62 watts.
ELECTRICAL EXECUTION.
+
Fio. 3.
Figure 3.
Assumed distribution of resistance and expenditure of energy
illustrative of possible conditions of a contact from arm to arm,
immersed to the elbow, the total potential remaining as before,
but the current, of course, increasing and the distribution of fall
of potential entirely changed. Width of channel illustrates com-
parative conductivity; current, 11-43 amperes. Total resistance.
140 ohms. Total watts expended (1,600 x 11-43) = 18,288 watts.
or 24-4 II. P. — 14 per cent, of total energy is here ex-
18,288
pended upon the blood channels, nerves, and lungs.
A.— Salt-water contact: (say) 10 ohms. 114 volts drop, 1 .303 watts.
H to G. — Elbow to shoulder: 50 ohms, 571 volts drop. 6,532 watts.
G to D.— Heart and trunk generally : 20 ohms, 228 volts drop,
2,613 watts.
May 14, L899.]
JENES: ELECTRICAL EXECUTION.
543
also, total paralysis of all the vital organs and of the nerv-
ous centers -by which they are directly or indirectly vital-
ized, and by which the muscles of the extremities are actu-
ated, so that when the current is broken there can be no
reflex action of the muscles, such as would indicate the
presence of residual life energy, or a possibility of its re-
suscitation.
I think none of these factors are settled, because it is
not yet known how small a resistance may be found when
only those parts of the body which must be paralyzed, and
the surface tissues which most readily lead the current to
those parts, are included in the circuit. That the contact
surfaces are excellent (and satisfactory) no intelligent wit-
ness of one of the later executions will deny. The peculiar
scalding effects of the current at the edges of each of the
electrodes nearest to the electrode of opposite polarity, and
for some distance along the track most readily followed by
the greatest density of the current, has been attributed — er-
roneously, I think — to the contacts themselves, and to the
idea that accidental surface moisture has been followed by
the current and heated till dissipated in vapor.
The rough sketch (Fig. 1) will illustrate what I believe
to be the correct idea. Near each electrode the area of
comparatively good conducting material (moisture-filled tis-
sues) which lies in the line of least resistance is limited,
and a high degree of current density results, until in its
course from one electrode toward the other the current finds
an expanded path and can spread itself over a larger area
without departing very much from a direct line, or at any
rate without encountering largely increased resistance..
Within this area of great current density or large expendi-
ture of volts to the unit of cross-section of the conducting
tissues the few blood-vessels, nerve channels, and moisture
ducts oppose so great a resistance to the rush of energy as
to occasion a great drop of potential and thus great heat, and
the moisture is quickly raised in temperature to the scald-
ing point. Much of it must have been turned to steam
under the epidermis and perhaps in the minute blood-ves-
sels, and those portions of the body close to the electrodes
are parboiled if a large current is maintained.
How useless this great expenditure of potential is, I
have tried to show by the calculations attached to Figs. 1,
2, and 3. The correctness of this general analysis was dem-
onstrated by the intensity of the heat observed in the fore-
arms and near the head and leg electrodes in the case of
McElvaine, and the fact that the bony structure of these
parts of the body contributed materially to the resistance
was evident from the high temperature (120° F. or more)
which was noted for nearly two hours after death.
It is also evident that a fall of potential, under the con-
ditions of Fig. 2, between the hands and the shoulders is
not useful in producing instant death. Hence it appears
that the energy expended outside the vital centers (on the
assumptions of these rough sketches) is greater by far than
that which actually accomplishes the paralysis desired.
Hence, probably three quarters or more of the total horse-
power applied to the body is of no substantial effect. If a
current of the same number of amperes could be expended
exclusively at the life centers, it might be found that only
a low voltage (perhaps 100) would be ample, and that the
concentration of 10 amperes or less in these centers of
nervous activity might allow of the reduction of the time
also to a fraction of what has thus far been considered
necessary or desirable.
For example, in the case of McElvaine, the heat energy
expended was approximately, in the first contact, 1,(300
(volts) X 2-5 (amperes) X 50 (seconds) = 200,000 (joules) ;
in the second contact, 1,500 X 7 X 36 = 3Y8,000; total,
578,000 joules.
Suppose it should be found that proper application of
the electrodes would reduce the voltage to 200, the amperes
to 5, and the time to 10 seconds. We should then have an
expenditure of only 10,000 joules of energy, and may it not
be found in the future practice of this method that thus no
disfigurement of the body need be produced, and absolute
animal death may occur more quickly than that of any of
the seven victims of whom Dr. MacDonald has spoken '.
Thus the " forty-horse-power death " desired by Dr. Mor-
ton may not be necessary. May it not often be the case
that death by the thunderbolt is caused by the expenditure
in the body of 10,000 volt-amperes or even less for y^-gVro
of a second, or even a shorter time ?
As an aid to a settlement of these questions of how
many volts, amperes, and seconds are necessary, or rather
how few of each can be relied upon to do the work with ab-
solute certainty, it would be important to determine the rela-
tive resistance of various portions of the body, because when
we apply a deadly current, the fall of potential and the work
done at every point are in exact proportion to the percentage
which the resistance of that point bears to the resistance of
the whole.
I regret that Mr. A. E. Kennelly, consulting electrician
at the Edison Laboratory, with whom I attended McEl-
vaine's execution, is not present. In his absence I will
take the liberty to read extracts bearing upon this point
from a letter which he wrote me under date of March 14th,
in answer to the suggestion I have just expressed.
" I think that a high pressure brought to bear upon a man's
body between any two points, say hand to hand, finds the re-
sistance initially just what we measure it by the bridge, but that
it breaks down at a rate rather difficult to foresee. Also that
valuable experimental measurements could be made (as you sug-
gest) of the resistance in different parts of a man's body, thus —
[drawing] "A B represents (diagrammatically, I should men-
tion) a man lying on his back in a semi-nude condition. A bat-
tery or dynamo current (direct or alternating) is applied of the
right, and readily supported strength at convenient points, say
the extremities 0 and D, by means of wet bandages. Sponge-
faced electrodes E, F, connected with an electrometer, are then
moved from point to point by various distances apart and the
fall of potential studied. I suspect — without pretending to
know — that the resistance of the body and its distribution from
point to point mapped out by this method, would be maintained
in ratio or relative proportion under fatal pressures, even
though the absolute resistance fell everywhere.
" I confess that, while the hand method is the simple and
practical method witli or without deep immersiou as you out-
line it, the head method is the true way for rapid and complete
nerve destruction. I give that point to the doctors. I do not
think that the difference between three and seven amperes ac-
544 OVERLOOK: INFLUENZA IN
counts for the difference we saw in the after-effects and reflex
sensibilities.
" I think that an accurate knowledge of the resistance from
point to point of an average human body might assist occasion-
ally in the diagnosis of disease, and the comparison with the re-
sistances of a corpse might have useful results to show."'
I am not a believer in capital punishment. The idea is
to me revolting and inconsistent with the theory of a high
civilization. It has never seemed to me that the deliberate
destruction of human life ought to be necessary to the
well-being of society. The same safety might, I think,
be secured by a law which would doom the murderer to
life imprisonment beyond any possibility of escape save
the one chance of proving that he had been wrongfully
convicted.
But if " life for life " is in the future to be the law of
the land, electricity is an agent by which we may take
life swiftly, surely, and mercifully. The dignity which has
marked the electrical executions thus far has been as note-
worthy as the previously unattained rapidity of every move-
ment by which the result has been secured.
INFLUENZA IN NORTHERN NEW ENGLAND.
By S. B. OVERLOOK, M. D.,
STEUBEN, MAINE.
As to the articles that have been written on la grippe
since it has become a prevalent epidemic disease in this
country their names are legion, and my only excuse for
offering anything additional to the medical profession is
that my experience with the disease has been confined to a
section of country different from that of any author's whose
article has come to my notice. Also, that while the mor-
tality has been high in towns but a few miles distant from
this, out of over three hundred cases to date no one of them
has ended fatally here.
The outbreak of this disease during the present winter
has been more severe than that of last winter or of two years
ago, a much larger number of cases terminating in pneumonia.
During the latter part of December and the whole of January
the epidemic was confined to the outlying districts east of
the town and along the sea-board, not a single case appear-
ing in the town proper, or in the outlying farming and lum-
bering sections to the westward. After nearly every person,
and at times whole families, had been prostrated and recov-
ered in the first-mentioned sections, cases began to appear
in town, which rapidly spread into the outlying districts
westward. Every age and condition were alike seized —
hardy fishermen and lumbermen, exposed to every change
in weather, and the merchant and artisan, who had hardly
been out of doors for the winter — showing conclusively
that " colds " had little or nothing to do with the spread of
the disease.
Clinical features have varied according to age and
physical condition of the patient, but all have had enough
in common to furnish a chain of symptoms highly charac-
teristic of the disease. In children under ten or twelve
years of age vomiting has been an almost constant symptom-
NORTHERN NEW ENGLAND. [N. Y. Med. Joto.,
Constipation has prevailed in a large majority of cases ; in
a few the reverse has been present — diarrhoea. In adults
rapidity of pulse, marked rise in temperature, cephalalgia,
and pain in limbs have been constant symptoms for the first
twenty-four hours. At the end of this time a cough and
acute bronchitis are prominent features. In aged people
there is always a sense of fatigue, nervous depression, and
sometimes somnolence.
In the epidemic of two years ago an attempt was made
to formulate some regular plan of treatment, but without
satisfactory results. In the present epidemic a general
plan of treatment has been followed, varying, of course,
with the age and general physical condition of different
patients. In sthenic subjects with high arterial tension,
marked rise of temperature, cephalalgia, pain in limbs, if
there has been no movement of the bowels for the previous
twenty-four hours or longer, a full dose of calomel was
usually given, and if this failed to produce an evacuation in
twelve hours, it was followed by a saline. In one hour ten
grains sulphate of quinine with Dover's powder was given.
In a short time the skin became moist, arterial tension be-
gan to lower, cephalalgia and pain in the limbs to abate.
Tincture of aconite in small doses frequently repeated was
given, watching meanwhile respiratory movements. The
aconite seemed to lessen the amount of work done by the
organs of respiration, and by blunting sensibility of the
sensory nerves relieves the neuralgic pains to a greater ex-
tent than any other antipyretic. Usually after twenty-four
hours' treatment arterial tension has become nearly normal,
temperature is reduced in a marked degree, and there is
little or no pain in head or limbs. When bronchitis was
present, as it may be said to have been in every case, an
expectorant mixture consisting of fluid extract of ipecac,
chloroform, and syrup of squill or Tolu syrup was given
every two, three, or four hours, according to indications. If
the expectorated matter was particularly viscid or took on
the peculiarly bluish tint seen in many instances, carbonate
of ammonium and iodide of potassium or iodide of ammo-
nium was added to the cough mixture. If a marked sore
throat was present, chlorate of potassium was used with good
results, combined either with the expectorant mixture or
with tincture of the chloride of iron, and applied to the
throat with a swab. Pneumonia, as a complication, received
the usual treatment. Alcoholic support was used earlier
than in a pneumonia not preceded by la grippe. With
children the principal antipyretic used was the liquor am-
monii acetatis. This with a simple cough mixture usually
brought the attack under full control in from eighteen to
twenty-four hours. In old and feeble subjects alcoholic
stimulants and an expectorant were administered at once,
and this was the principal treatment adopted.
In a few cases the newer analgesic, antikamnia, was
used with good results, so far as relief of pain was con-
cerned. Acetanilide and antipyrine do not fulfill the in-
dications or meet the wants of the patient in the sympto-
matic fever accompanying the disease. Physicians who use
acetanilide, especially in case of the weak, irritable heart of
brain-workers, will be obliged to write "heart failure" fre-
quently in their death certificates.
May 14, 1892.]
LEADING ARTICLES.
545
THE
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by Edited by
D. Appleton & Co. Frank P. Foster, M. D
NEW YORK, SATURDAY, MAY 14, 1892.
THE THYREOID GLAND AS A CAUSATIVE AND CURATIVE
AGENT IN MYXIEDEMA.
In an interesting paper on the function of the thyreoid
gland, published in the British Medical Journal for January
30th and February 6th, Mr. Victor Horsley concludes that this
gland, is a structure essentially connected with the metabolism
of the blood and tissues, being both directly and indirectly
haematopoietic in fulfillment of its functions, secreting from the
blood a colloidal substance that is transmitted by means of the
lymphatics from the acini of the gland to the circulation. This
position seems to be sustained by the general results of experi-
mental thyreoidectomy, and they seem also to favor the view
that the gland is an important origin of metabolic influence.
As a consequence of experimental researches, he believes that
the symptoms of disease or obliteration of the gland may be
divided into a first, or neurotic; a second, or myxedematous;
and a third, or cretinic stage. Death may occur in any of these
stages, according to the virulence of the cachexia. The indis-
pensability of the gland seems to be demonstrated by the hyper-
trophy of its tissue when a portion of it is lost; and a certain
proportion of its tissue must be maintained for the purpose of
health, though its importance varies with the activity of the
vital processes, being greatest in early life and diminishing with
age.
The constant additions that experimental physiology has
made to our knowledge of the functions of this gland have been
a stimulus to further research regarding the means of alleviat-
ing the conditions consequent upon its disease or removal.
Among the first experiments were those made in grafting a
portion of an animal's thyreoid into the peritoneal cavity or
on to some other structure of an individual afflicted with the
" cachexia strumipriva." But such an operation is open to many
objections.
Recently experiment and practice have essayed another
method. Mr. George Murray presented a paper at the last
meeting of the British Medical Association (British Medical
Journal, Oct. 10, 1891) in which he stated that, if we consid-
ered that myxedema and cachexia strumipriva were due to the
absence from the body of some substance which was present in
the normal thyreoid gland, and which was necessary to main-
tain the body in health, it was at least rational treatment to
supply that deficiency as far as possible by injecting the extract
of a healthy gland. Vessale's experiments with intravenous in-
jections of an extract of that gland in dogs after thyreoidecto-
my suggested the beneficial results that would follow similar
injections, and in his paper the author reported the case of a
lady, aged forty-six, who had suffered with myxedema for five
years, in which sterilized extract of sheep's thyreoid was in-
jected hypodermically with resulting improvement in all the
symptoms of the disease.
Recently Dr. W. Beatty (British Medical Journal, March
12, 1892) has reported a case of this disease in a lady, aged
forty-five, who had had gradually progressive symptoms for
four years, in which he first tried massage for five weeks with
very moderate benefit. Then injections of the extract of sheep's
thyreoid were given at intervals of from four to ten days with
rapid and marked improvement in the patient's condition.
In a communication to the same journal for October 10,
1891, Mr. E. Hurry Fenwick reported a case of myxcedema in
which he had grafted a sheep's thyreoid, and on the following
day the temperature had risen from its usual subnormal level
to normal, while the urinary excretion increased from twenty
to fifty ounces per diem. In a subsequent case of the disease
in which he injected thyreoid juice hypodermically similar re-
sults were obtained, persisting for twenty-one days and occur-
ring more rapidly. So it seems from this latter report that the
action of the juice when injected is quite rapid and, as com-
pared with the operation, quite as efficacious.
It has not yet been demonstrated that the thyreoid tissue
will persist as such after transplantation, and, while the benefi-
cial results of injections of the juice may be limited to the time
during which their use is continued, still the excellent results
obtained in an amelioration of the symptoms of what has been
considered an incurable disease would warrant their adminis-
tration with the precautions the orginator has prescribed.
A MUSICAL ANUS.
Some four or five years ago M. Vernenil exhibited to his
class in Paris a case of what he facetiously denominated "musi-
cal anus." The patient was able at times, when sufficient flatus
had accumulated in his colon, to evacuate it with some force,
thereby producing a high-pitched musical note resembling that
of a violin. On close examination, he was found to have, in
the cellular tissue about the lower end of the rectum, a pneu-
matocele, with an opening into it from the rectum, formed by a
narrow slit between two thin folds of mucous membrane,
which, acting like a reed, produced the sound when the air was
expelled from the tumor by forcible pressure from above.
Numerous cases of fistula and other deformities of the anus
have been seen in which the expulsion of gas from the bowel
was accompanied by peculiar sounds, some perhaps musical to
the enthusiastic observers. But in all these cases there has
been some deformity or malformation of the rectum or anus.
Dr. Baudouin, however, has lately reported in the Semaine
medicale a case that may with justice be called one of musical
anus, and one that is of much interest from a physiological
point of view. The patient, or rather the exhibitor, is a man
aged thirty, well developed, but without muscular excesses,
tall, of full weight, and, so far as can be made out, entirely free
from any disease or deformity. His digestion is good and he
does not develop an unusual quantity of gas in the bowel after
54:0
MINOR PARAGRAPHS.
[N. Y. Med. Jour.,
eating. Tbere is no pyrosis or abdominal tympanites. His
fsecal passages are normal, regular, and well molded. The anus
and rectum, in a state of repose, present nothing abnormal.
The sphincter is moderately strong, but quite distensible, not-
withstanding its daily exercise. The rectum is normal and not
dilated. The remarkable feature of the case is that the lower
bowel, at least, seems to be absolutely under the control of the
man's will. He can empty it completely whenever he desires,
a very fortunate accomplishment for his clothing and for the
olfactories of his audiences. He was reared on the shores of
the Mediterranean, and it was here that he first noticed his re-
markable power. "While bathing one day he observed upon
strong inspiration the sensation of cold in his pelvis and ab-
domen, and at the same time felt the sea water entering his
rectum. In a short time he was compelled to empty his bowel,
and noticed that he had taken in a much larger quantity than
he had supposed. By practice in the ordinary bath and in the
sea, he became able to store a considerable quantity of water,
to retain it for some time, and to eject it with much greater
force than at first. Later on he noticed that he could accumu-
late air in bis bowel, as well as water, and by its expulsion could
give rise to certain variations of sound. Applauded by his
associates, who acknowledged his superiority in this class of ex-
ercise, he eventually developed the faculty beyond measure, and
frequently gave exhibitions of his art before a select circle of
his friends. From these reunions he began to exhibit his
powers in the clubs and cafes until he became the best-known
and greatest curiosity of the place. As his reputation spread
he made journeys to the surrounding towns and villages, Bezin,
Nimes, Toulouse, and Bordeaux. At the latter place he was
examined by many of the medical faculty, and a discussion of
the case was reported in the Gazette hehdomadaire des sciences
medicates de Bordeaux for March, 1892, in which Dr. Ferron
and Dr. Boursier said they had each seen men possessing the
power of storing and expelling considerable quantities of water
from the rectum, but had never seen one able to draw in and
expel air. In addition to this power, however, this individual
has a peculiar control over the external sphincter, by which he
is able not only to control the escape of air but also to imitate
the sounds of a violin, a trombone, and other instruments, and
to reproduce melodies thereby which may be distinctly recog-
nized. To do this he stands with his legs straight, his body
flexed upon his thighs, and his head bent first to one side and
then to the other. During the performance he moves his but-
tocks in all directions, seeming thus in some way to be able to
govern the conformation of the anus and to produce the differ-
ent sounds and tones. There is said to be no disagreeable odor
to the expelled air, as he clears the ground well before begin-
ning operations. The process consists of two acts, inspiration
and expiration, the former taking only one or two seconds, and
the latter being capable of being prolonged from ten to fifteen
seconds.
These facts have been verified by Professor Richet and Pro-
fessor Poirier, who have made a prolonged study of the case, as
well as by many others of the faculty of Paris. From a
physiological point of view the case is very interesting, opening
up the field for discussion and study as to how far the colon
can be made to supplant or supplement the lung in voluntary
respiration, and the sphincter of the anus to take the place of
the lips in playing on wind instruments.
MINOR PA RA GRAPHS.
ALBUMOSURIA.
De. Lee Dickinson, as reported in the Medical Press and
Circular for December 2, 1891, has presented before the Clini-
cal Society of London twenty cases of pneumonia and other
affections in which the urine contained albumose. These
cases, or some of them, are probably the same essentially as
those that have in times past been designated peptonuria.
Neither by Dr. Dickinson nor by Dr. Fyffe, his collaborator,
was true peptone found, but whenever the biuret, or purplish-
red, reaction was obtained, albumose was its cause. This is
a point of importance because many albumoses are poisonous,
and the ordinary albumoses of peptic digestion have a much
more powerful action than true peptones when injected into
the circulation of animals. From the effects of injections in
animals it seems probable that the diarrhceal complications
from which many of these patients suffered may have been due
to the passage of albumose through their blood. The notewor-
thy point in these cases was their high mortality ; they also
were marked by serious sequela?, apart from the development
of empyema. Again, it was noted that albumosuria was absent
throughout some of the cases that were accompanied by exten-
sive hepatization of lung and had a virulent course and fatal
termination ; and it is judged probable that, cceteris paribus, a
favorable prognostic sign in severe pneumonia may be based on
the existence of albumosuria. The origin of the albumose is
pus, or at least inflammatory exudation, especially that of pneu-
monia; and it is probable that it is the product of the pyogenic
micro-organisms. Albumosuria has been observed in acute
rheumatism. Ovarian cysts when ruptured have been recog-
nized by the presence of albumose in the urine. This substance
is clinically related with intercurrent diarrhoeas, but it seems to
have no special relation with organic renal disease.
PHYSICAL INSTRUCTION IN THE PUBLIC SCHOOLS.
The superintendent of the public schools has prepared a
scheme of instructions in physical exercise, to be the guide of
the principals of the various schools in teaching gymnastics to
their pupils. At present there is more or less of drill in calis-
thenics in most of the schools, but there are special appliances
in five schools only. Next year the number in which appliances
will have been introduced will probably be quadrupled. A
regularly educated physician has been appointed to have over-
sight of the physical instruction in the schools, under the con-
trol of the Board of Education.
THE RED BLOOD-CORPUSCLES AS A SOURCE OF ANIMAL
HEAT.
The Lancets Paris correspondent states that Professor Mosso,
of Turin, has recently communicated to the Societe de biologie
an account of certain experiments of his going to show that the
red blood-corpuscles have something to do with the thermogenic
function. Having curarized a dog, Professor Mosso practiced
artificial respiration with hydrogen, so as to remove every trace
of carbon dioxide. Sensitive thermometers were then inserted,
May 14, 1892.]
MINOR PARAGRAPHS.— ITEMS.
547
one into the carotid artery, and others into various viscera ;
whereupon, as- soon as artificial respiration witli ordinary air
had heen begun, the mercury in the carotid thermometer sud-
denly rose, while in the others it did not.
THE NEW YORK EYE AND EAR INFIRMARY.
TnE family of the late Dr. Abram Dubois, who for many
years was one of the surgeons of the infirmary, are, it is an-
nounced, about to add to it a pavilion in his memory. As this
will require the destruction of a portion of the old building and
the erection of another new one, the trustees will appeal to the
public for contributions to the necessary fund. These they
ought to have no difficulty in obtaining to any requisite extent,
for the institution has served the community most solidly for
well-nigh three quarters of a century, and has been remarkably
well managed.
THE " KAISERQUELLE " AT TOLZ.
The Medical Press and Circular for January 20th comments
on an apparently intentional deception in the matter of an al-
leged mineral water. The Kaiserquelle spring has been lauded
as the richest " iodine spring " in the world since the time of its
so-called discovery in 1890. It has been shown in a court of law
that it was a manufactured and not a natural product. The
" discoverer " of the spring, named Bertsch, caused a small stream
of water to pass through a milk-can filled with a lot of chemicals
suitable to yield the kind of water he thought he could sell to
sick people. All might have gone well if the owner of the spring
could have kept his secret a year or two longer.
FEVER AT FLORIDA RESORTS.
Some of our citizens are said to have made a speedy exodus
from Florida recently, under the belief that a fever, typhoidal
in nature, had appeared at two or more of the best hotels fre-
quented by Northern people. There have been some serious
cases of sickness brought home from the South, but no deaths
have been reported.
ITEMS, ETC.
The American Surgical Association wil meet iu Boston, in the hall
of the Natural History Society, on Berkeley Street, on Tuesday, Wednes-
day, and Thursday, May 31st and June 1st and 2d, under the presidency
of Dr. Phineas S. Connor. The preliminary programme gives the fol-
lowing titles : The Treatment of Uncomplicated Fractures of the Lower
End of the Humerus and of the Base of the Radius, by Dr. John B.
Roberts, of Philadelphia ; Fibroid Tumors of the Uterus, by Dr. John
Homans, of Boston ; Surgical Operations on Persons suffering from
Diseases not. connected with that necessitating the Operation, such as
Chronic Malarial Poisoning, Diabetes, Organic Heart Disease, etc., by
Dr. W. T. Briggs, of Nashville, Tenn. ; The Surgery of the Tongue, by
Dr. N. P. Dandridge, of Cincinnati ; Conditions demanding Excision of
the Globe of the Eye, by Dr. W. H. Carmalt, of New Haven, Conn. ;
Ancient Contractures of the Hip and Knee Joints, by Dr. T. F. Prewitt,
of St. Louis ; and A Report of Operations upon Spina Bifida and En-
cephalocele, with remarks, by Dr. A. T. Cabot, of Boston.
The Death of Dr. Charles Fremont Clark, of Brooklyn, occurred on
1 April 21st. He was born at Wheeling, West Virginia, in 1856. He
obtained his education in letters at the Washington and Jefferson Col-
| lege, and was there graduated in 1878. The College of Physicians and
'■ Surgeons gave him his medical degree in 1883. After a year spent as
interne at the Brooklyn City Hospital, he was for several years in pri-
, vate practice in Brooklyn. His final illness was apparently of the
nature of an obscure typho-malarial fever. He had for seven or eight
years past supposed himself to be the victim of malarial poisoning, and
he had treated himself for that condition until about a week before his
death. He then had alarming elevations of temperature, as high as
107° F., also a great increase of abdominal pain. Consultations were
called, but the unusual elements of Dr. Clark's malady could not be
satisfactorily accounted for, and its untoward progress could not be
stayed. An autopsy revealed the true cause of this painful attack and
untimely death to have been a chronic inflammation of the vermiform
appendix, on which an acute attack had supervened, with multiple
metastatic suppuration in liver, lungs, and kidneys. He was found also
to have been the subject of an abnormally free, or " floating," caput
coli. The mesentery on the right side was faultily developed and per-
mitted the cascum and appendix to swing out to the left side in such a
way as to keep alive and to aggravate the trouble that had probably
begun years before in the appendix. The latter organ contained a for-
eign body, which had evidently been the source of a chronic and sub-
acute irritation, and given rise to the belief that malarial influences
were at work to undermine the sufferer's health. Dr. Clark's life ap-
peared not to have been in imminent peril, except for the added burden
of this anatomical abnormity, the floating caecum, which masked the
ordinary indications for surgical interference until the time had passed
for that plan of treatment.
The Death of Dr. Lorenzo W. Elder, of Hoboken, N. J., took place
on Wednesday, the 11th inst. The deceased, who was in his seventy-
third year, had for many years been a much respected practitioner in
Hoboken.
The Buffalo Medical and Surgical Association. — The special order
for the meeting of Tuesday evening, the 10th inst, was the reading of
a paper on Some Sources of Error in Obstetric Diagnosis, by Dr. P. W.
Van Peyma.
The Medical Association of Central New York will hold its twenty-
fifth annual meeting in Syracuse, at the Empire House, on Tuesday, the
31st inst.
Thymacetin. — " Hofmann, of Leipzig, applies this name to a deriva-
tive of thymol bearing the same relation to the latter which phenacetin
does to phenol. Its chemical composition is represented by the formula
CieH9iNO'a. It is a white, crystalline powder, difficultly soluble in alco-
hol. It has hypnotic properties." — Druggists' Circular and Chemical
Gazette.
Changes of Address. — Dr. Austin Flint and Dr. Austin Flint, Jr.
to No. 60 East Thirty-fourth Street ; Dr. James A. Nichols, to No. 143
West Thirty-fourth Street.
Army Intelligence. — Official List of Changes in the Stations and
Duties of Officers serving in the Medical Department, United States
Army, from May 1 to May 7, 1892 :
Wolverton, William D., Lieutenant-Colonel and Assistant Medical
Purveyor, is granted leave of absence until July 10, 1892.
Appel, Aaron H., Captain and Assistant Surgeon, is relieved from duty
at Fort D. A. Russell, Wyoming, and will report in person for duty
to the commanding officer, Fort Buford, North Dakota, relieving
Cabell, Julian M., Captain and Assistant Surgeon, who will then
report in person for duty to the commanding officer, Fort D. A.
Russell, Wyoming.
Crampton, Louis W., Captain and Assistant Surgeon, is relieved from
further duty at Fort Townsend, Washington, and will report in per-
son to the commanding officer, Fort Spokane, Washington, for duty
at that station.
Ball, Rohert R., Captain and Assistant Surgeon, is relieved from fur-
ther duty at Fort Spokane, Washington, anil will report in person to
the commanding officer, Fort Townsend, Washington, for duty at
that station.
Bradley, Alfred E., First Lieutenant and Assistant Surgeon, will, upon
the arrival of Acting Assistant Surgeon George I). Dksiion at
Columbus Barracks, Ohio, return to his proper station (Omaha,
Nebraska).
McCreery, George, Captain and Assistant Surgeon. The leave of ab-
sence granted for seven days is extended fifteen days.
548
ITEMS.— LETTERS TO THE EDITOR.— PROCEEDINGS OF SOCIETIES. [N. Y. Med. Jode.,
Naval Intelligence. — Official List of Changes in the Medical Corps
of the United Stales Navy for the week ending April 30, 1892 :
Heneberger, L. G., Surgeon. Detached from the U. S. Steamer Iro-
quois and granted three months' leave of absence.
Page, J. E., Assistant Surgeon. Detached from the U. S. Steamer
Iroquois and ordered to the Receiving-ship Independence at Navy
Yard, Mare Island, California.
Waggexer, J. R., Surgeon. Detached from the U. S. Steamer Kear-
sarge and Naval Hospital, New York, and placed on waiting orders.
Marine-Hospital Service. — Official List of the Changes of Stations
and Duties of Medical Officers of the United States Marine-Hospital
Service for the three weeks ending May 7, 1892 :
Bailhache, P. H., Surgeon. Detailed as chairman of boards for physi-
cal examination of candidates for promotion and appointment, Rev-
enue-Marine Service. April 26 and May 3, 1892.
Mead, F. W., Surgeon. Detailed as chairman of board for physical ex-
amination of candidates for appointment, Revenue-Marine Service.
May 5, 1892.
Kalloch, P. C, Passed Assistant Surgeon. To proceed to Providence,
R. L, on special duty. April 29, 1892.
Kin you. n, J. J., Passed Assistant Surgeon. Detailed as recorder of
board for physical examination of candidates for appointment, Rev-
enue-Marine Service. May 5, 1892.
Stoner, J. B., Assistant Surgeon. Ordered to examination for promo-
tion. April 20, 1892.
Decker, C. E., Assistant Surgeon. Detailed as recorder of boards for
physical examination of candidates for promotion and appointment,
Revenue-Marine Service. April 26 and May 3, 1892.
Gardner, C. H., Assistant Surgeon. To report to Commanding Officer,
Revenue Steamer Rush, for duty. April 18, 1892.
Promotion.
Wheeler, W. A., Surgeon. Commissioned as Surgeon by the Presi-
dent. April 20, 1892.
Society Meetings for the Coming Week :
Monday, May 16th : New York Academy of Medicine (Section in Oph-
thalmology and Otology) ; New York County Medical Association ;
Hartford, Conn., Medical Society ; Chicago Medical Society.
Tuesday, May 17th : Missouri State Medical Association (first day —
Pertle Springs) ; Illinois State Medical Society (first day — Vandalia) ;
Pennsylvania State Medical Society (first day — Harrisburg) ; New
York Academy of Medicine (Section in General Medicine) ; New
York Obstetrical Society (private) ; Medical Societies of the Counties
of Kings and St. Lawrence (annual), N. Y. ; Ogdensburgh, N. Y.,
Medical Association ; Hampden, Mass., District Medical Society (an-
nual— Springfield) ; Baltimore Academy of Medicine ; North Carolina
State Medical Society (first day — Wilmington).
Wednesday, May 18th : Iowa State Medical Society (first day — Des
Moines) ; Missouri State Medical Association (second day) ; Illinois
State Medical Society (second day) ; Pennsylvania State Medical
Society (second day) ; New York Academy of Medicine (Section in
Public Health and Hygiene) ; Northwestern Medical and Surgical
Society of New York (private) ; Medico-legal Society, New York ;
Harlem Medical Association of the City of New York ; New Jersey
Academy of Medicine (Newark) ; North Carolina State Medical So-
ciety (second day).
Thursday, May 19th : Iowa State Medical Society (second day) ; Mis-
souri State Medical Association (third day) ; Illinois State Medical
Society (third day) ; Pennsylvania State Medical Society (third day) ;
New York Academy of Medicine ; Brooklyn Surgical Society ; New
Bedford, Mass., Society for Medical Improvement (private) ; North
Carolina State Medical Society (third day).
Friday, May 20th : Iowa State Medical Society (third day) ; Pennsyl-
vania State Medical Society (fourth day) ; New York Academy of
Medicine (Section in Orthopaedic Surgery) ; Baltimore Clinical Socie-
ty; Chicago Gynaecological Society; North Carolina State Medical
Society (fourth day).
Saturday, May 21st : Clinical Society of the New York Post-graduate
Medical School and Hospital.
fetters to ibt €hltox.
THE LONDON TEMPERANCE HOSPITAL.
London Temperance Hospital, Ha.mpstead Road, N. W., /
London, April 12, 1892. f
To the Editor of the New York Medical Journal:
Sib: In your issue of April 2d I see a paragraph under the
title of Ether as a Stimulant, in which reference is made to the
Lancet as the authority for stating that in " a certain English
temperance hospital " ether is used instead of alcohol.
As this institution is the one referred to, I am sure I can rely
upon your sense of justice for the insertion of these lines, in
which I wish to give the strongest denial to the charge implied
in the words of the Lancet — a charge resting entirely on the re-
port of an anonymous correspondent of a London evening paper.
In this hospital there is no need to substitute ether for alco-
hol, as the latter can be used by the medical staff when they so
decide.
Ample evidence has been laid before the Lancet of the
falsity of the statement to which it so erroneously gave credit,
and an editorial amende has appeared in its pages.
Dawson Burrs, D. D.,
Hon. Secretary, London Temperance Hospital.
proccebhtgs of Sorietits.
NEW YORK ACADEMY OF MEDICINE.
SECTION IN PUBLIC HEALTH, LEGAL MEDICINE, AND MEDICAL AND
VITAL STATISTICS.
Meeting of March 16, 1892.
Dr. Henry D. Chapin in the Chair.
The Infliction of the Death Penalty by Electricity.—
Dr. Carlos F. MacDonald read a paper on this subject. (See
pages 505 and 535.)
Dr. A. D. Rockwell said that electricity was, in its man-
agement, a capricious agent. It might sometimes, through
causes unforeseen, fail at the critical moment. He had seen an
illustration of this in some experiments at Clinton Prison last
year. A bull was about to receive the impact of 1.000 volts,
but, through a defect (entirely preventable, it was true), the
pressure instantly fell to half the original voltage. If this had
occurred during an execution the criminal not only would not
have been killed, but might not have been rendered uncon-
scious even. But, as compared with hanging, the use of
electricity was, in the interest of humanity, a step in advance.
Suppose, for example, that it had always been customary to
execute by electricity instead of by hanging, and some one had
suggested that the former method be abolished and the latter
substituted; that a method practically instantaneous, painless,
without mutilation, and unattended by convulsions or any dis-
tressing outward manifestations of pain, be replaced by one
that failed to extinguish life in less than ten or fifteen minutes,
which in many cases was possibly attended with torture, and
where the convulsive manifestations were horrible to witness —
such a suggestion could not have the slightest title to serious
consideration; as a matter of fact, it would never be offered.
In connection with Dr. MacDonald and Professor Laudy, the
speaker visited the different prisons of the State and experi-
mented upon a large number of animals, to determine the best
methods of carrying out the provisions of the law. They had
found that a thousand volts was sufficient to kill the largest
animal, and they had therefore thought it certain that no hu-
May 14, 1892.]
PROCEEDINGS OF SOCIETIES.
549
man being could resist that strength of current. Subsequently,
to their surprise, it had been demonstrated that a greater press-
ure was necessary to destroy vitality in a man weighing one
hundred and fifty pounds than in one of the lower aDimals
weighing a thousand pounds or more. This, it seemed to him,
should be attributed to causes both physical and psychical.
The body conducted electricity by virtue of its saline solutions.
Fright drove the blood away from the surface to the central
portions of the body. When a man was placed in the chair he
was necessarily terribly frightened, and the result was that the
surface tissues were unnaturally dry, and therefore inferior
conductors. He also knew what was coming, and every nerve
and muscle was tense with involuntary resistance. It seemed
reasonable to believe that this nervous tension operated di-
rectly to impede the action of the electricity. A suggestive
confirmation of this statement was afforded by the greater
readiness with which men were killed when accidentally re-
ceiving the electric current. Being in an entirely normal con-
dition as to both mind and body, they succumbed to the shock
almost as readily as the lower animals "When a man was exe-
cuted by electricity he became entirely motionless; there was
not even the outward appearance of suffering, and, aside from
the fact that a human life was being taken, there was little that
was revolting in this method of execution. It was to be hoped
that in time electricity would replace the rope in all the States.
Dr. W. J. Morton said that, unlike the reader of the paper
of the evening and many of those who were to discuss it, he had
not had the advantage, if advantage it might be, of witnessing
the infliction of death by electricity ; and he had not been awrare
of the points to be touched upon until after he had listened to
the paper. Regarding the objection that had been made to phy-
sicians' discussing the question of how to kill human beings, it
seemed to him that this discussion might be considered analo-
gous to a discussion on the best method of performing a justifia-
ble foeticide — a subject that would not be out of place in any
medical society. Regarding the present topic, that electricity
killed the subject was beyond question. The question of prime
importance was, Did it kill humanely ? for it was upon this
ground, if he recollected, that this bill had been passed and that
the continuance of the method was demanded. From this point
of view they were justified in examining critically the methods
employed to kill. Such an inquiry also naturally involved the
question of how electricity killed and why. To kill human be-
ings would seem to require a due adjustment of the relations be-
tween voltage and amperage — viz., a relation translatable into
the largest possible horse power. It was not voltage alone that
killed, for we might receive with impunity a current of 100,000
or many more volts from a Holtz machine, if the current was
uninterrupted. And amperage alone did not kill, for a continu-
ous current gradually increased from a minimum might be readily
endured which, if interrupted, would cause violent shock to
nerve and muscle and probably death. Neither did alternations
alone kill, for a Tesla d ynamo gave 20,000 alternations a second
(the voltage also running up to 50,000) ; and yet no shock was
felt from this current when it was passed through a human being.
But it wa3 a proper adjustment of voltage, of amperage, and of
alternations that killed, and it certainly did not appear that this
adjustment had yet been reached. If it had been, death would
be intantaneous and not, as now, prolonged through several ap-
plications, or even through a prolonged single application. Take,
for instance, the application in the case of McElvaine ; it had
been one of 1,600 volts, giving from two to three amperes,
during fifty seconds. From a humane point of view, fifty sec-
onds was an age to die in, if the subject could be killed in one
fiftieth of a second ; and the speaker had no doubt that he
could be.
It was undoubtedly the watts — i. e., the horse power — that
killed. Electric power was the product of the volts multiplied
by the amperes. The watt was the name of the unit employed
to express this product, and it was equivalent to of a horse
power — in other words, 746 watts were equal to one horse pow-
er. Referring to the example of 1,600 volts and 2 amperes, and
, , . »i f i tt d volts x amperes tT r> 1,600 x 2
taking the formula II. I . = !- , H. P. =-2— =
" 746 746
= about 4 horse power. The question, then, was, if 1,600 volts
and 2 amperes took 50 seconds to kill the criminal beyond
doubt, why not employ a horse power that would kill him in
one fiftieth of a second or less? This would simply require a
readjustment of the parts of the electrical outfit used to kill
with — viz., an increase of voltage obtained by strongly exciting
the field of the dynamo, by increasing the number of revolu-
tions, and by decreasing the resistance (by enlarging the elec-
trodes and preparing the surface of the skin by removing the
oils). The electrodes now used presented only about one hun-
dred square centimetres of surface, or about three inches and
three quarters. An example of what might easily be done
would be to use a voltage of 3,000 instead of 1,600, to increase
the size of the electrodes, and to produce 10 instead of 2 amperes.
This was a very moderate estimate. Again, using the formula
xx r, volts x amperes v 1 1 . n r> 3,000 x 10
H. P. = — — , we should have H. P. =
746 746
= 40 horse powers — in other words, 40-horse-power death in-
stead of 4-horse-power death. There could be no question as
to which would be the more nearly instantaneous, and therefore
the more humane. The 40-horse-power current would kill in a
fraction of a second, as against the possible agonizing seconds of
the prolonged application. But, granting the most absolute per-
fection of electrical machinery for killing the criminal, the
question might properly arise, Was. death by electricity instan-
taneous? This involved the question of how electricity killed.
Did it kill by electrolysis, by molecular disintegration ; or
physiologically, by producing functional death of the part ? The
current that killed could only be conveyed through the fluids of
the body by electrolytic conduction, which meant a decomposi-
tion of molecules. But since there was no discoverable evi-
dence of this decomposition, he was obliged to say that recom-
position took place as fast as decomposition, and that by this
change of partners of the atoms of the molecule the current was
conveyed with no loss of integrity to the fluid and the tissue ex-
cept immediately at the surface of the electrodes, where free elec-
trolysis occurred. Since, then, microscopically, no actual de-
composition of fluids and tissues could be proved to have taken
place, and since, electro-chemically, no such decomposition need
be expected, he could hardly see how it could be maintained
that death was caused by electrolysis. There was, hovVever, one
point of view that might warrant one in attaching importance
to electrolysis. In tissues the current was carried mainly by the
salts ; the tissue acted like a solution of its salts. There was,
therefore, a constant decomposition of the salts, with an ac-
cumulation of the products of the decomposition at the elec-
trodes. This meant a diminution of the salts in the intrapolar
region. How much robbery of its salts would a tissue stand be-
fore it became a dead tissue ? The salts varied from one to two
per cent., but this amount was in intimate union with the proteid
constituents of the tissue and was essential to their life. Elec-
trolysis might, therefore, kill without exhibiting any signs of
decomposition to the eye, even aided by the microscope, by re-
moving the inorganic constituents to such a degree that func-
tional life ceased. An interesting point in resistance was to
carefully wash the oil out of the skin. He made a suggestion as
to a change in the position of the electrodes. A point made by
the microscopist in searching in ganglionic cells for evidence of
550
BOOK NOTICES.
[N. Y. Med. Joce.,
fatigue or exhaustion was that the nucleus lost hulk. It' death
was due to the sudden arrest of physiological function, there
would he no time to produce these changes in the nerve cells.
These latter had the usual functions of all cells; slowly irritate
them, as in Hodge's experiments, and they would change, but
act on them with an electric current, and the change was im-
perceptible. While this method was in the line of progress, he
thought that we might as well go further and give chloroform,
as Wilder had suggested.
Professor Laudy, of Columbia College, had been called to
measure the machines previous to their acceptance from the
contractors. With one exception, the motive power had been
perfect. The failure of the Kemmler execution had been no
surprise to him, as the plant at. the Anburn State Prison had
been condemned, and he had remarked that failure would result
there from the sudden drop of potential in the dynamo. Elec-
tro-motive force was not under complete control, and one could
not raise or lower it; the prison machines had been designed
for 1,000 volts, and they had increased them to 1,800 — as high
as was judicious. The engine motion was conveyed by belting,
and there were the dynamo, wires, switchboard, etc., each time
there was a new contact, increasing the chance of failure.
Mr. W. J. Jenks was the next speaker. (See page 542.)
Dr. Andrew H. Smith said that, while it was, of course,
highly desirable that at the points of contact the resistance
should he reduced to a minimum, yet, when the current was
once within the body, its lethal effect would be in direct, not
reverse, proportion to the resistance it encountered. If the vital
organs were perfect conductors, offering no resistance, there
would be no effect from the passage of the current. In this re-
spect the lethal resembled the mechanical, the electrolytic, and
the thermal actions of electricity. The result in each case
would be iD proportion to the detention of the fluid in the sub-
stance acted upon. The speaker said that, in his judgment, the
deadly effect of the briefest possible contact in accidental cases,
in which also the voltage was often comparatively low, was due
to the concentration of the current in a very narrow path. En-
larging the surface of the electrodes, therefore, would, he be-
lieved, be a mistake, unless the volume of the current was pro-
portionately increased. As to the humanity of this method, it
had been his lot to witness six executions — one by the guillo-
tine, one by shooting, and a triple military execution by hang-
ing, in which the drop was used, and one other by hanging
where the culprit was jerked up by the falling of a weight. At
four of these he had been present in the performance of military
duty. All had been horrible and revolting beyond description,
and the contrast with what Dr. MacDonald had described con-
vinced him of the enormous advance that had been made by the
introduction of the new method.
Dr. A. Jacobi said that Dr. MacDonald had dealt with this
disgusting topic in a better manner than he had thought it could
be done; but it should not be considered by any medical so-
ciety, for the purpose of medicine was to save, not to take life.
Physicians had always been condemned for experiments on the
human body. Only a few years ago a well-known physician
had been condemned for making some localization experiments
on an exposed brain.
Dr. Rockwell said that the criticism seemed severe ; in ob-
stetrics sometimes life was taken to save life.
The Citairm an did not consider that he had admitted a paper
that was not entitled to a hearing in his Section. The laws of
the State provided not only for that method of execution, but
also for the presence of physicians. Dr. MacDonald had pur-
sued this work as a State official in a department that had cer-
tainly to do with legal medicine, and so long as such provisions
were on the statute books of the State they would — while the
present incumbent was chairman — have a hearing in this Sec-
tion.
Dr. MacDonald said that he agreed with Dr. Morton that
death should be produced as rapidly as possible. The present
apparatus was crude, and he had recommended that the central
prison be supplied with a proper dynamo, if the use of this
method was to be continued. Regarding the employment of
chloroform as less offensive, he would simply recall the familiar
struggles of the persons to whom that drug had been adminis-
tered. He had no apology to offer for his work, as it was in the
nature of humanity. The subject had been an unpleasant one
to him, one that he had had to take up by request of his official
superiors, and his paper was a farewell to the subject, as his
further aid was not needed.
§00h -Hotices.
Manual of Operative Surgery. By Ehedekick Treves, F. R. C. S.,
Surgeon to, and Lecturer on Anatomy at, the London Hos-
pital, Member of the Board of Examiners at the Royal Col-
lege of Surgeons. Two volumes, medium 8vo, with Four
Hundred ana Twenty-two Illustrations. London: Cassell &
Co., 1891. Pp. 775, 775.
The field of surgery has corne to be so extensive, and the
methods of operation have become so numerous, that it is im-
possible for a work on general surgery to contain even a com-
paratively full list of them from which the reader may make a
choice, unless it runs into encyclopaedic proportions. It has
therefore become necessary that we should have special works on
the art of operating. Jacobson, in his admirable work, has led
the way more recently in this line of literature, and now comes
this more pretentious effort of a noted English surgeon. Books
of this class must of a necessity be more or less compilations,
but the present one bristles with originality in almost every sec-
tion. The author makes experience his guide in approving or
disapproving of an operation, and does not allow himself to be
led off by the favorable statistics of the originators of different
procedures. Conscientiousness is exhibited in the very first
chapter, The Patient, showing that he is first in the author's
thoughts, and not the brilliancy or feasibility of the operation.
Is he able to undergo the operation? Will he be truly benefited
by it? and, Is there less risk from the operation than from the
disease if left untreated — are questions which must all be an-
swered in the affirmative before operating. After describing the
different conditions which should influence one in determining
whether to operate or not, and laying down rules for the neces-
sai-y preparation of the patient for the operation, he turns to the
second most important consideration — The Operator. Is he capa-
ble? Is he prepared? Is he in the proper frame of mind to do
this particular operation ? " A shakiness of the hand," he says,
"may be some bar to the success of an operation, but he of
shaky mind is hopeless." " Precision of knowledge, precision
of judgment, precision of hand are all needed in a surgical oper-
ation." " In the handling of a sharp instrument in connection
with the human body a confusion of the intellect is worse than
chorea." These are expressions showing how carefully the au-
thor has thought over the personal element in an operator. In
the succeeding chapter, on instruments, he deprecates the mul-
tiplication of them, saying: " Some of the least progressive peri-
ods in the development of the surgeon's art have been marked
by the prolific production of instruments," and " among the very
numerous names of designers of instruments, there are but few
belonging to surgeons who are or have been eminent as first-
May 14, 1892.]
BOOK NOTICES.
551
class operators." It is wonderful to see the immense catalogues
of these aids to surgery, when so much can be done with a sim-
ple scalpel and forceps. The remarks upon the indiscriminate
use of sharp retractors, thereby irritating and mutilating the tis-
sues of a wound, and the suggestion of thread retractors, while
not new, are certainly timely. We can not altogether agree
with the author in what he calls the " barbarous procedure "
of using " the sturdy and dangerous piece of steel," a grooved
director. While a clean-cut wound is mo>t desirable, and no
doubt heals more rapidly, nevertheless in the bands of those who
do not operate constantly, in vascular areas, or in operations in-
volving the peritoneum and abdominal viscera, the director is
a much safer instrument than the sharp point of a knife.
Very little is said on the subject of antiseptics in the work.
Although advising the strictest adherence to the principles of
antiseptic surgery, the author seems to consider the technique
thereof a hackeyed theme, and lays down no rules or principles
to guide one in these matters. After stating the aims upon
which surgeons are agreed in the treatment of a wound, the au-
thor proceeds to say : " One surgeon accomplishes these ends
in one way and another in another, and the results are equal.
. . . New antiseptics appear from time to time upon the scene.
They are vaunted as perfect, are diligently employed, and then
not a few of them fade away, some very gradually, others with
the suddenness of the South Sea Bubble." He shirks the re-
sponsibility of taking a stand upon this subject, and this is not
in keeping with the rest of his work. He insists on the free
access of air to surgical wounds, and never allows a part oper-
ated on to be kept in the hot, moist, and often foul atmosphere
beneath the bed-clothes. He also uses sponges, instead of gauze
or cotton, for dressing wounds, arguing that they do not lose
their elasticity when saturated, and thus they persistently hold
the parts in close apposition during the whole period of healing.
We believe the point to be well taken.
Space will forbid our taking up seriatim the different chap-
ters of this interesting book, and could we do so we should find
our opinions upon the different sections diverse enough. It is
exceedingly irregular in its excellencies ; the good far outweighs
the bad, but still there is enough of the latter to make a revision
and second edition desirable.
The sections on ligations and amputations are perhaps the
best in the book, and, without disparagement to others, deserve
special notice. In the latter we find an excellent description of,
and very just conclusion upon, that remarkable osteoplastic re-
section known as Wladimiroff's. To save all we can of a limb
is a good principle, but to preserve a part which will not only
be useless but absolutely in the way of its possessor is certainly
unwise if not bad surgery. To us this operation seems to be
simply an illustration of surgical gymnastics unjustifiable by its
results.
The sections on the surgery of the nerves, and that on tenot-
omy, are disappointing indeed, as is also that on the surgery of
the rectum and anus. This latter may, in fact, be called the
poorest part of the book. The author seems to have confined
himself to the British works upon these subjects in working up
this portion of his book. The methods of Kraske, Bardenhauer,
and Levy for excision, the method of Van Buren for procidentia,
and the American method of transfixion for hajmorrhoids, are
left unnoticed. The great interest and advance in these subjects
of late demand that closer attention and more space should be
given them in a work of this character.
The second volume of this valuable work begins with a chap-
ter on plastic surgery, and in it we find one of the best accounts
of rhinoplasty that it has been our fortune to see. Beginning
with the Indian operation, as modified by the German surgeons,
which he thinks is the best, the author describes minutely all
the principal operations of this class, including Keegan's, von
Langenbeck's, Dieffenbach's, Weir's, the Italian, the French, and
other methods. < >ne can not want for a choice of operations or
a clearer description of their technique than is here found for
complete or partial rhinoplasty. As much may be said for the
chapter on operations for cleft palate. The chapter on plastic
operations for diseases and deformities of the lips does not com-
pare favorably with the last two mentioned. We are surprised
to find described only one each of Serre's and Szymanowski's
operations, and that of Burow omitted altogether. A liberal
reference to either one of two American works on surgery that
we know would have made this section more complete. Read-
ers of this portion of the work will be surprised to see the name
Diday substituted for that of Didot as the author of the anterior-
and-posterior-flap method for the cure of webbed fingers. This
we thought at first an error, but, on investigation, find that the
author is correct, and that whatever merit the operation has is
due to Diday and not Didot.
In the section on abdominal surgery we have perhaps the
fullest exposition of Treves's own personal experience and work,
for he has long been prominent as an operator in this line. We
can not go over his views seriatim, but mention one or two that
seem a little out of line with the latest teachings on the subject.
He thinks no special preparation of the patient necessary for ab-
dominal section beyond that for any ordinary surgical operation;
he believes in the intraperitoneal treatment of the stump in hys-
terectomy and in the superiority of lumbar over inguinal coloto-
my. On all these points we dare say he will find many eminent
surgeons taking decided issue with him. In this same chapter
he uses the name Atloe for that of Atlee as a pioneer in ab-
dominal surgery, but this may be a typographical error.
We have thus noticed at length this important addition to
surgical literature, and, if we have criticised somewhat closely,
it has been because we have been much interested in the work,
and appreciate it very highly. It is, in our opinion, one of the
best books in the English language on the subject of operative
surgery, and does credit to the energy, conscientiousness, and
liberality of its noted author.
BOOKS, ETC., RECEIVED.
Treatise on Gynaecology, Medical and Surgical. By S. Pozzi, M. D.,
Professeur agrege a la Faculte de medecine, etc. Translated from the
French Edition under the Supervision of and with Additions by Brooks
H. Wells, M. D., Lecturer on Gynaecology at the New York Polyclinic,
etc. Vol. II. With One Hundred and Seventy-four Wood Engravings
and Nine Full-page Plates in Color. New York : William Wood & Co.,
1892. Pp. xiv-583.
A System of Gynaecology. With Three Hundred and Fifty-nine Il-
lustrations ; based upon a Translation from the French of Samuel Pozzi.
Revised by Curtis M. Beebe, M. D., Chicago. New York : J. B. Flint
& Company, 1892. Pp. viii-17 to 604.
A Treatise on Bright's Disease of the Kidneys : its Pathology, Diag-
nosis, and Treatment. With Chapters on the Anatomy of the Kidney,
Albuminuria, and the Urinary Secretion. By Henry B. Millard, M. A.,
M. D., Fellow of the Academy of Medicine of New York, etc. With
Numerous Original Illustrations. Third Edition. Revised and enlarged.
New York: William Wood & Company, 1892. Pp. xviii-322.
Yellow Fever : a Monograph. By James W. Martin, M. D. Edin-
burgh: E. & S. Livingstone, 1892. Pp. !> to 56.
Diseases of the Nervous System. By Jerome K. Bauduy, M. D.,
LL. D., Professor of Diseases of the Mind and Nervous System and of
Medical Jurisprudence, Missouri Medical College, St. Louis, etc. Sec-
ond Edition. Philadelphia: J. I?. Lippincott Co., 1892. Pp. 10-11 to
352. [Price, $3.]
Miners' Nystagmus and its Relation to Position at Work and the
Maimer of Illumination. By Simeon Snell, F. R. 0. S. Ed., etc. Bristol :
John Wright & Co., 1892. Pp. x-143.
552
BOOK NOTICES.
[N. Y. Med. Joub.,
Transactions of the American Orthopaedic Association. Fifth Ses-
sion, held at Washington, D. C, September 22, 23, 24, and 25, 1891.
Volume IV.
Recherches cliniques et therapeutiques sur l'epilepsie, l'hysterie et
l'idiotie. Compte rendu du service des enfants idiots, epileptiques et
arrier6s de Bicetre pendant l'annee 1890. Par Bourneville, m6deein de
Bicetre, avec la collaboration de MM. Camecasse, Isch-Wall, Morax,
Raoualt, Seglas et P. Sollier, internes et anciens internes du service.
Volume XI. Avec 16 figures dans le texte et 10 planches. Paris: Vve.
Babe et cie., 1891. [Publications du Progres medicaid Pp. c— 8 to
252.
Hospice de la Salpetriere. Clinique des maladies du systeme ner-
veux. M. le Professeur Charcot. Lecons du professeur, memoires,
notes et observations. Parus pendant les annees 1889-'90 et 1890-'91,
et publics sous la direction de Georges Guinon, chef de clinique. Avec
la collaboration de MM. Gilles de la Tourette, Blocq, Huet, Parmentier,
Souques, Hallion, J. B. Charcot et Meige, anciens chef de clinique, in-
ternes et interne provisoire de la clinique. Avec 47 figures et 3 planches.
Paris : Veuve Babe et cie., 1892. [Publications du Progrh medical.]
Pp. iii-468.
Les nouvelles decouvertes en electricite. Histoire d'un inventeur.
Les moteurs electriques. Machine dynamo de demonstration. Bijoux
electriques lumineux. Eclairage eleetrique, domestique, industriel et
militaire par les lampes Electriques. Electricite medicale. Photophores
electriques. Micrographie et photomicrographie. Telephones et mi-
crophones. Installation telephonique domestique. Tricycle electrique.
Applications de l'electricite' k la navigation fluviale, maritime et aeri-
enne. La navigation electrique, etc. Par G. Barral. Deuxieme Edi-
tion. Paris : J. Michelet, 1891. Pp. xvi-610.
Removal of Adenoid Growths from the Vault of the Pharynx. By
H. Hoyle Butts, M. D., New York. [Reprinted from the Medical News.]
A Flying Trip by Rail from New York to California. By Stephen
Smith Burt, M. D. [Reprinted from the Post- Graduate.]
The Care of Women in Pregnancy. By Charles M. Green, M. D.
[Reprinted from the Boston Medical and Surgical Journal.]
A Case of Associated Streptococcus Infection of the Vermiform Ap-
pendix and Falloppian Tube. By Hunter Robb, M. D., Baltimore, Md.
[Reprinted from the Johns Hopkins Hospital Bulletin.]
Amputation at the Hip Joint by Wyeth's Method, the Patient being
Five Months Pregnant. A Clinical Lecture delivered at the Jefferson
Medical College Hospital, February 3, 1892. By W. W. Keen, M. D.,
Philadelphia. [Reprinted from the Medical News.]
Two Cases of Removal of Laminae for Spinal Fracture. By De For-
est Willard, M. D., Philadelphia. [Reprinted from the Transactions of
the College of Physicians of Philadelphia.]
The Caustic Treatment of Cancer. By Daniel Lewis, M. D. [Re-
printed from the Medical Record.]
Ataxia. A Clinical Lecture delivered at the Arapahoe County Hos-
pital, Denver, Colorado. By J. T. Eskridge, M. D. [Reprinted from
International Clinics.]
Ideality of Medical Science. The Evil Events of the Profession, and
an Available Device for its Reformation. By Maurice J. Burstein, A. M.,
M. D., New York. [Reprinted from the Doctor's Weekly.]
Where Dentistry looks over into Oral Surgery. By Lenox Curtis,
M. D., New York. [Reprinted from the Dental Cosmos.]
Errors in Ventilation. By William Henry Thayer, M. D., Brooklyn.
Medical Orthoepy. By J. F. Oaks, M. D., Chicago. [Reprinted from
the Chicago Medical Recorder.] .
Nephrotomy for Calculous Pyelitis. Nephrectomy rightly decided
against because of the Small Percentage of Urea ; an apparently almost
Destroyed and Useless Kidney found to secrete over Four and a Half
Times as much Urine as the other Kidney ; Death. By W. W. Keen,
M. D., and David D. Stewart, M. D. [Reprinted from the Therapeutic
Gazette.]
The Teachings of Experience and of Rational Therapeutics as to the
Treatment of Pneumonia. By Boardman Reed, M. D., Atlantic City,
N. J. [Reprinted from the Therapeutic Gazette.]
Ectopic Pregnancy. By C. A. Kirkley, M. D., Toledo, Ohio. [Re-
printed iYom the American Gynxscological Journal.]
Two Successful Cases of the Conservative Caesarean Section. By
Charles Jewett, M. D. [Reprinted from the New York Journal of Gy-
necology and Obstetrics.]
Syphilitic Spondylitis in Children. By John Ridlon, M. D. [Re-
printed from the Medical Nevjs.]
Congenital Malformation of the Genital Tract. Persistence of the
Sinus Uro-genitalis as a Common Opening with the Urethra. Bicomate
Uterus. By C. P. Strong, M. D., Boston. [Reprinted from the Trans-
actions of the American Gynaecological Society.]
Pelvimetry for the General Practitioner. By J. Whitridge Williams,
M. D., Baltimore. [Reprinted from the Medical News.]
Contributions to the Normal and Pathological Histology of the Fal-
loppian Tubes. By J. Whitridge Williams, M. D., Baltimore. [Re-
printed from the American Journal of t/ic Medical Sciences.]
Contributions to the Histogenesis of the Papillary Cystoma of the
Ovary. By J. Whitridge Williams, M. D., Baltimore. [Reprinted from
the Johns Hopkins Hospital Bulletin.]
Ideals of Medical Education. The Address in Medicine, Yale Uni-
versity, 1891. By John S. Billings, M. D., LL. D.
The Premature Induction of Labor in Contracted Pelves. By J.
Whitridge Williams, M. D., Baltimore. [Reprinted from the Maryland
Medical Journal.]
Two Cases of Hernia, both treated by Laparotomy : 1. A Preperito-
neal Hernia. 2. A Femoral Littre's Hernia. By W. W. Keen, M. D.
[Reprinted from the International Medical Magazine.]
The Insane and the Asylums. By Horace G. Wetherell, M. D.
Gastrotomy. By N. Senn, M. D., Ph. D., Chicago. [Reprinted from
the Chicago Medical Recorder.]
A Case of Associated Streptococcus Infection of the Vermiform Ap-
pendix and Falloppian Tube. By Hunter Robb, M. D., Baltimore. [Re-
printed from the Johns Hopkins Hospital Bulletin.]
Athetosis, with Clinical Cases. By Archibald Church, M. D., Chi-
cago.
A Contribution to Spinal-cord Surgery. By Archibald Church, M. D.,
and D. W. Eisendrath, M. D. [Reprinted from the American Journal
of the Medical Sciences.]
Surgical and Mechanical Treatment of the Deformities following In-
fantile Spinal Paralysis. By De Forest Willard, M. D., Ph. D., Phila-
delphia. [Reprinted from the American Journal of the Medical Sci-
ences.]
Handbuch der physiologischen Optik. Von H. von Helmholtz.
Zweite umgearbeitete Auflage. Mit zahlreichen in den Text einge-
druckten Holzschnitten. Sechste Lieferung. Hamburg und Leipzig :
Leopold Voss, 1892. Pp. 401 to 480.
Report of the Joint Committee upon the State Lunatic Asylum at
Trenton, N. J.
Second Report of the Monmouth Memorial Hospital, Long Branch,
N. J.
Reports of the Trustees and Superintendent of the Butler Hospital
for the Insane.
Nineteenth Annual Report of the London Temperance Hospital.
Differentiation of Rheumatic Diseases (so called), based upon Com-
munications read before the Royal Medico-chirurgical Association,
1892, Bristol Medico-chirurgical Association, May 14, 1890, and re-
printed from the Lancet, October, 1891. By Hugh Lane, L. R. C. P.,
M. R. C. S., etc. Second Edition. London: J. & A. Churchill, 1892.
Pp. 12-14 to 121.
Cancer and its Treatment. By Daniel Lewis, A. M., M. D., Ph. D.,
etc. Detroit: George S. Davis, 1892. Pp. 127. [The Physicians'
Leisure Library.]
A New Astigmatic Test Chart. By L. Webster Fox, M. D., Phila-
delphia. [Reprinted from the Ophthalmic Record.]
Gymnastic Exercise as a Prophylactic and Curative Remedy in
Chest Diseases. By Edward 0. Otis, M. D., Boston, Mass. [Reprinted
from the Clirn otologist.]
Orthopaedic Surgery as a Specialty. [Reprinted from the North-
western Lancet] Disease of the Hip Joint. [Reprinted from the Medi-
cal News.] By Arthur J. Gillette, M. D., St. Paul, Minn.
Nomenclature of Diseases to be followed by Physicians in the
Indiiin Service in making Reports to the Indian Office. [Department of
the Interior.]
May 14, 1892.]
NEW INVENTIONS.— MISCELLANY.
553
The Nineteenth Regular Report of the Medical and Surgical Staff of
St. Francis Hospital, Jersey City.
Intestinal Anastomosis and Suturing. By Robert Abbe, M. D., New
York. [Reprinted from the Medical Record.']
|leto Jnbentions, etc.
AN INSTRUMENT FOR
THE MEASUREMENT OF THE RESISTANCE IN A STRICTURE.
By E. W. Scripture,
WORCESTER, MASS.
While at the University of Leipsic I attended a clinic by Dr. Koll-
mann on diseases of the genito urinary system. One point that specially
struck me was, that although there was so much difference in the resist-
ance to the dilatation exerted by strictures, yet we had hardly any
knowledge of the variation in this respect and no means of measuring it.
To attain the means of measuring the resistance I took a dilator of the
Oberlander pattern and inserted a spring between the wheel turned by
the fingers and the axle that communicates the movement to the dilat-
The application of the instrument would be in somewhat the follow-
ing manner : It is introduced closed and without the usual rubber sack
over it into the urethra. The rubber sack not only is unnecessary with
a carefully made instrument, but it also introduces an insurmountable
error into the measurements. N is slowly turned ; the little pointer
will at most move only a degree or two against its face. When the
bars reach the extent of the stricture, the catch L will begin to click
over the ratchet-wheel, the pointer J will stop, and N will move behind
its pointer. Finally, the clicking stops and both the pointers begin to
move ; in other words, the spring has reached a tension equal to the re-
sistance of the stricture. The positions of both pointers at this moment
are noted. A glance at the table gives the resistance of the stricture.
isrcilanjr.
ing portion. The original form can be approximately seen from the
illustration if all to the right of the letter I is covered up. When in-
troduced into the urethra the instrument is closed, but in dilatation the
screw I carries forward the bar E, which, being connected by C to the
bar D, is obliged to move away from it. B is a joint connecting it to a
small piece the other end of which slides in a groove back from A.
The extent of the dilatation is indicated in bougie-numbers on the
dial J. H is a means of holding the instrument. G is a very small
wheel for holding the two flat portions together ; a joint is introduced
at each end of F. In the modification of the instrument which I have
made, the screw I is not moved directly by a large milled head or wheel
as in the original ; on the contrary, it is prolonged in the form of an
axle, and is seen projecting to the right through the wheel N, and car-
rying a small pointer. N and M are made in one piece ; M contains a
small clock-spring, which is attached at one end to the axle I, and at
the other to the inner surface of M. K is a ratchet-wheel fixed to the
axle I, and L is the catch fixed to M. Now suppose the instrument to
be closed. Press the lever L so that M N may move freely to its resting
place ; the spring will then be in a condition of equilibrium, and the
little pointer in front of the wheel N will indicate a point which we
will call zero. Turn N gently to the right ; the dilator will begin
to open and the pointer will move over J. There is so little re-
sistance from friction that there will be no noticeable strain on the
spring (if of proper strength), and the little pointer will move around
with N, always indicating zero, until the instrument begins to ap-
proach its maximum dilatation. If, however, at any moment we place
an obstruction in the way of further opening — c. ff., by pressing the
thumb and finger against the two bars D and E — the wheel N will con-
tinue to turn, but " I" will stop till the spring is sufficiently spanned to
overcome the resistance. The resistance thus bears a definite relation
to the tension of the spring ; the latter, however, is indicated by the
extent to which the wheel N has passed behind the little pointer before
the tension was sufficient. The catch L keeps the spring at this ten-
sion. Let the face of N be graduated in degrees ; then at any time we
can find out, by proper application of weights, just how much resistance
is necessary in order to have the pointer move over any given number
of degrees. This can be done by the physician himself, but it is better
for the maker of the instrument to provide a little table giving the
various amounts of resistance overcome which correspond to the various
positions of the pointer.
The Natural History of the Species Medicus. — A German publica-
tion entitled Zur Nature/eschichte des Medicus, by " Dr. Risorius Santo-
rini," illustrated by " Dr. Corrugator Supercilii," with the motto Dem'i
juekt, der kratze sich, has been thus translated by " Famulus*' :
Contents. — Historical Introduction. Class I. Medici
Academici. Order 1. Professor Ordinarius Consilarius Se-
cretus. Order 2. Professor Extraordinarius. Order 3.
Priviit-Docent. — Class II. Specialists. Order 1. The Neu-
rologists. Order 2. The Gynaecologists. Order 3. The
Charlatan. — Class III. Birds of Passage. Order 1. The
Bath Physician. Order 2. The Clinic Fiend. — Class IV. Medicus
Practicus. Order 1. The Lion of the Boudoir. Order 2. The Gradu-
ated Jackass. Order 3. The Honest Old Family Physician.
Historical Preface.
Mankind, as Mr. Darwin states,
Belongs to the class " Vertebrates."
The " Genus Homo " roamed the land
With sea-horse, mammoth, elephant,
Before the age diluvian,
The so-called " prehistoric man."
But many a learned antiquary
Thinks these deposits tertiary.
A miocene discovery
Would strengthen Darwin's theory ;
The fact of species-variation
Would surely find its explanation
In secrets geological
Anthropomorphologkal.
Then up, ye paleontologists !
Grasp spade and hammer in your fists ;
Search the coal-measures carefully
Until the long-sought spoor you see
In caenozoic gloomy night
Of our ancestral Troglodyte.
The law of natural selection
Leads ever upward toward perfection.
Mankind the effort never ceases
To propagate the human species.
Prcewmptio est, the man ideal
Is slowly now becoming real ;
As each sire grants to son, unmerited
Virtues lie from his sire inherited.
As type, Te Denin Laudamus,
Is reckoned foremost .Medicus.
For it is known to every proctor
That Father Adam was a doctor.
And Henry Faust with equal ease
Read Scripture and Hippocrates.
554
MISCELLANY.
[N. Y. Med. Jouk.
And the foul fiend, fresh from damnation,
Oft aids in biblical translation;
Again appears with counsel wary
As a physician literary.
He would have penned the great creative process
" In the beginning was the diagnosis."
Earliest history tells the story
Of drugs and operations gory.
And as we learn from Homer's Iliad,
Wounds then were dressed with balm of Gilead ;
And in Achilles's bold array
The doctor was an attache,
Although inpuncto chirurgice
He had not much that's called esprit.
How would our dapper surgeons feel
Should a slight wound upon the heel,
Such as befell this general,
Prove to be instantly lethal ?
The ages crown with recognition
Hippocrates as a clinician.
His fame is dear to every heart
As " Father of the healing art."
But in his day we note this feature :
He was empiric as a teacher.
He had no inkling of dissection,
Nor of arterial injection.
Enough — 'mid medical afflictions
We're spared his " positive convictions."
But high above all mean disguises
The learned Egyptian doctor rises —
A privy councilor in condition,
Herophilus, the court physician.
His research took a new direction,
He practiced bloody vivisection.
In which, by Seleukos's permission
(Physiology then had a mission),
Material for researches loyal
Was amply found in debtors royal.
Peril surrounded noble clients,
But 'twas a golden age for science.
When thus by royal favor fostered,
Our colleagues and our calling prospered.
The (irs eurandi made advance
And worthy spirits joined its ranks.
This was the time when Galen wrote,
Whom our own authors freely quote,
Who, in the sixteenth century,
Enjoyed infallibility.
In short, the medical profession
Has proved the truth of evolution.
Where one the grip has failed to keep,
Two others are set on their feet.
And with the multiple diseases
The corps of specialists increases.
As Darwin's theory proved true,
The species strong and stronger grew ;
And from division of their labor
Established races, each a neighbor.
How these have thrived and propagated
Will now in rhyme be briefly stated.
Though occupying different spheres,
The species one to be appears.
We speak of " heterogeny,"
And call the whole a " colony."
As sample of instinct politic
Observe the insect-republic
Which the industrious Forrnieidee
Maintain for rich as well as need}'.
Each member of the insect nation
Pursues a certain occupation.
A. guards the city from surprise ;
B. furnishes the food supplies ;
While G, with eager emulation,
Devotes himself to copulation.
That in the " struggle for existence "
They may present a firm resistance.
In human arts the insect law persists,
The " colony " as " faculty " exists.
The " Adjunct " X. strives valiantly
To guard scholastic dignity ;
Professor Y., with cautious unction,
As number G performs his function ;
The beast of burden least resistant
Is the " Instructor " called " Assistant."
Order 1. Professor Ordinarius Consilarius Secretus.
As chief official in this corps
We see some hoary Councilor.
Sometimes he's even " State Physician,"
Which really is no mean position.
Early and late, where'er he be,
His eye is on the Faculty ;
That the bald heads of fossils hoary
May not be shorn of former glory ;
And that no modern heretic
Some middle-ages bubble prick.
Because the " honored faculty "
Presents infallibility.
The theory their wisdom utters
Is therapeutics for the gutters.
To keep the caste inviolate,
Maintain ideas long out of date ;
To keep youth well refrigerated —
This is the mission of the aged.
And to prevent things getting mixed
They like their own offspring well fixed.
For, if his name be Gray,*
He looks around him every way,
How he can plan that Number One
May fall to his beloved son ;
And all the members of the breed
With pride their comrades supersede,
So that the dynasty of Gray
Grows more extensive every day
By in-and-in maternity
From now until eternity.
For this, important points appear
As motives, salient and clear.
Science takes secondary place
In elevation of the race,
When with a title like a steeple
An old man hoodwinks " common people."
Class I.
When several separate generations
Dwell in harmonious relations,
* Any of the other indifferent colors may be selected, instead of the
one here mentioned, according to the chromatic requirements of the
reader.
May 14, 1892.]
MISCELLANY.
555
The title " City Inspector "
In worth more than a newspaper,
To the proud conciliarum
With all the high-priced publicum.
For a prescription from his pen
Costs a gold eagle ; but then —
Ten times the action surely follows
Than if the doctor charged three dollars.
Order 2. Professor Extraordinarius.
The Laboring Family Man.
From instinct comes the aspiration
In mankind for official station.
A title renders great assistance
In the long struggle for existence.
When once he's reached the " Adjunct's " fame
He longs for the " Professor's " name.
And out of twelve, perhaps eleven
No greater boon could ask of Heaven.
But here, like as in Holy Writ,
Many are called, but few are fit.
So, pour plaisir, we read and hear
Things only which are popular.
Science attracts both him and her,
Thanks to the efforts of Pasteur.
The public reads with glad surprise
The effusions of this Solon wise
In every agricultural paper,
As well as in the Gospel Taper.
Which all declare his genius rising :
This is " judicious " advertising.
His various " researches " amount
Only to swell his bank account.
There's sometimes great utility
In fashionable charity.
But to all hearts he gains the key
By " Lectures on Emergency,"
Enhanced, if he possess the nickel
The editorial palm to tickle,
When great and small will surely read
That he is a " great man " indeed.
But genius her great triumph wins
When the Professor now begins
To bring his daughters under cover
By means of eligible lover :
Especially if female lambs
Be the sole product of his hams.*
Order 3. The Adjunct Professor.
Salute, my lay, with studied grace
The most imposing of the race.
As clouds soar o'er the city's pile,
He towers above the " rank and file."
" Adjunct Professor " is the name
To which this animal lavs claim.
A prototype of erudition,
It graciously grants recognition
To other works of God's creation ;
But only like a " poor relation."
It poses as Hvgeia's watchman
Cpon the walls of learning's Zion.
It seizes Nature's blindest riddles,
Groups them in systems while it piddles ;
Its eyes sometimes to mortals sink,
Because the beast must always think.
* /. e., loins.
Anon it shows on forehead high
The wrinkles of philosophy ;
And trims, in aping the Professor,
Its beard, designed by the hair-dresser.
The above is but the fcetal state
Of what develops soon or late,
According to the elements,
Into " Surgeon to Out-patients."
The earlier is the stage latent ;
This is the full development.
But meanwhile in his surgery
There is a cloak of mystery.
And mystery alone is able
To grant a halo round the Sehaedel.
What virtue would the halo have
If every layman could perceive
The veil which hides the goddess-form ?
That was the reason that in Rome
The Haruspices took their rise
To throw dust into prying eyes,
And pull the wires behind the curtain.
With the first blush of coming day,
Our Doctor starts upon his way.
The hospital first claims his skill,
Where the Internes with eager will
Pulse, respiration, temperature
Have taken with precision sure ;
Have tried each patient's fragrant urine
To see if it contains hippurin ;
Secured the anamnesia,
And booked the whole with pious care ;
For it is far beneath Docents
To investigate the elements —
Charms for philosophers like these
Have only the " higher analyses."
" Clinical material " useless is,
Except to build hypotheses,
Which, comet-like, blaze one by one
Upon the clinic's horizon.
A novel remedy is found ;
With great discretion handed round,
Quickly it everywhere is tried.
The special journals all describe
The clinical experiments ;
Each one the other compliments.
Things thus four weeks at most remain ;
We never hear of it again.
The discoverer smiles whene'er alone
" By Jove ! it's pleasant to be known ! "
When this mild comedy is played,
Quickly another scene is laid :
Now thallin, next day pyridine,
And the day after methane !
And even thou, potent cocaine,
Into what mischief hast thou been
That man should show thee such abuse,
Per os et anum introduce ?
Though we the fraud at length observe,
The plan shows method and shows nerve.
Hence people call this deviltry
The "only rational therapy."
But even the man of sense acutest
Can win no fame as therapeutist,
For just now Science her favor yields
Only in pathognostic fields.
556 MISCELLANY. \ N. Y. Med. Joob.,
The claims of Science now demand
At times with speed like that of steam
Quasi "researches" from his hand.
It rushes through life's vivid dream.
Therefore he pays his amorous court
The pallid youth in teuderest years,
To bacteriology ; in short,
While yet scarce dry behind the ears,
He tries by tine hypotheses
Wrestles with Bacchus and Gambrinus,
Thus to account for all disease.
With nicotine and goddess Venus.
And being " modern," " just announced,"
The maiden, in steel corset tight,
No " want " was ever more pronounced,
Like the Nyauza, blooms at night ;
Each downy, newly-hatched Docent
Inflames her chaste imagination
Has need of " special experiment."
With scenes of Zola's mild creation ;
Each " Adjunct's " head presents a lump
Labeled, " Investigations-bump."
The suffering rabbit is infected,
All kinds of gurry are injected,
Acquires as sign of culture then —
For this belongs to " upper ten " —
Chlorosis and amenorrhea
Combined with "reflex diarrhoea."
And soon " pure cultures " we may see.
A nervous female in that line
■Oh, Koch ! What do we owe to thee !
Surpasses all the Muses nine.
Nothing now aids the " cause eternal "
As does a " liberal medical journal,"
Which kindly tells the " rank and file "
What this great mind achieves meanwhile.
This trouble is conveniently
Peculiar to the "Quality."
It stands the doctor in good stead
As a means to win his dailv bread.
Often we slumber o'er the letter —
The doctor is a pure clinician
His motto is, " The more the better."
In his rude, embryo condition,
Twelve columns upon Gonoeoccus !
But he attends most punctually
What need in hospitals to lock us ?
The lectures on psychiatry.
It also causes him no sorrow
If in the same review to-morrow
By Dr. X. the sham's exposed,
And all his canting fraud disclosed.
Each one " discovers " what he can
To make a name or mar a man.
Then modestly his name appears,
As " Specialist for many years,"
To which he adds, with zeal astute,
A Neuropathic Institute,
" In the most charming region " lives
[Particulars our pamphlet gives],
Forests with fragrance of pine cone,
His glory lasts about four weeks.
Atmosphere laden with ozone,
Afterward no one of it speaks.
From northern blasts by hills protected,
Each folly runs its course specific ;
Romantic picnic tours projected ;
And people call this " scientific." .
Around the Home a noble ground ;
So slowly passes year by year
Board reasonable [£100].
Of Docent's suffering career.
The doctor wins his way with ease
For, ah ! with all his application,
If he the fair, frail sex can please.
He fails the longed "Professor's" station ;
Platonic freedom from all passion
Thereby our Docent's entire stage
Is his most valuable possession.
Comprises but the larva age.
For " confidence is slowly won
For his own merit, of all things,
In nervous patients." [Xettleton.]
Is suited least for growth of wings.
The therapy is " rational "
Make but one other change in life ;
Only when " individual,"
Pay court to the Professor's wife ;
But the brave doctor has at hand
With higher aims strive valiantly
Three mighty adjuncts on demand.
To rise within the " colony."
These will respond with vigor bold
A kindly warmth your limbs will thaw
When water hot and water cold
When you've become a son-in-law.
And even electricity
Will not secure felicity ;
PIqcd II Tur ^D^fi * r Ttsf *j
VltisS 11. ] III prtLlALIM?.
In treatment, they're ace, king, and queen,
Bromkali, chloral, and morphine.
Even in our calling is provided
That higher art should be divided.
Each province is well isolated,
Order 2. The Gynaecologist.
For " science " is so complicated ;
Smith leans to neurotherapy ;
XifflU'tl ? 71/7 i" t II i II ft til «
jl/t(i(( '<ti /' - * / " III '-It H.l,
Jones more to gynaecology ;
Dip, gentle Muse, as " dame d'ho/nteur,"
Currie's a dentist and my own,
Thy magic wand in " eau de milk Jleurs " ;
And skin disease is cured by Cohu.
Lead me as guardian angel on
Each specialist is known to be
Into the incense-filled salon
Unquestionable " authority."
Where, gently dimmed, the light of day
Order 1. The Neurologist.
Through gauzy curtains makes its way ;
Where ornaments, in taste the best,
Median sanitarium neuropathicum privatum diriffens.
The heaving bosom's pangs arrest ;
A large role in disease to-day
While Rubens's deathless " Garden of Lore "
Neurasthenia is known to play.
Directs their thoughts to " things above."
May 14, 1892.J
MISCELLANY.
557
Here the fond patients timid wait
For the expeeted tete-d-tete
With him they love, while yet they fear ;
The deity they worship here.
In true artistic nonchalance
The picture of male elegance,
A velvet robe of pattern rare,
With " scientific " beard and hair,
While on his fingers soft and white,
Gems sparkle in reflected light.
He sits as if in marble cast —
Nature's best work, as well as last.
From top of head to plantar hollow
As ^Esculapius and Apollo,
To Madam faithful to advise,
To Magdalen a father wise,
He hears with patience the confession
Of honor's breach and love's wild passion ;
With " Ah ! " and " Oh ! " " what shall I do ? "
[Compare with Goethe's Faust, act two.]
On this one point without cessation
He centers all his application.
Ten dollars is the usual fee ;
It's double this sum frequently.
If, spite of all, the cure's delayed,
The " springs " serve as a lightning rod.
Who knows the " waters " knows their names,
Where cures are sought by gentle dames.
At Hot Springs, Baden, Saratoga,
Sibyllenort, Ems, Lake Ladoga,
Our doctor stands on best of terms
With all the various hotel " firms."
Carlsbad is now most highly prized,
By ladies greatly patronized.
Charms there are found which please the sense
With which at home they must dispense.
Ye Gods above ! women are wise !
Oh ! husbands ! have you then no eyes ?
Order 3. The Advertising Quack.
Medicus charlatan.
To former times we're carried back
By contemplation of the quack.
Well has this parasitic trash
Learned how to peddle spurious cash.
On open squares all ills of man
Were " treated " by the charlatan,
Aided by a street mendicant
Who lured the sufferers to his tent.
The " enlightened press " with powerful sway
Serves as his mendicant to-day,
Where every page the eye displeases,
With " Specialist in skin diseases."
For secret sins of every kind
He only knows the cure to find.
The assistant loudly shouts the praise
Of " Cohn, chief doctor of our days."
And Itzig wrote with pen which ran good
A treatise on Decay of Manhood.
The cure is wrought by a " specific."
The treatment's purely " scientific,"
But acts with greater certainty
When aided by an advance fee.
" Relations strictly confidential,
Absence from business not essential."
Practice of this kind pays quite well.
The doctor knows his clientele :
The student and the circus-rider,
The hogreve and the humble Schneider,
With troubles of a certain class,
Into his hands as patients pass.
It is well known through all the town,
His only terms are " money down."
And as each case is quickly stated
To be " uncommon complicated,"
The patient finds at last the fee
Quite a financial penalty.
The sufferer can not get away ;
For when he nothing more can pay.
As token of his penitence,
The villain stakes his confidence.
By " confidence " he keeps his " jobs,"
By " confidence " the patient robs,
By " confidence " his dupe denounces,
When he at last the doctor " bounces."
Therefore this kind of mountebank
Is numbered in the " Vampire " rank.
Class III.
Order 1. Birds of Passage. — The Hydropathic Specialist.
Medicus balneus elegans.
In spring, when from the Nile's green shore
The feathered warblers northward soar,
When amorous nightingles are singing,
And swallows their weird flight are winging,
When storks stride through the reedy bogs
In search of winter-fattened frogs,
The bath-physician, like the other
Gay birds ol passage, leaves his cover.
His winter beard falls to the razor,
For fashions new he leaves his measure,
Then circulates his " summer card,"
St. Moritz, Carlsbad, Martha's Yard.
Nature, scarce waked from winter chill.
Shivers in rime upon the hill,
While in the sheltered valley deep
Graze undisturbed the fleecy sheep.
Already in the leafy grove
The finches carol notes of love,
While peals from every hostelry
The " sanitary orchestra."
Behold ! The tardy signs appear !
Ho ! Invalids, the spring is here.
From north and south, from east and west,
Now comes the pale-faced summer guest.
From Maine the manufacturer,
From Buffalo the beer-brewer,
A colonel fresh from Bowling Green,
From England Lord and Lady Spleen.
And then, with rank and title higher,
From Russia, Poland, Turkey, Speyer
[Now, Doctor, play most carefully],
The princely crowd of -koff and -ky.
And finally — oh, height of bliss !
His Highness, " Serenissimus."
Take courage, Doctor, it's your mission,
" Highness" will make you Court-physician.
I see already on your breast
The " order-medal," softly pressed,
Of " Lippe-Detmold " and " Reuss-Sehleitz. "
Ambition now takes loftier flights ;
One further gracious act of power.
And, lo ! the Privy Councilor !
558
MISCELLANY.
[N. Y. Med. Jouk.,
Now as you write each proud initial
You'll say " The baths are beneficial."
To this you may with right aspire :
The laborer should have his hire.
Such a reward begets renown ;
Such merit should receive its crown.
Then head aloft ! nor feel a care,
However your colleagues may stare.
Their envy should not mar your joy,
No earthly bliss but has alloy.
You've won distinction through the State
By means of sodium carbonate.
Of hydrotherapy the staff,
See " interesting monograph."
[A learned work, anil finely bound,
At all the news stands to be found
By the beloved publicum.]
It treats of waters and of him.
Highly important 'tis to guard
In health resorts the promenade,
For only pne.tenle medico
Can healing from the waters flow.
At break of day, and full of grace.
Our Medicus is at his place,
In latest-modeled habitus.
With silver buttoned baculus.
Thus he approaches, brave, sedate,
In all respects immaculate.
At duty's bidding see him stan<,
With gold chronometer in hand.
Here, Countess's pulse must be inspected ;
There, Highness's tongue must be projected ;
Now lifts the hand to ask a swell
If " Excellency rested well."
" Two glasses, Marquis ? Hold, I pray !
Your health requires that I cry nay !
Your noble stomach debonnair
One and a half at most can bear."
" I beg your pardon, Admiral,
To-day, but one hour on the mall ?
Free exercise is Nature's balm,
Excess can lead to naught but harm."
" No, Countess, it is hard, I own ;
Nothing at present but bouillon ! "
" Excuse me, Baron, gracious Heaven !
Already it is near eleven ! S
His Highness waits ; d la lever,
Au revoir at dejeuner! "
Order 2. The Immature Clinical Fiend.
Medicus fere omnia sciens.
When science is to be acquired
The fruits of travel are desired.
The man of means may go for pleasure.
The merchant, sea and land must measure —
May gold reward his energy ;
His Lordship travels from ennui.
The bashful newly married pair
Travel they know not why or where.
By higher aspirations fired,
The doctor travels far and wide ;
His portmanteau is packed with care,
His " old man " must the drafts prepare,
And thus he journeys — grace divine —
Toward Vienna's classic shrine
As hastening to his waiting bride.
His bosom swells with conscious pride,
Celebrities of every land
Now as " colleague " extend the hand.
As a "distinguished foreigner"
He has a seat in the parterre,
And listens with upturned proboscis
To the symptomatic diagnosis;
At times he smiles in condescension,
To show his lofty comprehension.
Thus stalks this scientific vulture,
This greedy carrion crow of culture,
To clinics uninvited turning,
A windbag of promiscuous learning,
Till finally he moves his quarters
Near where earth's frail and fallen daughters
Promise " material " all too free
For living craniotomy.
Nowhere in surgical domain
Would be allowed this septic bane.
Here meanwhile he may boldly try
His virgin forceps to apply
As soon as he with silver balm
Has crossed the gentle midwife's palm.
The assistants also fully know
The meaning of a quid pro quo.
And when the labor is concluded
He seeks a restaurant secluded
Where Bacchus, Venus incarnate,
Assist him to recuperate.
Anon at home we see him landing,
A man of " ripened understanding."
Class IV. Medicus Practkts.
Order 1. The Lion of the Boudoir.
The doctor makes a gain emphatic
By aping ways aristocratic.
Especially in the female world
Much hangs on how the hair is curled.
Whoever then would be in tone
Must make these manners all his own,
Which act as " open sesame,"
For those who " upper teu " would be
Always in faultless taste arrayed,
Reeking with perfume and pomade,
With diamond ring, silk hat, glasses,
Shoes patent leather, gold pince-nez ;
Upon the hour of the visite
He waits upon the " haut elite."
And if with wit and bon esprit
He ornaments the causerie,
He knows the time not far away
For audience in neglige.
With gossip from the matinee,
From corso, grand ball, and soiree,
He drives away through eye and^ear
All that her fancy had to fear.
Till soon, from treatment without'end.
He is a most dangerous family friend :
He is a living neverslip
In point of close companionship.
Round noble minds he weaves his toils
Close as the gliding serpent coils,
And cultivates with ardent passion
The vices of the world of fashion.
May 14, 18&2.J
MISCELLANY.
559
The arts of gaming lie has learned,
To feats of chance his hand has turned,
The jockey club he also prizes,
And loud his winnings advertises ;
For knowledge of the Derby races
The climax on attainments places.
The news in latest buffet scenes,
Last scandals of the lyric queens ;
The newest " bon mots " of the street
He gives, the kernel and the meat,
With effort which no limit knows
Repeats the tale where'er he goes.
Thus only in the " higher walks "
Of life this gaudy creature stalks.
Cajoled by disappointed dames
He thus a certain standing claims.
Applaudite, then, colleagues all !
You all would suffer should he fall.
Science must rise, cost what it may,
E'en though her pedestal be clay.
Order 2. The Graduated Jackass.
Medicus acinus.
In ancient times the doctor's gown
Was like an heirloom handed down.
But even the garment most sublime
Grows shabby with the lapse of time,
And gowns, like other earthly wares,
Are also variable affairs.
Oft 'neath the doctor's hat appears
A prominent pair of ass's ears.
The first-born son is now sixteen . . .
And great anxiety is seen
In frequent family councils grave
As to what calling he shall have.
Law would cost father too much " tin."
As teacher he's not worth a pin ;
The aunt suggests theology.
" No ! that at least can never be ! "
Cries the whole family with misgiving ;
" In that he ne'er could get a living."
" No, dearest Auntie, in our day
Medicine is by a long way
The best — there is no doubt of it,
He could make something out of it."
Therefore, solely for the " tin,"
The fellow studies medicine.
Only that knowledge can be right
Which safely stands in black and white.
Therefore in notebook he records
The old professor's drowsy words,
And duly notes from A to Z
Whate'er of practice he may see.
For observation is in minority
Against a pedagogue's authority.
Their therapeutical " arrangements,"
The way they classify " derangements,"
The methods they in treatment try
Are most convenient for a_" b'y."
He does not need to doubt or quibble,
Only a daubed receipt to scribble ;
Goes only to his desk to seek 'em
From Doctor Docent's Vadc Mecum
For every dullard's quick advisement
[It answers as an advertisement].
The examination makes him tremble.
Its terrors he can not dissemble.
He has no confidence in shamming,
So zealously resorts to cramming.
That which he has in lectures taken,
Trusting thereby to save his bacon,
He rolls forth without hesitation,
To each his wordy peroration.
At length he passes all the quaestors,
Is ranked among the " coming Nestors,"
Is titled virum ilhixtrum
And all the rest of quid and quern,
Recorded in his grave diploma
In classic terms of ancient Roma.
Now Michael need not fear the future,
Although he know not pill from suture ;
Need not in science to speculate,
Nor theories to ventilate.
He has no use for such possessions
Now that he's joined the " learned professions."
Before his neighbors and relations,
Whate'er their state or occupations,
The cousins, uncles, nephews, aunts,
Whether in petticoats or pants,
Wet-nurses, midwives, foul or neat,
The officers upon the beat —
He throws the dust in all their eyes,
That they his skill may advertise.
It's quite essential the first cure
Should be made pleasant, prompt, and sure.
One does well to select migraine,
For morphine will relieve the pain ;
Should this fail, as sometimes it will,
We've plenty of narcotic still ;
If thus we give the patient rest,
The laity is much impressed.
A syringe is his first selection
For subcutaneous injection.
Next to his heart it finds a place
Within a silver-plated ease.
Where " indications " he detects
He " svmptomatically " injects.
Enough ; the valiant Michael quick
Is widely known among the sick.
But in regard to surgery
He shows a marked antipathy.
For pulling teeth he has a passion,
For knives are now quite out of fashion.
By salves much comfort is achieved ;
Fear of the knife is thus relieved ;
And should the patient not do well,
He's carted to the hospital.
Order 3. The Honest Old Family Physician.
I turn my gaze from these delusive forms.
Bring from the shadows of the honored past,
Fond memory, the bravest of our race,
And let me glance at long-neglected worth.
No laurel decks thy brow, but where thy spirit true
Thy comrades showed the way to live and do.
There lives thy form, enthroned in every heart ;
There thou art still, and hast in life a part.
On the low couch within the chamber dim
A sufferer waits the last long struggle grim ;
Thou comest ; it is light, and sorrow disappears,
Pain is forgotteu ; hope replaces fears.
560
MISCELLANY.
|N. Y. Med. Jotjr.
So happy makes thy face, so brave thy kindly glance,
The touch of thy loved hand brings ease and confidence.
And, what with sordid gold can not compare,
The tears of gratitude reward thy care.
I see thee, dearest councilor and best,
The children's friend, the always welcome guest.
Sorrow is shared, and doubled is the joy,
Affection true, and trust without alloy.
I hear thy accents, fresh from noble mind,
In language chaste, in motive always kind.
Thy cutting satire, causing fools to quake,
Who on some passing whim their fortunes stake.
Shall I entice thee to the motley crowd,
Thou hoary guest of period long since past,
That tricksters of an age beneath thy worth
Should air their folly on thy classic robe V
Let us away from busy streets' commotion.
Turning aside into the silent vale,
And where some ancient comrade kindly beckons,
There let us rest, and grant me thy communion.
Mortality in Cities in the United States. — The following table
represents the mortality in the cities named, as reported to Dr. Walter
Wyman, Surgeon-General of the Marine-Hospital Service, and pub-
lished in the Abstract of Sanitary Reports for May 6th :
New York, N. Y Apr. 30.
Chicago. Ill Apr. 30.
Philadelphia, Pa Apr. 23.
St. Louis, Mo Apr. 30.
Boston, Maes Apr. 30.
Baltimore, Md Apr. 30.
San Francisco, Cal. .. j Apr. 23.
Cincinnati, Ohio Apr. 29.
Cleveland, Ohio Apr. 30.
New Orleans, La i Apr. 25.
Washington, D. C Apr. 23.
Washington, D.C.... Apr. 30.
Milwaukee, Wis Apr. 30.
Minneapolis. Minn. . . , Apr. 23.
Minneapolis, Minn... 1 Apr. 30.
Louisville, Ky Apr. 30.
Rochester, N. Y j Apr. 30.
Providence, R. I Apr. 30.
Denver, Col Apr. 8.
Denver, Col Apr. 9.
Denver, Col I Apr. 10.
Denver, Col Apr. 23.
Toledo, Ohio , Apr. 15.
Richmond. Yu Apr. 30.
Nashville, Tenn j Apr. 30.
Portland, Me Apr. 30.
Binghamton, N. Y. . . I Apr. 30.
Mobile, Ala Apr. 30.
Auburn, N. Y Apr. 30.
San Diego, Cal Apr. 23.
Pensacola, Fla Apr. 23.
DEATHS FROM—
cs ■ X
is*
1,515
1,009.
1,046
451.
448,
437,
298.
296.
261,
242,
230,
230.
204,
164,
164,
161,
133,
132,
100.
106.
106,
106,
81,
81,
76,
36.
35.
31.
25
16.
11
,301
'.850
964
770
477
,439
,997
,908
,353
039
392
392
468
,738
738
129
896
146
713
; 13
713
713
434
388
168
425
005
oro
858
159
7.50
950
500
436
150
201
212
129
94
159
106
90
92
45
58
68
58
52
38
52
21
29
-30
32
15
121
26 33 25
1014
8 16
Medical Misinformation. — In an article with this title the Drug-
gists Circular and Chemical Gazette says : " The kind-hearted busy-
body who is always ready to tell his sick friend exactly the right
medicine to effect a sure cure is a bad enough person ; but the news-
paper prescribe!- is a great deal worse, for his utterances acquire a
certain fictitious authority in the eyes of many people because they
appear ' in the paper.' Some dangerous outbreaks of this kind of
prescribing have lately occurred in several English journals. In one a
' cure for vertigo ' was given in which ' glonoin ' was directed as an in-
gredient. This article is much better known to the public by its
chemical name, nitroglycerin, and the quantity of the ' cure ' directed
to be taken at one time would give the patient a two-grain-and-a-quarter
dose of this violent remedy. In another paper a prescription for
' pains in the head' was given, in the taking of which the unfortunate
patient would be dosed with a sixth of an ounce of mix vomica tincture
three times a day. Still another recipe in the same paper orders
as a ' hair tonic ' a seven-ounce mixture containing one ounce of
strong ammonia water and two ounces of tincture of canthai ides. The
same style of medical tinkering may not infrequently be observed also
in newspapers printed on this side of the water, although it is perhaps
uncommon to find such dangerous ignorance displayed as has been re-
corded above. We have in mind a note on the treatment of insomnia,
in which a mixture of chloral hydrate, potassium bromide, and codeine
was directed in pretty stiff doses on the authority of a foreign physi-
cian, who ' highly recommended ' it. The use of such a prescription
under the direct supervision of a medical man and its employment by
an unskilled layman might, of course, easily make the difference be-
tween life and death or between temporary help and the most wretched
slavery. People have a great deal too much half-knowledge about
drugs already, and the less attention they pay to newspaper prescribing
the better. Here, as in the regular kind, the pharmacist is bound to
stand between the patient and danger. When a customer comes to
him with a nitroglycerin recipe or a blistering hair tonic he must
promptly warn him of the true state of affairs, and by his watchfulness
much damage can be averted and the cause of education be a little
helped."
To Contributors and Correspondents. — The attention of all who purpose
favoring us with communications ts respectfully called to the follow-
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dressed to the publishers.
THE NEW YORK MEDICAL JOURNAL, May 21, 1892.
NEW OUTLOOKS IN THE
PROPHYLAXIS AND TREATMENT OF
TUBERCULOSIS.
THE MIDDLETON GOLDSMITH LECTURE FOR 1892,
DELIVERED BEFORE THE NEW YORK PATHOLOGICAL SOCIETY,
By FRANCIS P. KINNICDTT, M.D.,
PHYSICIAN TO ST. LUKE'S HOSPITAL AND THE PRESBYTERIAN HOSPITAL,
NEW YORK.
Gentlemen : When your committee did me the honor
to request my acceptance of the Middleton Goldsmith lect-
ureship of the present year and suggested the suhject — The
Present Aspect of the Treatment of Tuberculous Disease,
and especially of Pulmonary Tuberculosis — my first inclina-
tion was to decline. Their representations that a review of
this subject was particularly desirable at the present time,
and would serve a practical purpose, have alone induced me
to undertake a difficult task.
The lecture has been postponed beyond the customary
time of its delivery, in the hope that investigations which
have been carried on during the past winter in St. Luke's
Hospital and in the pathological laboratory of the College
of Physicians and Surgeons might be sufficiently advanced
to be incorporated in it. This hope, in part, has been ful-
filled.
Any consideration of methods of treatment of infectious
diseases at the present time must necessarily be in the light
of modern pathology and bacteriology. Through the dis-
coveries in this field of medicine the term treatment has ac-
quired a new significance. A large number of the infectious
diseases of human beings and of animals have already been
shown to have their origin in specific pathogenic living or-
ganisms, and there are strong reasons for believing that a
similar aetiology will be demonstrated in the near future for
all diseases hitherto included in this category.
In the infancy of bacteriology it was not unnaturally as-
sumed that the sowing of the seed was alone necessary for
the production of a disease, that, if once the specific germ
gained access to the economy, its particular effects would
certainly follow. The " possession of a self-protecting
power by the organism of man and of the higher animals,
which could exercise its influence within certain limits
either in arresting the development of the living exciters of
disease or in counteracting their poisonous products," was
hardly dreamed of. To-day the splendid discoveries of
bacteriological research have abundantly demonstrated that
an unceasing contest is being waged between the growing
power and toxic activity of the pathogenic microphyte and
the living organism.
In this connection, wbat can be of more absorbing in-
terest than the discovery by the distinguished plant physi-
ologist, Professor Pfeffer (1), of the group of phenomena
to which he gave the name of chemotaxis, the definite rela-
tion between vital movement and chemical action ? Later it
was suggested by Dr. Leber that the emigration of leuco-
cytes in the human body was due to the same power ; im
other words, that certain harmful substances in the living
tissues, embracing effete materials, living pathogenic organ-
isms, and viruses of various kinds were agreeable to a rudi-
mentary sense of taste, as it were, in the leucocytes, which
were thus allured from the media in which they commonly
lived toward the attracting substance.
The mustering of the leucocytes in troops, in the neigh-
borhood of the bacterial invaders of the body, as a direct
or indirect protection to it, is almost as dramatic as it is
important. This action of the leucocytes, in virtue of their
chemotaxis, and the final incorporation or digestion by them
of the bacteria, constitutes Metschnikoff's well-known theory
of phagocytosis and phagocytic immunity.
Further, we may refer to the investigations of Buchner
(2) and Roemer, showing the association of a general leuco-
cytosis with febrile inflammatory processes. They found
that within eight hours after the intravenous injection in
rabbits of various proteids there was marked leucocytosis ;
the relation of white to red blood-cells on the evening of
the fourth day of the daily injection of solutions of the
protein of the Bacillus pyocyaneas (the bacillus of green
pus) was 1 to 38, the absolute number of the red blood-cells
remaining unchanged. It should be mentioned that the
office of policeman on the part of the leucocyte is not con-
sidered proved at the present time by many. Their work
as scavengers is acknowledged, but it is believed that the
true guardianship of the body resides in the body fluids ;
in other words, that the destruction of bacteria is accom-
plished by the germicidal power of the latter, and their re-
moval only is effected by the leucocytes.
Finally, we may refer to the investigations which have
shown that, while the living tissues and fluids of the body
possess the power in varying degree of arresting the de-
velopment of living disease-producing organisms and of
eventually destroying them, certain life products of the
latter are capable of impairing or inhibiting this protective
power.
In view of such facts, preventive medicine must neces-
sarily embrace the means of promoting the victory of the
organism in its contest, either by strengthening its defenses
or by weakening or destroying the power of the growing
microphyte.
With our present knowledge of the various media in
which the specific living exciters of disease most commonly
lurk, it should be a matter of reproach if we fail in securing
a more efficient prophylaxis than has been possible i ti the
past.
Previous to 1882 the pulmonary lesions of tuberculosis-
had been accurately described, and Villemin, as a result <>f
his successful inoculations of animals, had declared it to be
a specific infectious disease. With the announcement of
Koch, on March 14th of the year mentioned, that he had
discovered not only the constant accompaniment but the
cause of the tuberculous process, the infectious nature of
tuberculosis was finally established and the nature of the
relation between specificity of cause and specificity of pro--
cess in this disease was determined.
562
KINNIOUTT: PBOPHYLAXIS AND TREATMENT OF TUBERCULOSIS. [N. Y. Med. Jock.,
Before proceeding further, it will be advantageous to
have accurately pictured in our minds the pulmonary le-
sions which are directly or indirectly due to the tubercle
bacillus. The list is indeed a formidable one : Miliary
tubercles, both single and conglomerate ; larger and smaller
areas of epitbeloid cell growth, called diffuse tuberculous
tissue, and various aggregations of these, often in a state of
more or less advanced coagulation necrosis ; disintegration
and excavation as a result of the latter ; cicatricial forma-
tion ; peribronchitis, and extensive inflammatory consolida-
tions specific in nature ; and, finally, we must bear in mind
the bronchitis and lobular pneumonias, probably simple
(unspecifie) in character, so frequently present in tubercu-
lous lungs.
In the light shed by modern research upon the posses-
sion by the organism of man of a self-protecting power
against pathogenic organisms, with a knowledge of the
specific organism which causes tuberculosis and the lesions
which are directly or indirectly produced by its presence in
the economy, we are proportionately equipped to attempt
to consider the measures, prophylactic and remedial, which
have been proposed to cope with the disease.
Prophylactic measures must necessarily consist of those
'designed to destroy the vitality of the bacillus outside of
the human body, to minimize the sources of infection, and
to render the tissues insusceptible to its presence.
Three possibilities suggest themselves as specific means
for exercising a remedial effect. They are : First, the dis-
covery of a method of treatment capable of destroying the
bacillus within the body ; second, of some substance, or-
ganic or inorganic, which by its introduction into the body
may so modify the action of the bacillus as to deprive it of
its harmful effects — the possible abstraction of a constitu-
ent of its protoplasm or of its metabolic products, analogous
to the tetanus or pneumonic antitoxine, suggests itself in
this connection ; third, the discovery of a principle capable
on introduction into the economy of increasing the germi-
cidal power of the fluids of the body by stimulating cell
activity, upon which it ultimately depends, or by such
stimulation inducing connective-tissue changes in tubercu-
lous tissue, or both.
Prophylaxis. — I shall first consider the prophylaxis of
tuberculosis so far as it relates to destroying the vitality of
the bacillus outside of the human body, and to minimizing
the sources of infection. With the discovery of the spe-
cifically infectious nature of a disease, the means of infec-
tion are not necessarily directly evident. In tuberculosis a
series of brilliant investigations quickly threw much light
upon this point. Following Koch's discovery, it was very
earlv shown that the bacilli were not contained in the air
expired by patients suffering from pulmonary tuberculosis ;
on the other hand, that their sputum contained bacilli in
•enormous numbers. It was further shown that the bacilli
were incapable of escaping from fluid media, and, finally,
that the sputum in a dry state, conveyed in the form of
pulverized atoms by currents of air, was the most common
source of infection. Successive investigations demonstrated
that the stools of human beings afflicted with the intestinal
form of the disease and the discharges from tuberculous
ulcers, glands, and bones were positive, if infrequent,
vehicles of infection ; and, finally, that the milk of tubercu-
lous cows, with or without disease localized in the udder,
and tuberculous meat, were capable of producing tubercu-
losis in the consumer.
It will be interesting to refer at somewhat greater length
to inoculation experiments and clinical observations bearing
on these points.
The elaborate investigations of Cornet (3) in the Berlin
Institute of Hygiene in regard to the distribution of the
tubercle bacillus in the air are particularly instructive. The
dust from twenty-one wards of seven hospitals, from three
asylums, from two prisons, from the living-rooms of sixty-
two phthisical patients in private practice, from " out-pa-
tient" departments, from the public streets, and from in-
halation experiment rooms, was gathered and its virulence
or innocuousness determined by inoculation of susceptible
animals.
Of ninety-four animals inoculated with the dust of hos-
pital wards, twenty became tuberculous. Virulent bacilli
were obtained from fifteen out of twenty-one medical
wards. Negative results, on the other hand, were obtained
from the dust of the surgical wards, also from that of the
streets and the inhalation rooms investigated. Of one
hundred and seventy animals inoculated with dust from the
living-rooms of consumptives, thirty-four became infected.
As ninety-one of the one hundred and seventy died of sep-
tic disease, it is probable that the above-mentioned per-
centage of animals in which tuberculosis was produced does
not accurately represent the specific (tuberculous) virulence
of such dust. The dust was taken from the walls, articles
of furniture, picture frames, etc. From the room of a con-
sumptive in a private house virulent bacilli were obtained
six weeks after her death.
Cornet records the fact that he did not once find infect-
ive bacilli in the rooms of those patients who used only
spittoons for the sputum, although especially careful search
was made in these instances. Equally valuable evidence on
this point is furnished by Trudeau (4). In his sanitarium at
Saranac Lake, where rigid rules in regard to the use of
proper receptacles for the sputum are enforced and its ef-
ficient disinfection or destruction is accomplished, not a
single employee has acquired tuberculosis during the six
years since its institution. In Dettweiler's sanitarium at
Falkenstein, where presumably similar precautions are
taken, a similar experience is alleged.
AVith such observations before us, further clinical
statistics may be unnecessary, but are not without interest.
In response to questions sent in 1883 by the Collective
Investisation Committee of the British Medical Association
to physicians throughout Great Britain (5), asking for their
personal experience on the communicability of phthisis,
1,078 communications were received. Of these, 673 were
to the effect that cases of tuberculosis originating in infec-
tion had not come under their notice. Of the remaining
405, 261 were regarded by the committee as positive in evi-
dence of communicability, 39 as doubtful, and 105 as nega-
tive. Among the affirmative observers, 192 reported cases
of probable infection of husband by wife and the converse,
May 21, 1892,] KINNIOUTT: PROPHYLAXIS AND TREATMENT OF TUBERCULOSIS.
563
and in 130 of these cases there was an entire absence of in-
herited predisposition on the part of the person infected.
Turning to our own country, the investigations of
Flick (6) are of much interest. The localization of and
mortality from tuberculosis in one of the wards of the city
of Philadelphia for a period of twenty-five years preceding
1888 were verj carefully studied by him. It is shown that
while less than one third of the houses of the ward became
infected with tuberculosis during the twenty-five years prior
to 1888, considerably more than one half of the deaths from
this disease during the year 1888 occurred in infected
houses. Inasmuch as there were more than twice as many
non-infected as infected houses in the ward, a preponder-
ance of deaths in non-infected houses would be expected.
Cornet's investigations of the health statistics of the
Catholic nursing orders of Prussia (7) may be considered
as supplementary to those of the same author which have
already been described. Thirty-eight convents were se-
lected, representing a yearly average of four thousand and
twenty-eight persons, and the statistics relate to the twenty-
five years preceding the year 1889. It is known that the
general annual death-rate from tuberculous disease is from
one seventh to one fifth of all deaths. Among the above-
mentioned orders the enormous average mortality of 62-88
per cent, is shown to be due to tuberculosis alone. In nearly
one half of the convents it even rises to seventy-five per
cent., and in two " mother houses " it was the sole cause of
death. In others the death-rate from this disease varies
from forty to fifty per cent.
Cornet says that the different mortalities may be ex-
plained by the fact that some of the nurses are engaged in
attending altogether or for the most part upon surgical
cases. The average age at death of the inmates is 36-27
years, lower by ten years than that of men engaged in trades
notoriously the most unhealthful — i. e., file-cutters, copper-
smiths, locksmiths, blacksmiths, cotton-spinners, etc.
If the mortality due to tuberculosis and that resulting
from other diseases commonly regarded as infectious are
both deducted from the death-rate in the Prussian state and
in the convents, it is shown that up to the age of forty years
the death-rates in state and convents are remarkably equal.
From forty to sixty years the mortality due to non-infec-
tious diseases is less in convent than in state. Even ad-
mitting the insanitary conditions of convent life, it is im-
possible to believe, with our present knowledge of the aeti-
ology of tuberculous disease, that it can produce it. On
the other hand, these conditions are of the kind to lead to
its rapid extension when once introduced. It should be
mentioned that the health of all persons on entering the
nursing communities is excellent, admission being depend-
ent upon medical certificates to this effect.
Among the numerous investigations (8, 9, 10) of the in-
fectiousness of the milk of tuberculous cows, I shall only
refer to the very brilliant ones of our countryman. Dr. Ernst,
of the Harvard Medical School (11). They surpass in their
extent and importance those of continental observers. Ex-
perimental inoculations in rabbits and guinea-pigs, and
feeding experiments in calves and pigs with both the milk
and cream of tuberculous cows without disease of the udder,
proved in the most positive manner that such milk was ca-
pable of producing tuberculosis in the consumer. Inci-
dentally, in experiments with milk taken at random from
the common dairy supply of Boston, virulent bacilli were
found in two instances.
If Dr. Ernst's experiments are supplemented with the
clinical fact of the frequency of intestinal and mesenteric
tuberculous disease in children and with the statement, made
in the form of a resolution, by the United States Veterinary
Association in 1889, that from ten to fifteen percent, of the
dairy stock of the Eastern States was tuberculous, this sub-
ject assumes very grave importance. Although investiga-
tions have shown that tuberculous meat as such is infective,,
further experiments are necessary to determine whether
those parts of a tuberculous animal usually used for food,
and not specifically affected, are harmful.
I have been able to collect a large number of cases of
probable inoculation tuberculosis in the human being.
Many of them occurred through infection of post-mortem
and dissection wounds. Among others the following are
of interest :
A healthy girl of fourteen years, without inherited predispo-
sition, became locally infected through wearing the ear-rings of
a consumptive. A tuberculous infiltration of the glands and
general infection followed (12).
A male child, very vigorous at birth, began to suffer when
three years old from eczema of the skin of the abdomen. Ba-
cilli were searched for, but not discovered. After tour years
of age, he constantly slept with his consumptive mother, and
bacilli were shown to be present in the eczernatous vesicles (13).
A student received a slight wound in dissection; a nodule
appeared at its site and a swelling of the glands of the forearm
followed. The glands we're excised and showed central cheesy-
degeneration (14).
Ten Jewish boys were circumcised by the same physician
only a short time before his death from consumption. There is
positive evidence that the saliva of the operator came in contact
with the preputial wounds. The first symptoms of infection de-
veloped ten days later. Three of the children died of tubercu-
lous meningitis, three of marasmus, and one of intercurrent diar-
rhoea. Three survived, but developed tuberculous adenitis (15).
Accumulated experimental and clinical investigations in
demonstrating the most common sources of infection — viz.,
the sputum of patients suffering from pulmonary tuberculo-
sis, the milk of tuberculous cows, and finally, though to a
much less extent probably, tuberculous meat — clearly indi-
cate the direction which prophylactic measures should take.
The enormous number of tubercle bacilli contained in
the sputum of patients suffering from pulmonary tubercu-
losis, even admitting that many of them are dead, as Kita-
sato very recently has shown, is well known. In a series
of investigations kindly made for me by Dr. T. Mitchell
Prudden in 1891, as many as 21,4(50,000 were computed to
be present in the daily sputum of a single patient. Nut-
tail's experiments (10), conducted in the Johns Hopkins
laboratory, give quite similar results.
Sawizky (17) has shown, moreover, that tuberculous
sputum, dried and preserved under the conditions which
usually obtain in the dwelling-house, preserves its infective
properties for two mouths and a half.
KINNICUTT: PROPHYLAXIS AND
TREATMENT OF TUBERCULOSIS. [N. Y. Med. Jopb.
Stone's experiments (18), if corroborated by furtber in-
vestigations, apparently sbow that its virulence may be ex-
tended for as long a period as three years. If we further
consider the exceptional resistance of the tubercle bacillus
to the action of both chemical and other antiseptics, the
efficient disinfection or destruction of tuberculous sputum
becomes a matter of vital importance.
Chemical Disinfection. — Carbolic acid, potassa, sulphate
of copper, and chloride of zinc, all in solutions of 1 to 500,
were found by Grancher and De Gennes to be useless (19).
Histological examination of the sputum so treated showed
no change in the appearance of the bacilli, and inocula-
tions proved that they were still active. Later experiments
(20) have demonstrated that carbolic acid, even in ten-per-
cent, solutions and after twenty-four hours' admixture with
the sputum, is without effect. Corrosive sublimate is value-
less through the coagulation produced by it of the albu-
minoids contained in the sputum. The experimental inves-
tigations of Schottelius and Spengler (20) with the newer
antiseptics — creolin, aseptol, and lisol — of which much was
hoped, have also been disappointing. Ten-per-cent. solu-
tions of creolin and aseptol were found to be absolutely
without effect, even after twenty-four hours. Lisol, how-
ever, in ten-per-cent. solutions, proved to be capable of ren-
dering the sputum sterile in twelve hours.
These results indicate in the most positive manner that
we possess no practical means at present for efficiently dis-
infecting sputum by chemical antiseptics.
Experiments with heat, on the other hand, have shown
that the tubercle bacilli rarely survive a temperature of S0°
C, and are invariably killed at temperatures varying, ac-
cording to different observers, from 90° to 100° C. (21).
Simple rinsing of the cups or other receptacles of the spu-
tum with boiling water is not sufficient and is not without
danger to the attendant. Numerous observers report cases
of infection of cuts from sputum (v. Eiselberg [22], Fleur
[23], Hoist [24], L. Pfeiffer [25], and others).
In view of these facts, every consumptive should pos-
sess the knowledge that, while his disease is in reality a
menace to those about him, the foil is within his reach.
He should be taught never to use a handkerchief for his
sputum, never to spit upon the floor. An appropriate re-
ceptacle of glass, china, or paper, partially filled with wa-
ter, should be provided for the sputum, which should be
thoroughly disinfected or destroyed at least once in twenty-
four hours. For its disinfection in hospitals, an ordinary
Arnold's sterilizer, of sufficient size to accommodate all the
cups of a ward, and in which they should be placed daily
for half an hour, may be used.
A far better method, in my judgment, is the destruction
of the sputum by fire. The method at present in success-
ful use in St. Luke's Hospital, and which is of easy appli-
cation in private houses, consists in the use of paper boxes',
which are daily supplied to each patient, and at the end of
twenty-four hours destroyed, with their contents, by fire.
They are of convenient size and very inexpensive, and the
preparation used in their construction prevents all leakage.
The floors and the walls of living-rooms and of hospital
wards of consumptives Bhould be scrubbed or wiped with
damp cloths, not swept or dusted. The cast-off clothing of
such patients should be submitted to the action of live
steam, or to the degree of heat described as sufficient to
destroy the tubercle bacilli.
Public sentiment, in the absence of legislation, should
compel the proprietors of hotels and boarding-houses at
health resorts, at least, to take such measures as can be
designated with our present knowledge for disinfecting the
living-rooms of consumptives. Further investigations are
urgently needed to determine the most efficient and practi-
cal means for accomplishing this object.
A further most important prophylactic measure consists
in the systematic inspection of dairies, particularly those of
large cities, and of slaughter-houses. Commercial consid-
erations have secured the necessary legislation for the in-
spection of the pork products of the United States ; a con-
sideration of the public health should be sufficient to secure
a similar legislation to minimize the sources of infection of
tuberculous disease.
A bill for the inspection of dairies and the slaughter of
tuberculous animals, I am happy to state, will probably be
introduced in the Legislative Houses of the State of New
York during the present session. Such an example, it is
reasonable to hope, would gradually be followed by the
Legislatures of other States.
In the mean time, in the absence of necessary legisla-
tion, the only safeguard possessed by the public against
possible infection through dairy products consists in the
sterilization of milk and cream by boiling or through the
use of steam sterilizers.*
Many of the prophylactic measures which have been
mentioned have already been embodied in the form of sug-
gestions or in laws by various governments and municipali-
ties abroad, and the Board of Health of the City of New
York has issued some admirable rules " to be observed for
the prevention of the spread of consumption."
In considering the prophylaxis of tuberculosis I have
confined myself to measures designed to destroy the vitality
of the bacillus outside the human body and to means for
minimizing the sources of infection, in the belief that such
efforts are of far greater relative value than those directed
toward increasing the resisting power of the individual. I
shall even go further, and thus cease to be open to the re-
proach that the clinician's interest in the therapeusis of the
disease is almost to the exclusion of that in its prophylaxis,
and assert that infinitely more can be accomplished toward
the elimination of this terrible scourge by making practical
use of our present exact knowledge of its aetiology and pro-
phylaxis than by any or all therapeutic measures at present
at our command. As has been well said, " it is the seed of
the disease, without the implantation of which there can be
no harvest of death, that we are now most able to reach and
destroy." We shall fail, then, in our duties as true physi-
cians if we do not scatter broadcast among the laity this
knowledge. From a full appreciation of the dangers at
their doors and a knowledge of the means capable of divert1
* Investigations conducted in the Imperial Health Bureau of Berlin
demonstrated that tubercle bacilli also retain their vitality in butter and
cheese frequently- for weeks.
May 21, 1892.] KINNIGUTT: PROPHYLAXIS AND
TREATMENT OF TUBERCULOSIS.
565
ing them, surely good fruit will be borne, even to the en-
actment and .enforcement of laws for the protection of the
public health.
In turning our attention to the remedial treatment of
tuberculosis our thoughts naturally are first directed to
Koch's tuberculin (26). His hypothesis of its specific mode
of action is as follows: lie particularly states that other ex-
planations are possible and may be more correct. The
tubercle bacilli in their growth produce in the living tissues,
just as in artificial cultivations, certain substances which
have various but always deleterious effects upon the living
elements of their surroundings, the cells. Among these
substances is one which, in a certain concentration, destroys
living protoplasm and causes it to undergo what is known
as a coagulation necrosis. The necrotic tissue is unfavor-
able to the nutrition of the bacillus ; its further develop-
ment is checked, and finally, in some cases, its death fol-
lows. If the amount of the necrosis-producing substance
is artificially augmented, as he believes it to be by the in-
troduction of tuberculin into the system, not only will the
extent of the necrosis be increased and consequently the
conditions of the nutrition of the bacilli be more unfavor-
ably affected, but also more completely necrosed tissues will
disintegrate and slough, and, where this is possible, take
with them the inclosed bacilli, carrying them outward.
Large doses of tuberculin are capable of giving rise to a
certain amount of pyrexia and other symptoms in healthy
persons, he believes through irritative influences exerted
upon certain elements of the tissues, probably on the white
corpuscles of the blood or cells closely related to them.
The necrosis-producing substance in tuberculin Koch now
tentatively believes to be an albumose or a substance closely
related to it.
Many elaborate criticisms of this hypothesis, both theo-
retical and based upon experimental and clinical investiga-
tions, have appeared during the past year.
In a very recent monograph by Rosenbach (27) the au-
thor denies both a specific affinity of tuberculin for tuber-
culous tissue and the specific action alleged for it. The
general action and constitutional disturbance following its
inoculation he believes to be due to a general irritation set
up in the body, which, according to its degree, can assume
the characteristics of an inflammatory action, in some cases
even of a purulent type. The degree of the reaction, par-
ticularly of the fever, depends upon the predisposition of
the individual to febrile disturbance. Similar constitu-
tional disturbances have been shown to follow the inocula-
tion of cantharidal salts and the protein of other bacteria.
Rosenbach asserts that the specific activity of tuberculin
can only be demonstrated when it is proved that substances
derived from other micro-organisms can produce fever ex-
clusively in subjects w ho are the hosts of bacteria of the
same kind, and, further, that they can evoke reactions only
in the tissues in which changes have occurred from their
action and elsewhere remain without effect. lie maintains
that hitherto this has not been shown. The author ex-
presses a guarded opinion as to whether tuberculin pro-
duces an actual necrosis of tuberculous tissue; if it occurs,
he believes it is not a coagulation (specific) necrosis, but
rather is secondary to an acute inflammatory process and
exudation.
A new light has been thrown on the nature and action
of tuberculin through the investigations of William Hunter,
of England, and the German pathologist Klebs. As early
as January, 1891, the former began his investigations (28).
Starting with the assertion of Koch's that the remarkable
properties possessed by it — unfortunately for evil as well as
for good — were due to a single active principle which con-
stituted but a fractional part of the extract, he believed that
the chemical behavior of this hypothetical principle, which
was described by the discoverer as a derivative of albumi-
noid bodies, could not possibly apply to any one known
chemical substance.
His studies had for their objects :
(1) To isolate the chief constituents of. tuberculin and
to determine their chemical nature ; (2) to ascertain their
action, with special reference to their power of inducing
the two most characteristic effects of tuberculin — viz., local
inflammation and fever ; (3) to ascertain how far it was
possible to eliminate all substances having an injurious ac-
tion, and thus to obtain remedial without injurious effects.
His results may be summarized as follows, under the
heads of composition, action, and therapeutic value :
The chief substances found in tuberculin are : (1) albu-
moses;* (2) alkaloidal substances; (3) extractives, small
in quantity and of unrecognized nature ; (4) mucin ; (5)
inorganic salts; (6) glycerin and coloring matter.
Having ascertained that the only substances present in
tuberculin with which its active properties could be asso-
ciated were albumoses, organic bases of alkaloidal nature,
and probably various extractives, he proceeded to deter-
mine by experiments on mice and guinea-pigs to which
of these substances tuberculin owed its characteristic prop-
erties, remedial or other.
Four modifications of the original tuberculin were ac-
cordingly prepared by him. He has given to them the
designations A, C, B, and CB, and these terms will be re-
tained in the present paper.
From extensive investigations with these modifications,
he feels warranted in concluding —
1. That tuberculin owes its activity, not to one princi-
ple, but to several ; that its action in producing local in-
flammation, fever, and general constitutional disturbance is
not a simple but an extremely complex one.
2. That its remedial and inflammatory actions are con-
nected wTith the presence of certain of its albumoses, while
its fever-producing properties are chiefly associated with
substances of a non-albuminous nature.
3. That by the adoption of certain chemical methods it
is possible to remove the substances which cause the fever,
while retaining those which are beneficial in their action.
4. That the fever produced by tuberculin is thus abso-
lutely unessential to its remedial action. (He is inclined to
believe that the inflammation is almost similarly unessen-
tial, although admitting that under certain circumstances it
may assist the action of the remedial substance.)
* Chiefly pioto-albumose and deutero-albumose, along with hetero-
albumoee and occasionally a trace of dysallminoso.
566
KINNICUTT: PROPHYLAXIS AND
TREATMENT OF TUBERCULOSIS. [N. Y. Med. Jorm.,
5. That tuberculin possesses a truly remedial action
and that this is to be found in a protein — i. e., in an albu-
minous substance derived from the plasma of the bacilli
themselves and not formed by their action upon the sur-
rounding tissues ; and, finally, that it is possible to isolate
largely this protein.
Dr. Hunter's clinical investigations, in which he has
been assisted by Mr. Watson Cheyne, with the above-de-
scribed modifications of tuberculin, have led him to assert
tentatively the following propositions : Modification A dif-
fers but slightly in its action from tuberculin. Modifica-
tion C differs from tuberculin in being almost completely
freed from the substance which gives rise to local inflam-
mation. It contains, however, in a special degree the fever-
producing agents, which may be regarded as interfering
with its remedial properties and favoring rather than retard-
ing the growth of the bacilli. Modification CB contains
the remedial substance present in C, freed from the fever-
producing agents. Its use, moreover, is unattended with
any of the other constitutional symptoms following the
employment of tuberculin. Modification B contains the
remedial properties of CB with the additional property of
inducing local inflammation. Its action is free, so far as
has yet been observed, from ill effects.
From the marked improvement which Dr. Hunter has
seen occur in cases of ulcerative and other forms of lupus,
where it is possible to watch the local changes from day to
day, under treatment both with B and with CB, he be-
lieves the activity and probable remedial power of these
modifications to be demonstrated. It yet remains to be
determined whether the improvement noted in his cases
will be more or less permanent. The absence of marked
local inflammation, or of necrotic changes accompanying
their use, leaves the mode of action of the above-mentioned
modifications of tuberculin a matter of more or less specu-
lation at the present time. I shall refer later to the clinical
investigations of other observers, and to some personal
ones with Dr. Hunter's preparations.
Professor Klebs's researches evidently have been based
on the same line of thought as the foregoing, but were
made quite independently of them (29). Convinced that
tuberculin produced in the human being many effects which
had nothing to do with its action upon tuberculous tissue,
and which could be avoided without affecting the latter
property, he submitted tuberculin to various chemical pro-
cesses with the view of freeing it from its alkaloidal sub-
stances. Its noxious properties reside in the latter, he
believes.
He maintains that the extracted principle represents the
secretions of the tubercle bacilli and is a pure albumose.
Experimental investigations in animals indicate that the in-
jection of large doses of tuberculocidin, as he terms the
albumose, previous to inoculation with pure cultures of the
bacillus, delays the development of tuberculosis to at least
twice the usual period ; moreover, that a complete resolution
of previously developed tubercle may occur under its use.
The best results in animals were obtained when the
tuberculocidin was injected simultaneously with inocula-
tions of the bacilli. In such animals, killed tiiree months
later, tubercle was scantily present, and few bacilli were
found. In cases where treatment was begun six weeks
after experimental inoculation and continued for twenty-
five days, either complete healing or a high degree of retro-
gradation of the tuberculous lesions was observed.
Of seventy-five critically observed cases of pulmonary
tuberculosis in the human being treated with tuberculocidin,
18-6 per cent, are alleged to have been cured, and sixty
per cent, improved. In a single case of supposed tuber-
culous meningitis the symptoms also improved. Cases are
reported in detail by Klebs in which a successful issue oc-
curred, both tuberculin and creasote having previously
failed to give good results.
The treatment being practically unattended with con-
stitutional disturbances or fever, there is no interference
with the customary life and occupation of the patient.
As far as I am able to judge from Klebs's statements,
the remedial properties of tuberculocidin reside wholly in
its germicidal power — i. e., in its ability to destroy the
tubercle bacillus within the human body. He expressly
states that no inflammatory process or necrosis of tissue is
produced by it.
If Klebs's very positive statements on these points are
borne out by further, extended observations, a far-reaching
and very brilliant discovery has been given to the world.
In concluding his report, Klebs remarks that it only
remains to determine the limitations which control the cure
of the disease produced by the specific bacillus whose de-
struction we have succeeded in accomplishing. The first
cause may vanish, and yet the pernicious results of the con-
ditions developed from it remain. When advanced de-
struction of pulmonary tissue has occurred, where the
general vitality has greatly depreciated, and emaciation and
marked impairment of the heart's function have taken
place, cure is no longer to be expected, even with the re-
moval of the first cause of these conditions.
We have now to consider some very interesting and
noteworthy investigations of Roemer and Biichner (30).
The former, as the result of his experimental researches,
has made the surprising announcement that the same reac-
tions can be obtained in tuberculous guinea-pigs from in-
oculations with protein-containing extracts from the
Bacillus pt/ocyaneus (the bacillus of green pus) as with
tuberculin. He found that tuberculous animals died
quickly after injections of such extracts, while healthy ani-
mals lived ; that lesions occurred in the liver and spleen of
such animals apparently quite similar, both macroscopically
and microscopically, to those described by Koch as due to
the specific action of tuberculin. Biichner has corrobo-
rated Roemer's observations of the effect of injections of
the protein of the Bacillus pi/ocyaneus, and has found
similar effects to follow the use of the protein of other
bacilli — viz., Pneumobacillus (Friedlander) and the Bacillus
prodigiosus. Inoculations of healthy men with minute
doses of the protein of the Pneumobacillus or the Bacillus
prodigiosus were followed by redness and swelling at the
point of injection and a local rise of temperature, which
gradually disappeared and were of quite similar character
in the different persons experimented upon.
May 21, 1892.] KIXXICUTT: PROPHYLAXIS AXD TREATMEXT OF TUBERCULOSIS.
Constitutional symptoms were not produced, Biicbner
suggests, on account of the smallness of the dose adminis-
tered. The pronounced local reaction, in comparison with
that of tuberculin, he believes to indicate a more serious
action of the protein. Biicbner concludes his report on his
investigations as follows : " Are the protein extractives of
the tubercle bacillus alone capable of exciting a "latent irri-
tation to an appreciable inflammation and necrosis ? " " Are
not other ordinary exciters of inflammation, especially
proteins from harmless kinds of bacteria, possessed of the
same power?" The observations reported by him, he
thinks, speak favorably for such a possibility and open,
therefore, in a practical manner, new and perhaps not unim-
portant outlooks.
In the light of extended experimental investigations and
of very numerous clinical observations, the incorrectness of
many of Koch's original hypotheses and conclusions is
evident. It has been shown that tuberculin contains not
one but several active principles, respectively capable of pro-
ducing different effects ; that whatever remedial action it may
possess resides apparently in certain of its albumoses, while
its harmful properties are seemingly due to the non- albumi-
noid substances present in the extract. With the knowledge
that tuberculin is the concentrated fluid medium in which
the bacilli have been growing, thus presumably containing
both the products of their growth and the proteins derived
from their bodies, Prudden's experimental studies (31) of
the action of dead tubercle bacilli would seem to be further
corroborative of these views. His experiments indicate
that the dead bacilli, freed as far as is possible from the
products of their growth, are capable of enormously stimu-
lating cell activity and of producing lesions morphologically
similar to tubercle, but which are not indefinitely progressive
and do not tend to the production of an advancing coagula-
tion necrosis, and, finally, do not induce an infectious disease.
A legitimate conclusion from these observations would
seem to be that the coagulation necrosis which Koch's
hypothesis regards as the remedial mode of action of tuber-
culin is dependent upon a metabolic product of the growth
of the bacillus.
In view of the remedial effects obtained by Hunter,
Cheyne, and Klebs from the use of a tuberculin presuma-
bly freed from metabolic products, and the apparent dem-
onstration by Prudden that a constituent of the protoplasm
of the dead bacillus, probably a protein, is capable of enor-
mously stimulating cell activity, it is justifiable to feel that
much light has been thrown upon a most complex question.
Whatever beneficial results were obtained from Koch's
original tuberculin, I am convinced were not through, but
in spite of, a production of coagulation necrosis ; and that
the benefit alleged to-day by many from its use in exceed-
ingly small doses is partly through the avoidance of such
an effect. In exceedingly minute doses it is possible that
the action of the cell-stimulating protein preponderates,
and thereby a remedial influence is exerted.
A rather large clinical experience, now extending over
a period of eighteen months, leads me to reiterate an opin-
ion previously expressed that " tuberculin contains a remedial
principle.''1 This view is shared, among our own country-
567
men, by Trudeau and von Ruck, gentlemen who have en-
joyed in their sanitaria the widest possible opportunities
for thoroughly studying the subject.
In a recent communication by Schede, of Hamburg
(32), than whom no continental surgeon has a larger clinical
experience, a similar opinion is expressed. In concluding
this portion of my subject I can not but express my abid-
ing and earnest belief that the continued and exhaustive
investigation of Koch's discovery will lead either to such
modifications of the original extract, or to the preparation
of a new one based upon a similar principle, as will place
in our hands an agent specific in character and remedial in
tuberculosis in a degree hitherto believed to be unattainable.
The results obtained in the wards of St. Luke's Hospi-
tal in the treatment of pulmonary tuberculosis with modi-
fications of tuberculin already effected will be appended to
the present lecture.
The Treatment of Pulmonary and Laryngeal Tu-
berculosis by the Cantharidates. — In February, 1891.
Professor Liebreich, in a paper read before the Berlin
Medical Society, announced that he had discovered a new
remedy for the treatment of tuberculous disease. The
property of cantharidin, when taken internally, of pro-
ducing an exudation of serum from the capillaries, not
only of the kidneys, but also of the lungs and other organs..
unattended with increased arterial tension, hyperemia, or
extravasation of blood, when used in sufficiently small
doses, forms the basis of his theory. The irritability off
the capillaries, according to Liebreich, varies in different
parts of the organism in health ; in an abnormal state, such
as may be assumed to be their condition at the site of local
disease, this irritability is increased. By furthering such
irritability by the use of the cantharidates, an exudation of
serum occurs which may favorably affect tuberculous tissue
in two ways: (1) by stimulating cell activity and nutrition,
(2) through the germicidal action of the serum upon the
bacteria. His experimental investigations apparently indi-
cate in a measure the correctness of his theory.
The remedial effects which have followed the use of the
cantharidal preparations, while occasionally striking, espe-
cially in the case of laryngeal tuberculosis, fall short of se-
curing for them, it seems to me, a permanent place in the,
therapeutics of tuberculosis. Their apparent action is in»
harmony with one of the possible means of a remedial:
treatment of tuberculosis. Cell activity is stimulated, and
specifically diseased tissues are subjected to the germicidal
action of the blood serum, artificially increased at the site
of disease. There is a failure possibly in the degree rather
than in the kind of action. The preparations at present
employed are the potassium and sodium cantharidates,
They are administered hypodermically at intervals of forty-
eight hours or longer, and in doses of to grain.
The latter strength not infrequently causes symptoms of
vesical and renal distress.
Their use is contra-indicated in the presence of intesti-
nal and renal disease, and in patients with marked hectio.
Treatment with the Serum of Dog's Blooo. — The
interesting experimental investigations of Richet and Heri-
court, announced during the past year to the French Acadl-
KIN NIC U TT : PROPHYLAXIS AND TREATMENT 01 TUBERCULOSIS. [N. Y. Med. Jo
568
emy of Sciences (33), with the serum of dog's blood in the
treatment of tuberculosis are in the line of thought that at
present underlies our attempts to cope with the disease.
These observers have been able to demonstrate that in rab-
bits inoculated with a culture of the tubercle bacillus the
evolution of tuberculosis can be arrested by subsequently
subjecting the animal to injections of dog's serum. When
very virulent cultures are employed, the evolution is only
delayed. Injections of a healthy animal with the serum
prevent the development of experimental tuberculosis at a
later period.
The effective substance has not been identified as yet,
but a small dose of the serum is sufficient (0-5 c. c. to the
kilogramme of the rabbit).
The clinical results obtained in tuberculous disease of
human beings by this method of treatment, which has been
fully tried in the Paris hospitals, would indicate that it also
fails rather in the degree than in the kind of its action.
It certainly acts as a potent stimulant to cell activity.
Whether it possesses another action is undetermined.
The Chloride-of-zinc Treatment. — I shall briefly re-
fer to the treatment of tuberculous disease with chloride-
of-zinc injections at the site of the disease, announced to
the French Academy of Sciences in July of the past year
by Professor Lannelongue (34).
It is based essentially on the simple fact that fibrinous
induration is to be regarded as the natural curative process
in tuberculous lesions. The power of the chloride of zinc
to excite such sclerotic processes, when administered in
sufficiently small quantity to avoid its more powerful escha-
rotic action, suggested its use in the disease in question.
Its action in experimental tuberculosis is thus described by
M. Lannelongue and M. Achard : The anatomical elements
of the tissues which it penetrates are destroyed and an
enormous proliferation of embryonic cells occurs, not only
at the site of the injection but for some distance around it,
with infiltration of the tuberculous tissues with migratory
cells to the fullest extent. M. Lannelongue suggests that
the latter may destroy the bacilli through the exercise of
their phagocytic function. The morbid tissue destroyed
by the chloride of zinc is slowly absorbed and disappears ;
the embryonic cells, on the contrary, organize with great
rapidity and form firm fibrous tissue, which exists in appre-
ciable quantity as early as the day following the injection.
Twenty-two patients were subjected to this treatment
bv M. Lannelongue. The list embraces two cases of pul-
monary tuberculosis and twenty of suppurating and non-
suppurating tuberculous disease of joints and glands. Ex-
cellent results are alleged to have been obtained in a major-
ity of the latter. An opportunity was afforded, in a case
of more or less fused tuberculous glands, for comparing
histologically glands which had been injected and those
which had been left without treatment. Excision showed
caseous material surrounded by a zone of tuberculous tissue
within a fibrous sheath in each ; in the injected glands,
however, there was a large amount of dense fibrous tissue,
and there was firm adhesion to the investing membrane.
A report of the results in the pulmonary cases was re-
served until a longer period had elapsed.
While recognizing the possible utility of this method of
treatment in tuberculous joint and gland disease, either as
a remedial measure or as an adjunct to surgical procedures,
and suggesting the desirability of more extended investiga-
tions in this direction, its application in pulmonary tuber-
culosis, in my judgment, should be regarded with the great-
est reserve. Aside from the difficulty of introducing intra-
pulmonary injections in any exact way at the site of the
lesion, the extent and complexity of the morbid conditions
usually present would seem to preclude the possibility of
its usefulness as a method of treatment.
The technique of the method employed by M. Lanne-
longue is to inject two drops of a ten-per-cent. solution
in a number of places around the periphery of the diseased
part in cases of tuberculous joints, bones, and glands.
Suppurating glands are thoroughly irrigated with sterilized
water and the injections made under rigid antiseptic pre-
cautions. In cases of pulmonary tuberculosis a solution of
one in forty is used for the injections.
The Treatment of Tuberculosis with Creasote,
Guaiacol, and Carbonate of Guaiacol. — The literature
of the treatment of phthisis pulmonalis with creasote, both
by internal administration and by inhalation, is sufficiently
familiar to those interested in the subject to warrant the
briefest reference to it.
Discovered by von Reichenbach in 1830, it quickly se-
cured a reputation in Germany, France, and England as a
remedial agent in pulmonary diseases. It, however, gradu-
ally fell into disuse, and was only rehabilitated in favor in
1877 through the admirable clinical papers of Bouchard
and Gimbert on its beneficial effects in consumption (35).
Influenced by their statements, Beverley Robinson insti-
tuted its systematic use in his hospital and private practice
in this city as early as 1878, and valuable papers by him
have appeared from time to time since on this subject. In
Germany, a series of publications by Sommerbrodt, Fraent-
zel, von Brunn, Guttmann, and others, confirmatory of the
results obtained by Bouchard and Gimbert, appeared in
1887 and 1888. The literature of the subject at the pres-
ent time is very voluminous, and it may be said to be ex-
ceptionally favorable to the value of creasote in the treat-
ment of pulmonary phthisis. Varied opinions are held in
regard to its mode of action, its most efficient dosage, and
the best method of administration. The determination of
these several points is of scientific interest, as well as of
practical import.
The efficacy of creasote in hindering or arresting fer-
mentative processes in the digestive tract, so frequently
present in phthisical patients, and thereby promoting appe-
tite, digestion, and nutrition, is very generally admitted.
Its ability to favorably affect appetite, and to increase the
digestive secretions when given by the mouth, by locally
stimulating the gastric and intestinal nerve filaments, is also
very probable. Through the promotion of a better nutri-
tion, the beneficial effects alleged for creasote in stimulating
the resolution and absorption of the secondary inflammatory
exudations in tuberculous lungs may be explained. By its
local action, antiseptic and stimulating, especially when
given in the form of inhalations, a favorable influence upon
May 21, 1892.]
KINNIGUTT: PROPHYLAXIS AND TREATMENT OF TUBERCULOSIS.
569
the simple catarrhal processes so commonly present is con-
ceivable and probable.
In turning our attention to any specific action which
creasote may exercise upon the pathogenic cause of tuber-
culosis and its specific lesions, the results of experimental
investigations properly should be considered.
Guttmann (36), as the result of test-tube experiments
which, he maintained, demonstrated the power of creasote,
in solutions of 1 to 4,000, to greatly inhibit the growth of
the tubercle bacilli, and, in solutions of 1 to 2,000, to com-
pletely devitalize them, was led to believe that a similar
specific action could be effected in the human body by the
administration of sufficiently large doses of the drug. One
gramme of creasote, according to his calculations, present
in the circulation, would suffice for this purpose. The ex-
perimental investigations very kindly undertaken for me by
Dr. John Ely, in the pathological laboratory of the College
of Physicians and Surgeons, which will be given in detail
later, confirm the correctness of Guttmann's observations
on the germicidal power of creasote.
Granting, therefore, the germicidal action of creasote
outside of the human body, and also the possibility of ad-
ministering it, without injurious effects, in daily doses larger
than those demanded by Guttmann's hypothesis, a seem-
ingly fatal objection to the theory of the exercise of a ger-
micidal action in the economy is found in very recent in-
vestigations, which indicate that creasote enters at once in
the blood into chemical combinations with certain contained
albuminoids — combinations which are without specific ger-
micidal influence. Moreover, it has been wisely said that
" man is not a test-tube," and no fact appears to be more
clearly proved than that the germicidal action of a drug
outside of the body affords little basis for correct conclu-
sions of its therapeutic value. Experiments on animals are
necessary to determine this point.
In pursuance of this idea, numerous investigators have
attempted to test the antibacillary power, as well as other
effects, of creasote in tuberculosis, by the treatment of ani-
mals with large doses of this drug both before and after
the production of experimental tuberculous disease.
I shall refer only to the very interesting experiments of
Trudeau (37) and Cornet (38).
Trvdeau's Experiments. — Four rabbits were inoculated in
the anterior chamber of the eye and in the right chest with a
similar amount of pure cultures of tubercle bacilli suspended in
water. Two of the rabbits were kept as '• controls." Two were
treated every other day with subcutaneous injections of 5 c. c.
of a ten-per-cent. solution of pure creasote in almond oil. The
course of the eye tuberculosis in the test animals was daily com-
pared with that in the " controls," and was seen to be entirely
uninfluenced by the treatment. Tubercles became visible in the
iris from the twelfth to the thirteenth day in both sets of ani-
mals. Iritis, cloudiness of the cornea, and general secondary
inflammatory changes were noted in all the rabbits from the
•eighteenth to the twenty-first day, and the sight was soon lost.
All were killed two months after inoculation, and the lungs of
both the test and the control animals presented the lesions of
advanced tuberculosis.
Cornet's Experiments were as follows: Seven strong guinea-
pigs were treated with creasote, introduced into the stomach by
means of a tube, in doses equivalent, for the body weight of a
man, to rather more than two grammes daily for a period vary-
ing from one to two months. At the expiration of this interval
they, with four control animals, were either inoculated with or
were compelled to inhale finely atomized pure cultures of tuber-
cle bacilli, the creasote beiDg continued in the test animals. A
single test guinea-pig died of pneumonia ten days after inocula-
tion. The remaining six died, respectively, 30, 32, 33, 43, 77,
and 84 days after infection. Two of the control animals were
killed on the 32d and 43d day after infection; the two remain-
ing died on the 61st and 84th day after inoculation. All the ani-
mals, both test and control, presented the characteristic lesions
of tuberculosis, and very little, if any, appreciable difference in
the appearance, the degree, or the distribution of these could be
detected in the two sets.
Experimental investigations therefore show in the most
positive manner that creasote, administered even in heroic
doses, is incapable either of preventing the development of
experimental tuberculosis or of arresting its progress.
The theory of Bouchard, Gimbert, Jaccoud, and others,
that creasote promotes connective-tissue growth, by means
of which recovery in tuberculous disease is favored, also is
not borne out by experimental studies in animals.
The explanation of any favorable influence of creasote
on sclerotic processes which clinical observations may indi-
cate, should seemingly be sought in the improved nutrition
which obtains through its use rather than by the exercise
of any specific action.
Guaiacol, obtained by the fractional distillation of beech-
tar creasote, and constituting from sixty to ninety per cent,
of the latter, was suggested by Sahli (39), as early as 1887,
as a substitute for creasote in the treatment of tuberculous
disease. It represents the active principle of creasote and
may be substituted appropriately for it. As prepared in
the various laboratories it probably is not freed from all im-
purities. Owing to this fact, very lately Seifert and Hoel-
scher (40) have proposed the use of the carbonate of guaia-
col. Carbonate of guaiacol possesses the advantages over
creasote and guaiacol of being a simple, definite, crystalline
substance, which can be obtained chemically pure. It is a
neutral salt and is tasteless as well as odorless. It does not
produce digestive disturbances, it is indifferent to the gas-
tric secretion, and decomposes in the intestine into guaiacol
and carbonic acid. Many of the above-mentioned charac-
teristics of this salt have been demonstrated in its use in
St. Luke's Hospital.
Seifert and Hoelscher, as the result of experimental
studies with guaiacol carbonate, have advanced a new and
interesting theory of the mode of action of the creasote
preparations in tuberculous disease. The basis of their
theory apparently rests on the fact that experiments on
dogs show that creasote and guaiacol do not circulate in a
free state in the blood, and that they are eliminated by the
kidneys in the form of the salts of ethylsulphuric acid
(Aetherschwe/elsaure). They argue that during absorption
the active principle of creasote allies itself with the albumi-
noids in the blood, and specifically through the agency of
the sulphur contained in the albumin molecule. The blood
of tuberculous patients contains, in addition to normal albu-
min, other albuminoid substances arising from the disease
570
KINNICUTT: PROPHYLAXIS AND TREATMENT OF TUBERCULOSIS. [N. Y. Med. Jocb.,
process — e. g., the products of the tubercle bacilli. These
substances constitute unstable combinations, prone to cause
or undergo chemical processes which act poisonously. The
toxic albuminoids engendered by the disease are chiefly re-
sponsible for the fever, night sweats, etc. The guaiacol,
by allying itself with tbem, renders them stable and there-
fore non-toxic. The chemical combinations effected by the
guaiacol are without germicidal influence, and the favorable
results obtained through the use of the creasote prepara-
tions in tuberculous disease, therefore, should be regarded
as due in a large measure to their influence in assisting in
the elimination of the toxic products of the specific disease
process.
Seifert and Hoelscher's theory in no respect militates
against other favorable influences which have been ascribed
to the creasote preparations, such as the probable direct
stimulation of appetite and thereby improved nutrition, etc.
The observations thus far made in St. Luke's Hospital
in the use of guaiacol carbonate lead me to believe that it
may be substituted very favorably for both creasote and
guaiacol.
Investigations in St. Luke's Hospital with Modified Tu-
berculin, Creasote, Guaiacol, and Guaiacol Carbonate. — Dur-
ing the past winter sixty-five cases of pulmonary tubercu-
losis have been under my care continuously in the wards of
St. Luke's Hospital. Many of these were cases of very ad-
vanced disease, without the possibility of recovery, and the
treatment consisted merely in attempts to ameliorate the
most distressing symptoms. Nineteen of the remaining
cases were selected for treatment, respectively, with Hunter's
modification of Koch's tuberculin, with subcutaneous injec-
tions of guaiacol, and with creasote by the mouth. It was
my desire not so much to test the comparative merits of
different methods of treatment as to corroborate or other-
wise Cheyne's and Hunter's observations and to determine
both the practicability of employing a very large daily dosage
of creasote and any advantages this method might possess
over its use in smaller quantities.
Seven cases of well-marked tuberculosis are embraced in
the group treated with Hunter's modified tuberculin. The de-
tails of the histories of these patients and the results of treat-
ment are given in a tabulated form for convenience of study.
It will be seen that three cases have been under treatment
for three months, the remainder for nearly two months.
Physical examination in two of the former cases indicates
no appreciable change in the pulmonary lesions during
treatment. In the third case the improvement in the signs
of disease and in all other respects has been most marked.
Physical examination indicates not only the dryness of the
cavity, but also its very evident contraction, as well as a
diminution in the degree of the contiguous disease process.
In the four remaining cases, there has been no improve-
ment in one : in one, improvement has been marked ; in
one, it has been distinct, though less marked ; and in one,
an arrest of the disease, at least temporarily, has occurred.
It will be observed, in a study of the tabulated report, that
by improvement is meant a marked diminution in the
physical signs of disease. Case VII is certainly an ex-
ample of arrested phthisis. This is of such rare occurrence
in pulmonary tuberculosis of this degree, under conditions
which prevail in large city hospitals, as to be particularly
noteworthy. A very distinct impression has been made on
my mind in observing from day to day the cases treated
with modified tuberculin, that its stimulation of the nutri-
tive processes is not so marked as its effect upon the spe-
cific lesions. Creasote, on the other hand, has seemed to
possess the former quality in a greater degree.
To meet possible criticism, all these cases have received
no other treatment than tuberculin, beyond the administra-
tion of cod-liver oil and, from time to time, various ferru-
ginous preparations.
The exact mode of preparation of the modifications
used is given in a note. The rules of dosage were to give
0'002 gramme for the initial inoculation, and to increase by
O002 gramme daily. The rule also was made not to in-
crease the dose if any elevation of temperature followed in-
oculation.
With the modifications B and CB, appreciable reactions
did not occur in these cases. In a single case not reported
in the following table, treated with CB, a rise of tempera-
ture followed an inoculation of 0*008 gramme, and an acute
catarrhal process was developed at the apex of one lung.
At the expiration of the tenth day defervescence occurred
and no further ill effect has followed.
For this reason, modification B has been used in all
other cases but one. Trudeau has also adopted, I believe,
modification B as the preferable one.
Through the absence of all reaction and discomfort at-
tending the use of B, all patients treated with it have been
able to be continuously about the wards and out of doors.
Only the usual very inexact method for determining the
number of bacilli in the sputum was used. Repeated ex-
aminations were made, and they were found in all.
The number of cases treated with modified tuberculin,
while much too small to permit the expression of a positive
opinion of its power to exercise a specific remedial action,
is large enough to indicate in the strongest manner the de-
sirability of continued investigations of its apparently spe-
cifically beneficial effects.
Method of Preparation of Hunter's Modifications. — " Modi-
fication B: 1 c. c. of tuberculin, 5 c. c. distilled water, saturation
with preferably large crystals of ammonium sulphate for twenty-
four hours in the cold, the precipitate filtered off and freed, so far
as possible, from any crystals of ammonium sulphate, placed in a
dialyzer and dialyzed just so long and no longer in running water,
and then in distilled water, until all trace of the ammonium sul-
phate has disappeared. Crystals of thymol added to the solution
to prevent any putrefactive change; the solution then made up
to such bulk that 10 c. c. shall correspond to each c.c. of tuber-
culin employed. (Title, ' Bf ten per cent.) "
" Modification CB : 2 c. c. of tuberculin dropped into 20 c. e.
of absolute alcohol ; the heavy precipitate filtered off in a quar-
ter of an hour ; the filtrate evaporated over a water-bath at a
temperature preferably not over 40° C, and just sufficiently
long to drive off all alcohol ; the residue taken up in 12 c. c. of
distilled water, placed in a dialyzer and dialyzed for two hours
in a running stream of water. Quantity made up to 20 c. c,
including 2 c. c. of pure glycerin, used for preservative purposes;
a few crystals of thymol added. (Title, 1 CBJ ten per cent.) "
May 21, 1892.] KINNICUTT: PROPHYLAXIS AND TREATMENT OF TUBERCULOSIS.
571
TREATMENT WITH SUBCUTANEOUS INJECTIONS OF HUNTER'S MODIFIED TUBERCULIN.
No. of
case, sex,
and age.
1.
Male,
42.
Patient's history and physical examination
at beginning of treatment.
Profuse haemoptysis 6 years ago ; pleu-
risy 3 years ago ; night-sweats and
cough since, with loss of 40 lbs. in
weight. Physical signs : Slight retrac-
tion beneath right clavicle. Evidence
of cavity in first interspace ; also very
abundant largish moist rales at thfc
site. Abundant subcrepitation from
first space to base. Posteriorly, same
side, abundant subcrepitation, with
larger rales, over supraspinous fossa.
Abundant subcrepitation over whole of
scapular region. Patient apyretic.
History of 18 months; sputum occasion-
ally tinged with blood ; absence of
night-sweats. Physical signs : Consoli-
dation without crepitation over first and
second right spaces and over supra-
spinous fossa. Posteriorly, subcrepita-
tion over interscapular region. Left
lung, feeble respiratory murmur, with
scanty subcrepitation beneath clavicle
and over supraspinous fossa. Evening
temperature occasionally 100°.
History of cough and occasional haemor-
rhage for past 2 years. Physical signs :
Dullness, with rather abundant sub-
crepitation in first right interspace ;
scanty subcrepitation in second space.
Dullness, with moderate subcrepitation
posteriorly, over supraspinous fossa
and scapular region. Patient apy-
retic.
Cough for past year ; gradual loss of flesh
and strength. Physical signs : Impair-
ment of resonance over upper half of
left chest, anteriorly, with fairly abun-
dant subcrepitation over same. Pos-
teriorly, impairment of resonance over
upper half of left chest, with abundant
subcrepitation over supraspinous fossa
and scanty in areas over scapular re-
gion. Patient apyretic.
Haemorrhage 5 years ago and another 3
years ago, very profuse. Since latter,
unable to work, and has lost 40 lbs. in
weight. Treated with tuberculin in
Presbyterian Hospital a year ago, and
apparently improved temporarily. Phys-
ical signs : Diffuse infiltration upper
lobes of both lungs, with abundant sub-
crepitation at apices and scantier over
remainder of affected regions. Most
marked, right apex ; occasional night-
sweats. Patient apyretic.
Cough for 3 months ; no haemoptysis, no
night-sweats. Physical signs : Impair-
ment of resonance, with loss of vesicu-
lar respiration over right infraclavicu-
lar region. Abundant subcrepitation
in second and third spaces. Similar
signs over whole left chest anteriorly ;
in less degree also over left supraspi-
nous fossa and scapular region. Slight
pyrexia ; evening temperature, 100°-
100-2°.
Cough for b' months ; no haemoptysis, no
night-sweats ; gradual loss of flesh.
Physical signs : Impairment of reso-
nance, slightly prolonged and high-
pitched expiration, with abundant sub-
crepitation in first two spaces, left ;
scanty, fine crepitation below. Same
signs over supraspinous fossa as be-
neath clavicle ; over upper half scapu-
lar region, scanty crepitation after
cough. Slight pyrexia ; occasional even-
ing temperature, 10l>'.
Patient's weight, daily
sputa, inoculation used,
date when begun.
Jan. 13, 1892 ; weight,
134 lbs. Sputa, % iv,
daily average. " B."
0-002 gm. to increase
by 0-002 gm. daily.
Duration of treatment,
weight, and sputa, to date.
Jan. 14, 1892; weight,
122 lbs. Sputa, § j,
daily average. " C. B."
0-002 gm. to increase
by 0-002 gm. daily.
Jan. 17, 1892; weight,
105 lbs. Sputa, 5j,
daily average. " C. B."
0-002 gm. to increase
by 0 ()02 gm. daily.
March 2, 1892 ; weight,
144 lbs. Sputa, § j,
daily average. " B."
0-002 gm. to increase
by 0-002 gm. daily.
March 2, 1892; weight,
123 lbs. Sputa, §j,
daily average. " B."
d-002 gm. to increase
by 0-002 gm. daily.
April 25, 1892; weight,
141 \ lbs. Sputa, | j|,
daily average. " B."
0-198 gm. to increase
bv 0-002 gm. daily.
March 3, 1892, treatment
begun — March 21st,
weight, 132 lbs. Sputa,
§ ss., daily average.
" B." 0-002 gm. to in-
crease by 0-002 gm.
daily.
March 3, 1892; weight,
135 lbs. Sputa, 3 ss.,
daily average. " B."
0-002 gm. to increase
by 0-002 gm. daily.
April 25, 1892 ; weight,
125 lbs. Sputa, § j,
daily average. "C. B."
0-092 gm. to increase
by 0-002 gm. daily.
April 21, 1892; weight,
107 lbs. Sputa, I ft,
daily average. "C. B."
0-176 gm. to increase
by 0-002 gm. daily.
April 25, 1892; weight,
148J lbs. Sputa, less
than 3 j, daily aver-
age. "B." 0-110 gm.
to increase by 0-002
gm. daily.
April 25, 1892, weight,
119 lbs. Sputa, H,
daily average. " B."
0-078 gm. to increase
by 0-002 gm. daily.
April 25, 1892; weight,
135 lbs. Sputa, none.
" B." 0-100 gm. to in-
crease by 0-002 gm.
daily.
April 18, 1892; weight,
135 lbs. Sputa, none.
Discharged, through
desire and ability to
go to work.
Physical examination at present date.
April 25th. — Physical signs : Marked
retraction, directly beneath right clav-
icle. Signs of cavity distinctly less
marked, and it is apparently nearly
dry. Scanty subcrepitation in second
space; below this point, no adventi-
tious sounds present. Posteriorly,
adventitious sounds absent over supra-
spinous fossa and marked diminution
of subcrepitation over scapular re-
gion. Patient apyretic ; no night-
sweats. Very marked improvement.
April 25th. — Physical signs : Practical-
ly the same as on first examination.
Evening temperature occasionally
100°. Condition, stationary.
April 21st. — Physical signs : Dullness
with scanty subcrepitation in first
space ; absent in second. Dullness
with scanty subcrepitation over supra-
spinous fossa and scapular region.
Little appreciable difference from first
examination. Patient apyretic. Con-
dition stationary.
April 25th. — Physical signs : Little ap-
preciable difference in resonance over
upper half of left chest since first
examination. Crepitation has almost
wholly disappeared anteriorly, and is
practically absent posteriorly. Pa-
tient apyretic. Marked improvement.
April 25th. — Physical signs : No appre-
ciable difference from first examina-
tion. Occasional night-sweats. Pa-
tient apyretic. Condition stationary.
April 25th. — No appreciable difference
in impairment of resonance over af-
fected regions. Subcrepitation scanty
at present over right chest, and ab-
sent over supraspinous fossa and
scapular region, left. Anteriorly,
same lung, no appreciable difference
from first examination. Patient apy-
retic since March 18th. Improve-
ment.
April 25th. — Impairment of resonance
over first two spaces. Respiration
feeble, but expiration not prolonged
or increased in pitch. Entire absence
of a// adventitious sounds over whole
of left chest, anteriorly and posterior-
ly. Patient continuously apyretic
since March 18th. Disease at present
arrested.
572
KINNICUTT: PROPHYLAXIS AND TREATMENT OF TUBERCULOSIS. [N. Y. Med. Jock.,
TREATMENT WITH SUBCUTANEOUS INJECTIONS OF GUAIACOL RAPIDLY INCREASED.
Patient's history and physical examination
at beginning of treatment.
Cough for 10 months ; progressive loss of
flesh and strength ; no haemoptysis ;
moderate night-sweats. Physical signs :
Excavation at right apex anteriorly,
with consolidation below; posteriorly,
same lung, consolidation with numer-
ous large rales and abundant subcrepi-
tation over whole of scapular region,
below fine crepitation. Left, anteri-
orly, moderate consolidation at apex,
without crepitation. Advanced laryn-
geal disease. Marked hectic ; evening
temperature, 102°-103°.
Haemoptysis 3 years ago ; present history
of cough, 3 months ; progressive loss
of flesh and strength ; no night-sweats.
Physical signs : Dullness, prolonged and
high-pitched expiration over left infra-
clavicular region, with very abundant
subcrepitation. Same signs posteriorly
over upper half of left lung. Right,
similar signs, less in degree, anteriorly
and posteriorly over upper half. Slight
pyrexia ; evening temperature, 100°.
Pleurisy, right side, 3 years ago. Em-
pyema same side 1 year ago, exsection
of rib ; cough and frequent haemoptysis
since ; night-sweats. Physical signs :
Large antrum in first right space, near-
ly dry. Moderate consolidation, with-
out crepitation, in second space. Con-
solidation, apex, same lung, posteriorly,
without crepitation. Patient apyretic.
Pneumonia 3 years ago ; cough since ; no
haemoptysis ; no night-sweats at pres-
ent. Physical signs : Consolidation,
with fairly abundant subcrepitation at
both apices. Subcrepitation also pres-
ent over upper half right scapular and
upper third left scapular regions. Slight
pyrexia ; occasional evening tempera-
ture, 100-2°.
Grippe a year ago ; cough since ; no
haemoptysis ; profuse night - sweats.
Physical signs : Areas of infiltration
throughout upper lobe, right lung, with
abundant subcrepitation. Areas of in-
filtration upper lobe, left lung, with
abundant subcrepitation and evidence
of beginning excavation at apex. Hec-
tic ; evening temperature, 101°-102°.
History of 10 months ; a single haemop-
tysis ; night-sweats almost continuous-
ly. Physical signs : Large antrum, apex
left lung, with impaired resonance and
abundant subcrepitation to base ante-
riorly. Posteriorly, areas of subcrepi-
tation to base. Beginning disease at
right apex. Hectic ; evening tempera-
ture, 101°-102°.
Typical history since last November ; sev-
eral haemoptyses ; no night-sweats.
Physical signs : Feeble respiratory mur-
mur, with abundant subcrepitation over
whole of right lung, anteriorly, and up-
per half of scapular region. Similar
signs in slightly less degree over upper
lobe left lung anteriorly and posterior-
ly. Pyrexia ; evening temperature,
101°- 102°.
Patient's weight, daily
average of sputa ( I ), when
guaincol mi, increasing mj
daily, was begun ; date.
Weight, Feb. 27, 1892,
70} lbs. Average daily
sputa, 3 ss.- 3 j. Guai-
acol, 0-05 gm. daily, to
increase 005 gm. daily
to 1 gm.
Weight, Feb. 27, 1892,
91 J lbs. Average daily
sputa, § j. Guaiaeol,
0'05 gm. daily to in-
crease 0'05 gm. daily
to 1 gm.
Weight, Feb. 27, 1892,
135 lbs. Average daily
sputa, 3 ij- ? ss- Guai-
aeol, 0'05 gm. daily to
increase 0'05 gm. daily
to 1 gm.
Weight, Feb. 28, 1892,
91 1 lbs. Average daily
sputa, 1 ss.- § j. Guai-
aeol, 0'05 gm. daily to
increase 0"05 gm. daily
to 1 gm.
Feb. 28, 1892, 72 lbs.
Sputa, § ij-iv, daily av-
erage. Guaiaeol, 0'05
gm. daily ; increasing
O'Oo gm. dailv. March
12, 1892, 0'60 gm.
Weight, 72 lbs. ; sputa,
Feb. 28, 1892, 96$ lbs.
Sputa, § j-ij, daily av-
erage. Guaiaeol, 0"05
gm. daily ; increasing
0-05 gm. daily. March
9, 1892, 0-45 gm.
Weight, 93J lbs. ; spu-
ta, 3 ij-iij.
March 2, 1892, 92 lbs.
Sputa, | vij-xjss., daily
average. Guaiaeol, 0'05
gm. daily ; increasing
0'05 gm. dailv. March
21, 1892, 1 gm. for 2
days. Weight, 88$
lbs. ; sputa, | vij.
Duration of treatment,
weight, and sputa, to date.
March 20, 1892, 71 lbs.
Average daily sputa,
3 j - 3 'j- Guaiaeol, 1
gm. reached to-day ;
discontinued.
April 25, 1892, 91 J lbs.
Average daily sputa,
§ j-l ij. Guaiaeol, 1
gm. daily for 37 days.
April 25, 1892, 141 lbs.
Average daily sputa,
0-§ss. Guaiaeol, 1
gm. daily for 37 days.
April 25, 1892, 90 lbs.
Average daily sputa,
§ ss. Guaiaeol, 1 gm.
daily for 37 days.
March 15, 1892, guaiaeol
by mouth, mi; tiliv
daily average. March
24th, miij daily in pill,
not increasing. April
1, 1892, weight, 64 lbs.
April 6, 1892, sputa,
I iv-v.
Treatment discontinued
before maximum dose
reached ; no further
treatment. March 24,
1892, weight, 96} lbs.
March 31, sputa, § ss.-
3ij-
March 22, 1891, guaiaeol
carbonate, gr. vj daily
by mouth. April 12,
1892, weight, 86} lbs.
Sputa, § iij ; treatment
stopped. April 19,
1892, guaiaeol pill, mvj
daily; increasing, Uliij.
April 25, mxxvij ;
weight, 88 lbs. ; sputa,
3 "j-
Physical examination at present date.
March 20th. — Physical signs : Progress-
ive increase of lesions ; night-sweats.
Marked hectic ; evening temperature,
102--103'.
April 25th. — Physical signs : Little ap-
preciable difference from first exam-
ination, except subcrepitation now
heard over whole left lung posterior-
ly. No night^sweats. Slight evening
temperature.
April, 25th. — Physical signs : Anterior-
ly, no appreciable difference from
first examination ; posteriorly, mod-
erate subcrepitation at apex and over
upper half of scapular region. Pa-
tient apyretic ; occasional night-
sweats. Marked improvement in gen-
eral condition.
April 25th. — Physical signs : No appre-
ciable difference from first examina-
tion ; no night-sweats. Occasional
evening temperature, 100'2°-100'3°.
April 1st. — Physical signs : Progressive
increase of lesions ; moderate sweats.
Treatment apparently some effect on
sweats, none on fever. Died April 7,
1892.
March 10th. — Progressive increase of
lesions. Treatment apparently some
effect on night-sweats, none on fever.
Died April 1, 1892.
April 25th. — Physical signs : Very simi-
lar to those of first examination, ex-
cept subcrepitation heard over whole
of left lung anteriorly and posterior-
ly ; no night-sweats ; pyrexia. Even-
ing temperature, 100°-101°. Gen-
eral condition worse.
These modifications were prepared for me in the chemi-
cal laboratory of the College of Physicians and Surgeons.
My desire to test the practicability of employing a very
large daily dosage of the creasote preparations, and to de-
termine, if possible, any advantage which this method
might possess over their use in smaller quantities, has been
fulfilled in a measure.
Several of the patients selected for this treatment pre-
sented in a well-marked degree many of the symptoms — viz.,
hectic, sweats, etc. — attributed to the toxic influence of the
May 21, 1892.] KINNIGUTT: PROPHYLAXIS AND TREATMENT OF TUBERCULOSIS.
bid-
products of the bacillus, and were well adapted, therefore,
to test the effect of creasote upon such manifestations.
It will be seen in the tabulated record that seven cases
have been treated with subcutaneous injections of guaiacol,
rapidly pushed to a daily dosage of one gramme, and five
cases with creasote by the mouth, also rapidly increased to
six grammes daily.
In four of the former cases there has been little if any
appreciable change in the physical signs of disease. In one
of these, however, the general condition has greatly im-
proved, and there has been a gain in weight of eight
pounds. In one the weight has decreased by a pound and
three quarters ; in one there has been a loss of four pounds :
in one the weight has remained stationary.
In two of these cases the daily sputum has slightly in-
creased in amount ; in two it has slightly diminished.
In the three remaining cases there has been a progress-
sive increase of the pulmonary lesions. No influence upon
hectic, when present, has been observed. Night sweats*
however, have been affected favorably.
In a single patient, suffering from chronic diffuse ne-
phritis (confirmed by autopsy), a marked increase in the
albuminuria was observed when a daily dosage of one
gramme was reached. The treatment was then discontinued,
and the albuminuria gradually diminished. In no other
case treated either with guaiacol or with creasote has any
trace of albumin appeared in the urine, in examinations
made every other day. In a single case, when the maxi-
mum dose of guaiacol was reached, the urine became dark
in color and very similar in appearance to urine containing
carbolic-acid products.
Dr. Ely's report on the enumeration of tubercle bacilli
in the daily sputum of several patients treated with guaia-
col contains observations of interest and practical import.
It indicates the possibility of incorrect conclusions even
from the best method at our command for this purpose ;
also the absence of bacilli, from time to time, in the spu-
tum of patients suffering from grave pulmonary tubercu-
losis.
In Cases II and IV, where there has been no apparent
increase in the lesions and the general condition has re-
mained stationary, the number of bacilli has greatly dimin-
ished.
In Case VII, in which the area of disease has slightly
increased and the general condition has deteriorated, the
bacilli have greatly increased in number.
In the cases treated with creasote there has been no
appreciable difference in the physical signs of disease up
to the present date in two. In these there has been a gain
of one pound and a loss of three pounds, respectively. In
the three remaining cases there has been a progressive in-
crease of the lesions.
The effect of a very large daily dosage of creasote upon
" hectic " and sweats corresponds to that noted in the use
of guaiacol.
Entire tolerance of six grammes (over a drachm and a
half) of creasote was exhibited by three of the five patients.
One complained of gastric discomfort when a daily dosage
of five grammes was reached, and one patient, who had suf-
fered from occasional nausea and vomiting previous to the
administration of creasote, believed that these symptoms
were increased by it. Several other patients at present in
my wards are taking from four to six grammes of guaiacol
daily, without gastric or intestinal discomfort.
Carbonate of guaiacol has been used so far as its sup-
ply permitted, and, aside from the advantage of being-
tasteless and odorless and only being decomposed by the
intestinal secretions, it has seemed to me to very posi-
tively stimulate appetite.
The clinical conclusions which I have formed from a
careful study of these cases are : That both creasote and
guaiacol, in certain forms, can be given in very large doses
with entire tolerance and without injurious effects ; that
such dosage apparently possesses no advantages over a
much smaller one ; and that it has no greater effect upon
hectic and night sweats.
That subcutaneous injections of the drug possess no
advantages over its administration by the mouth.
That whatever beneficial influence creasote may exert in
pulmonary tuberculosis can be effected with a compara-
tively small dosage ; and that favorable results can be ex-
pected only by its continuous and prolonged employment.*
Dr. Ely's reports of his investigations on the germicidal
action of creasote on the tubercle bacillus outside of the
human body, and on the enumeration of bacilli in the daily
sputum of patients treated with guaiacol, are appended.
For valuable assistance rendered me in my investiga-
tions, I desire to express my thanks to Dr. John Ely and
Dr. Robert J. Devlin and to the gentlemen of the house
staff of St. Luke's Hospital, Dr. Hollis, Dr. Rogers, Dr.
Bunce, and Dr. Tuttle.
Dr. Ely's Report on the (xERiMiciDAL Action of
Creasote Outside of the Human Body. — Shortly after
the revival of interest in creasote as a therapeutic agent in
tuberculosis, the question arose as to the manner in which
its beneficial effect was produced. Its general preservative
and antifermentative properties had long been recognized
and made use of in the arts, and the possibility of a similar
inhibiting or germicidal action upon the specific germs of
tuberculosis at once suggested itself. With a view to the
solution of this problem, Guttmann undertook a more defi-
nite determination of its germicidal action.
In his experiments nutrient gelatin was impregnated
with creasote in proportions varying from 1 to 500 to 1 to
8,000. Into this seventeen different species of bacteria,
thirteen of them pathogenic, were inoculated, and at the
same time similarly inoculated tubes of ordinary gelatin
serving as controls. The inhibiting action of creasote was
found to vary considerably with different species, but in
general a creasote proportion of 1 to 2,000 was found suffi-
cient to prevent growth. The plan of experiment received
slight modification in the case of the tubercle bacillus, blood
serum being used as the nutrient medium, and the cultures,
* Creasote was administered, w ithout exception, in the form of
what are known as the "enteric pills " of a well-known manufacturer.
The nature of their protecting envelope 1 am ignorant of. Personal
investigations of the effect of an artificial gastric juice upon the envel-
ope showed that it was partially dissolved after one hour,
574
KINNIGUTT: PROPHYLAXIS AND TREATMENT OF TUBERCULOSIS. [N. Y. Meu. Jock.,
after inoculation, being placed in the thermostat at a tem-
perature of 37° C. After several weeks, examination showed
a meager growth in the tubes which had contained creasote
in the proportion of 1 to 4,000 and 1 to 16,000; none in
the otbers.
Since these experiments of Guttmann, so far as I am
aware, stand quite alone, it has been thought advisable to
repeat them in so far as they relate to the tubercle bacillus,
but in a slightly modified form. Instead of blood serum,
glycerin-bouillon and glycerin-agar have been used as
nutrient media, both of which have shown themselves par-
ticularly well adapted to the growth of the tubercle bacil-
lus ; and an aqueous solution of guaiacol, the principal in-
gredient of creasote, has been substituted for the alcoholic
solution of creasote employed by Guttmann in the prepara-
tion of his media.*
These media were impregnated with guaiacol in the pro-
portions of 1 to 1,000, 1 to 1,2000, 1 to 3,000, and 1 to 4,000,
and into them were introduced particles of a rapidly grow-
ing culture of the tubercle bacillus, other media, not contain-
ing guaiacol, being at the same time inoculated as controls.
All were then sealed and placed in the thermostat at 37° C.
At the end of seven weeks they were examined and the
records tabulated below noted. It may be permissible to
state here that every slightest indication of growth was
carefully searched for, and that no record is made except
where all the conditions necessary to the growth of tubercle
bacilli were observed, so that the entry " No growth " in
the tables below means literally what it says.
Series A.
Glycerin-bouillon. Inoculated March 11, 1892 ; examined April 29,
1892.
Series B.
Glycerin-agar. Inoculated March 11, 1892 ; examined April 29, 1892.
Control.
Four flasks .
1 to 1,000.
Two
flasks.
1 to 2,000.
Two
flasks.
1 to 3,000.
Time
flasks.
1 to 4,000.
Two flasks.
1. Moderate growth,
^ not spreading
much, but heaping.
2. Luxuriant
growth, overgrow-
ing the whole sur-
face of the bouillon.
1. No
growth.
2. No
growth.
1. No
growth.
2. No
growth.
1. No
growth.
2. No
growth.
1. Apparently slight
heaping up, thought
to indicate very
slow growth.
2. Slight heaping,
though somewhat
questionable.
4. Moderate growth,
growth.
While fully recognizing the illusive nature of conclu-
sions as to the value of therapeutic agents based upon peri-
odical determinations of the number of tubercle bacilli in
the sputum, it has been thought desirable to make such de-
terminations in a number of cases treated with creasote
and guaiacol.
The method employed for this purpose has been that
recommended by Nuttall, the details of which are to be
found in the Bulletin of the Johns Hojrtins Hospital, vol. ii,
No. 13, May-June, 1891.
* Notwithstanding Guttmann's statement to the contrary, it was
thought possible that the alcohol necessary for the solution of the crea-
sote might have a disturbing influence upon the experiment.
Control.
Four tubes.
i tn 1 nnn
Five
tubes.
1 tn 9 OOO
1 l>\) «,IJUO.
Five
tubes.
i tfto oon
i LO 0,UUU.
Five
tubes.
1 to 4,000.
Five tubes.
1 \ pfv 111 Y 11 PI '1 Yl t
1. No
1. No
1. No
1 r\ n iri'i iwf n
l . n \j t; 1 1 1 n bill
growth, heaping
growth.
growth.
growth.
1 1 1 1 1 1 spreading.
2. Abundant
2. No
2. No
2. No
2. Very slight heap-
growth, heaping
growth.
growth.
growth.
ing and cloudiness
and spreading.
at edges, as if grow-
in"" slu'rtrishlv
3. Moderate
3. No
3. No
3. No
3. Abundant
growth.
growth.
growth.
growth.
growth.
4. Moderate
4. No
4. No
4. No
4. Very slight heap.
growth.
growth.
growth.
growth.
ing ; no apparent
spreading.
5. No
5. No
5. No
5. Slight heaping
growth.
growth.
growth.
and cloudiness at
edges, as if slowly
spreading.
Although this method is unquestionably the most accu-
rate thus far proposed, it is nevertheless subject to great
error, and the results are liable to be particularly mislead-
ing in cases in which the expectoration is large and the
number of bacilli small. Case VII, tabulated below, may
be referred to as an example. About eleven ounces of spu-
tum were eliminated daily. This was so viscid that its dis-
integration necessitated the addition of considerably more
than an equal bulk of potash and water, so that once the total
amount after dilution came to be 700 c. c. Since the drop-
per used delivers about 100 drops to the cubic centimetre,
the contents of each drop (in this particular case) must be
multiplied by 70,000 in estimating the total number of ba-
cilli eliminated in twenty-four hours, and, of course, any
error in the determination of the number of the bacilli to
the drop is similarly multiplied ; and where there are only
a few bacilli to each drop, all may be overlooked in count-
ResvlU of the Determination of the Actual Number of Tubercle Bacilli
in Twenty-four Hours' Sputum, by NuttaWs Method.
Case.
Date.
Feb. 24, 1892.
Feb. 24, 1892.
Mar. 23, 1892.
Apr. 6, 1892.
Apr. 29, 1892.
Feb. 22, 1892.
Mar. 23, 1892.
Apr. 29, 1892.
Feb. 26, 1892.
Mar. 23, 1892.
Apr. 6, 1892.
Apr. 29, 1892.
Mar. 17, 1892.
Mar. 28, 1892.
Apr. 6, 1892.
Apr. 29, 1892.
Quantity of
sputum in
24 hours.
9 fl. dr.
12 "
Number of tubercle bacilli in
24 hours' sputum.
10
and
11
and
11
fl. oz.
6 fl. dr.
fl. oz.
4 fl. dr.
fl. oz.
227,684,401.
7,798,791.
4,189,915.
1,946,657.
380,828.
579,792.
About 100 fields carefully gone
over without finding any bacillus.
Whole drop then examined sys-
tematically, and still none found.
Stain good.
6,858,090.
7,707,033.
274,246.
202,149.
270,228.
100 fields carefully gone over ; no
bacillus. Whole drop ; no bacil-
lus. Stain good. A second cover
of the same examined with the
same result.
100 fields searched as above; no
bacillus. Duplicate cover gives
the same result.
1,307,395.
2,915,976.
May 21, 1892.]
ROCKWELL: A CASE OF HEREDITARY NERVOUS GOUT.
575
ing fifty fields, or, on the other hand, a disproportionate
number may-chance to be seen. Thus, in Case VII, while
the majority of the fields contained no bacilli, one had
three. A discrepancy of 100,000 or so is a matter of
small import where many millions of bacilli are present,
but maybe very misleading when there are only a few hun-
dred thousand.
References.
1. Pfeffer. Unters. a. d. botanischen Institut zu Tubingen,
1886-1888.
2. Buchner. Berlin, klin. Woch., 1890, No. 47.
3. Cornet. Zeitsehrift f. Hygiene, v, 1888.
4. Trudeau. Trans, of the Assoc. of Am. Phys., v, p. 208.
5. Collective Investigation Record, London, July, 1883.
6. Flick. Paper read before the Phil. Co. Med. Soc, May
22, 1889; also Trans, of the Med. Soc. of the State of Pennsyl-
vania, 1888.
7. Cornet. Zeitsehrift f. Hygiene, vi, 1889, p. 65.— Heron.
Evidences of the Communicability of Consumption, London,
1890.
8. Bang. Congres pour V etude de la tuberculose, i, 1888.
9. Bolliuger. Deutsch. Zeitschr.f. Thiermed., xiv, p. 264.
10. Hirschberger. Deutsch. Archiv f. klin. Med., xliv, p.
500.
11. Ernst. Trans. Assoc. of Am. Phys., iv, 1889; also Pub-
lications of the Mass. Soc. for promoting Agriculture, February,
1891.
12. During, E. Monatsschrift f.prakt. Derm., vii, 22, 1888.
13. Demme. Twenty -third Report of Jennet's Children's
Hospital in Berne, during 1888, Berne, 1886.
14. Pietz. Wien. med. Woch., No. 11, 1889.
15. Lehmann, E. Deutsch. med. Woch., No. 9, 1886.
16. Johns Hopkins Hospital Bulletin, May, 1891.
17. Gtrlbl.f. Bakt., February 10, 1892.
18. Am. Jour, of the Med. Sciences, March, 1891.
19. Grancher and De Gennes. Annates d'hyg. pub., xix,
1888.
20. Spengler. Muncheuer med. Woch., No. 45, 1891.
21. Grancher and De Gennes. Annates d'hyg. pub., xix,
1888. — Kirchner. Ctrlbl. f. Bakt. u. Parasitenkunde, ix, 1,
1891.
22. V. Eiselsberg. Wien. med. Woch., 1887, No. 53.
23. Fleur. Etudes exper. etclin.sur la tuberculose, publiees
sous la direction de M. le Prof. Verneuil, ii, 1888.
24. Hoist. Lancet, 1886, ii, No. 9.
25. Pfeiffer. Zeitsehrift f. Hygiene, iii, 1887.
26. Koch. Deutsch. med. Woch., January 15, 1891'; Brit.
Med. Jour., January 17, 1891.
27. Rosenbach. Kritik des KocKschen Verfahrens, Wien
und Leipzig, 1891.
28. Hunter. Brit. Med. Jour., No. 1595, July, 1891.
29. Klebs. Deutsch. med. Woch., November 5, 1891 ; Die
Behandlung der Tuberculose mit Tuber cut ocidin, Hamburg und
Leipzig, 1892.
30. Buchner. Tuberculinreaction durch Proteine nicht
specifischer Bakterien. Munch, med. Woch., No. 49, 1891.
31. Prudden. New York Med. Jour., December 5, 1891.
32. Schede. Deutsch. med. Woch., December 3, 1891.
33. Brit. Med. Jour., No. 161 1, November 14, 1891.
34. Lancet, 1891, ii, Nos. 2 and 3; Brit. Med. Jour., No.
1593, 1891.
35. Bouchard and Gimbert. Qaz. hebd., 1877, Nos. 31, 32,
and 33.
36. Guttmann. Zeitschr.f. klin. Med., 1888, pp. 488-494.
37. Trudeau. Personal communication, April 3, 1892.
38. Cornet. Zeitschr.f. Hygiene, v, 1888.
39. Sahli. Correspondenzbl. f. schweizer Aerzte, 1887, No. 20.
40. Seifert and Hoelscher. Berlin, klin. Woch., 1891, No.
52 ; 1892, No. 3.
(Original Communications.
A CASE OF HEREDITARY NERVOUS GOUT.
By A. D. ROCKWELL, M. D.,
NEW YORK.
Gout is a disease which, in the majority of instances,
is so thoroughly dependent upon errors of food, drink, and
exercise, and the influences of heredity, that its prevention
and cure depend, for the most part, on the observance of
strict hygienic methods.
It is within the experience of every physician that he-
reditary influences are alone sufficient, in many cases, to
occasion attacks of gout. The victim may be most ab-
stemious in all his habits of eating and drinking and active
in his exercise, yet suffer at intervals from the characteristic
pain and swelling of the smaller joints, clearly indicating
the Iithic-acid diathesis.
I have seen several cases of this character in which the
loss of nervons tone was such a prominent feature that the
term " nervous gout " seemed entirely applicable. There
is one phase of the subject to which more consideration
should be given in the study of electricity in its relation to
gout, and that is the remarkable variation in the suscepti-
bility of different individuals to its effects. One can ap-
preciate fully this fact, however, only after long and
varied experience. To say that some persons were not
born to be treated by electricity is a strong expression, but
thoroughly true. The observation was made years ago,
and proofs of its substantial accuracy accumulate year
by year without regard to the nature of the symptoms
or the disease. There are, on the contrary, those whose
tendencies and susceptibilities are quite in the opposite di-
rection, and who respond most readily to any form of elec-
trical treatment.
One of the most interesting evidences of the truth of
this statement occurred in the person of a young man who
first consulted me some ten years ago and whom I have
been able to keep under observation ever since.
When I first saw him he was twenty-six years of age and
was suffering from a distinct gouty swelling of the metatarso-
phalangeal articulation of the great toe and the large joint of
the index finger.
He gave a history of direct hereditary transmission through
several generations, and although both his father and grand-
father had been high-livers and indulged freely in the choicest
wines, he himself had been from childhood unusually abstemi-
ous in eating, had never touched liquor of any kind, and was
an enthusiast along the line of athletic sports. He belonged,
however, to the true neurasthenic type that is now so familiar
to every observing physician. This was by no means his first
attack. They were accustomed to come on at irregular inter-
576
KAKELES: SENILE GANGRENE OF THE TOES.
[N. Y. Med. Jouk.,.
vals, sometimes one or two years intervening between the
paroxysms, and then again only a few months.
On each occasion the joints were exceedingly stiff, swollen,
and painful, invariably keeping him from all active exercise for
a month or six weeks.
The results that followed the use of electricity on many
different occasions in his case conclusively proved that he was
one of those "born to be treated by electricity." General
faradization has always been followed by immediate and almost
complete alleviation of pain, and has always very considerably
shortened the attack.
In all the attacks from which the patient has suffered, six or
seven in number, since electricity was first attempted, ten years
ago, only once was he prevented from receiving the customary
treatment.
On this occasion it was five weeks before he fully recovered,
while in all previous and subsequent attacks three weeks was
the limit of the duration of the disease.
Acute attacks of gout, however, depending upon errors
of food and drink, combined with indolent habits, offer no
encouraging field for the beneficial effects of electricity.
It is indeed doubtful whether it would ever prove of suffi-
cient service during the attacks in these ordinary cases to
be worth the time and labor necessary.
Taking into consideration the catalytic and absorptive
power of the galvanic current, it has been suggested that
much could be accomplished through its use in dissipating
the gouty concretions that form in the various joints of the
body. Experience has not, however, confirmed the correct-
ness of this suggestion. The deposits of urate of sodium
resist with great persistency all external and mechanical
methods of treatment, as well as the internal administra-
tion of remedies.
I have in past years treated many cases of this charac-
ter, but I am bound to say that I have never yet seen a true
calcareous deposit in the joints appreciably diminished by
any form of electrical treatment. I have, however, known of
actual damage being inflicted by a too confident and care-
less resort to the galvanic current.
In December last a gentleman called upon me, inquiring if
electricity could do anything to relieve his hands and feet, stiff
and crippled from repeated attacks of gout. That the urates
had been deposited in large quantities was evidenced by the great
deformity and unusual size of many of the joints, and especially
those of the hands. The skin, as it stretched over the concre-
tions, presented the characteristic bloodless and shining appear-
ance, and looked as if, under provocation, it might entirely give
way.
I told him that electricity could do nothing for him. With-
in a week he returned, saying that he had been assured by an-
other that the galvanic current would certainly help him. Upon
this assurance he submitted to two local applications of the cur-
rent strong enough to occasion sharp burning and reddening of
the skin. The almost immediate result was an excoriation,
which is likely to be permanent. While the continuous press-
ure of the deposits might in time have caused ulceration, yet it
is quite certain that this result was hastened by the injudicious
treatment to which he had been subjected.
There is much truth in the expression that " he only has
gout who will have it." Leaving heredity out of the ques-
tion, it is an entirely preventable condition, and is brought
about in the majority of cases by grossly unhygienic meth-
ods of living.
Its prevention and cure depend, for the most part, on a
return to proper methods of living, both as regards eating
and drinking and exercise, and only in so far as electricity
can be made to produce effects similar in kind to those
obtained through muscular exercise is it of any therapeu-
tic value in this disease. In those cases, therefore, where,
from any cause, adequate active exercise is not practicable,
the mechanical effects of the faradaic current, by the method
of general faradization, or of the static induction current of
electricity, are certainly indicated and are capable of service..
SENILE GANGRENE OF THE TOES;
AMPUTATION AT THE LOWER THIRD OF THE THIGH;
RECOVERY.
By M. S. KAKELES, M. D.,
NEW YORK.
Last March (1891) I was called to see a lady, seventy
years of age, who had been confined to her bed for three
months. It was on the 19th of the month when I first saw her
and received from her the following history : For twelve years
she suffered witli pains in the lower left extremity, which she
supposed were due to a varicose ulcer situated a little above the
external malleolus which now and then healed over, but oftener
was in an open condition. During the latter part of the three
months that she was bedridden the ulcer had healed, but the
pains persisted around the ankle joint and foot.. She had been
treated for rheumatism until a small dark spot appeared on the
big toe, about a week before I first saw her. The physician
then had diagnosticated commencing gangrene, and ordered
poultices to the parts ; this had been kept, until I was called in..
On examining the patient, one would, from her appearance,
have judged her to be ninety years old instead of seventy.
Anaemic, haggard, and in a debilitated condition. Appetite
poor. The pulse fairly good, and evidenced sclerotic condition
of the vessels. The heart was weak. No murmurs. Lungs
normal. There was no rise of temperature. The urine, from re-
peated examination, contained neither sugar, albumin, nor casts.
The skin was wrinkled and in a flabby condition. Over the
sacrum there was an abrasion of epidermis and cutis about the
size of the palm of the hand, as result of continual pressure.
The left big toe was entirely gangrenous, the second in an in-
cipient stage of mummification. From her general appearance
and debilitated condition, and from the character of the gan-
grene, there seemed to me at the time no hurry to amputate the
foot, or even the toes, until the nature of the progress of the
disease was well established and the patient been put in a better
condition, although I had in view at the time that an amputa-
tion above the middle of the leg would give better results than
removal of the toes or even the foot.
The first indication to be met was the extreme weakness of
the patient, and I resolved to stimulate her for a few days with
tonics and good nourishment, in order that she could better be
able to withstand the shock of an amputation. The gangrenous
toes were treated antiseptically, and the course of the disease
carefully watched until it commenced to spread to the back of
the foot.
As my patient had reacted well to the- tonics (strychnine,
iron, etc.), which had been given for two weeks, and the bed-
sore taken on a healthy granulation, it then seemed that the
time had arrived when amputation was imperative. The ques-
tion was at what place.
May 21, 1892.]
BIRMINGHAM: IRREDUCIBLE UMBILICAL HERNIA.
577
Koenig, in his Surgery, gives three causes of senile gangrene.
1. As consequence of inflammatory stasis, resulting from
some slight injury, in such patients who have exhibited symp-
toms of impoverished nutrition of parts — such as coldness and
insensibility of toes, fingers, etc.
2. Less frequently as a consequence of marasmic thrombus
of the capillaries without preceding inflammation which leads
to localized mummification of skin and gradual spreading.
3. Still less frequently gangrene as result of embolus or
localized thrombus in a large arterial branch.
I attributed in my patient the cause of the gangrene to that
class due to thrombus in the capillaries, and, on account of the
unhealthy condition of skin above the ankle, due to her chronic
ulcer, thought to amputate above the seat of the ulcer — namely,
the middle or upper part of the leg ; but still the fear that my
flaps might slough deterred me from taking this seat of election.
The popliteal artery was also much sclerosed, which also led me
to believe that the higher I would amputate (without forgetting
the serious risks taken in removing so much of an extremity)
the better chance I would have of avoiding a recurrence of the
gangrene. I decided, therefore, after careful deliberation, that
the prognosis would be far better by amputation above the knee
than below, through a skin which in all likelihood, from its ap-
pearance, would have sloughed, and thus endangered my pa-
tient's life through septic infection.
On April 2d, as careful an aseptic operation (under a nar-
cosis with the A. C. E. mixture) as could possibly have been
done was performed through the junction of the middle and
lower thirds of the femur. The circular method was used ; the
flaps sewed with silkworm gut, and three small drainage-tubes
inserted — one at each end, and one in the middle of the wound.
The stump dressed, and patient put to bed with a good pulse.
She rallied well and primary union obtained, except where
drainage-tubes were inserted. After four weeks the patient
was walking around on crutches, and said she felt better than
she had in the last twelve years. She left the city perfectly
happy that she could once more walk about.
I report this case to confirm the value of Haidenhain's con-
clusions that amputation through the thigh, when once senile
gangrene has commenced in the toes and spreads to the foot, is
far better (barring contra-indications) than running the risk of
rapid sloughing of flaps in a lower operation.
IRREDUCIBLE UMBILICAL HERNIA
(OMENTAL) SIMULATING LIPOMA.
OPERATION.
By Captain H. P. BIRMINGHAM,
MEDICAL DEPARTMENT, U. 8. ARMY,
BOISE BARRACKS, IDAHO.
{Published by authority of the Surgeon- General.)
In October last Mrs. M. R., a laundress at this post, a wom-
an of large build and very fleshy, consulted me about a tumor
of the abdominal wall. She is a French Canadian with Indian
blood, forty-seven years of age.
About ten years ago she first noticed a small lump a little
to the left of the median line, near the umbilicus, which at
times appeared to remain stationary and again would increase
in size with considerable rapidity. She had some time previ-
ously been examined by two civilian physicians, who pronounced
it a fatty tumor of the abdominal wall.
Upon examination, I found what appeared to be a lobulated
growth nearly the size of an adult head, with a distinct pedicle
when the patient was standing, but which seemed to flatten out
somewhat when she lay down. She gave no history of strain
or traumatism of any kind at the time, although, after the oper-
ation, when it was explained to her what was found, she re-
membered being hurt by attempting to save a man from falling
under the burden of a too heavy log, and of feeling a very acute
pain in the abdominal wall at the time — a statement which, if
made before the operation, would probably have saved me from
an error in diagnosis. She also stated that the tumor begau to
grow shortly afterward, although she did not consider the acci-
dent a causative factor.
The location of the tumor seemed to be against its being of
a lipomatous nature, but the general appearance and history
pointed that way, and I wras also influenced somewhat by an
idea which prevails in the Northwest that people of the mixed
type are more liable than others to lipomatosis.
I asked a physician from the neighboring town of Boise
City to see the case with me, and, after a careful examination
and the application of Nelaton's circumduction test, we con-
cluded that it was a fatty tumor. As the patient was anxious
for relief from the annoyance due to the weight and consequent
dragging, I decided to operate, which I did on October 16,
1891, under conditions of strict surgical cleanliness.
Upon cutting through the integument I came upon what
looked like a peritoneal sac, and soon discovered what I had to
deal with. I opened the sac, and, upon introducing my hand,
found that it contained omental fat only, from which the mem-
brane proper had in great part disappeared. I found the whole
mass firmly adherent at the neck and wholly irreducible. I
separated the adhesions with some difficulty with my finger-
nails, and while so doing violent retching set in and several feet
of small intestine were forced out through the ring and tightly
and immovably held there. I then determined to remove the
sac and its contents, which I did by doubly ligaturing them
separately with aseptic silk, cutting them off close to the ring,
and dropping the pedicles back into the abdominal cavity. In
hastily separating the intestine from some adhering omen-
tum I tore a hole in the mesentery, which caused a very free
haemorrhage, but which was readily controlled by haamostatic
forceps ; two vessels were ligated with catgut. After returning
the prolapsed gut, which had been protected by towels wrung
out of hot, previously boiled water, I decided to attempt a
radical cure, but, as the patient's condition was none of the best,
whatever was done had to be done quickly, so I hastily passed a
double silk ligature, in purse-string fashion, around the umbili-
cal opening, well back from its cartilage-like border, drew it
tight, tied it, and brought out the ends at the upper angle of
the wound. I did this with the McBurney idea in view — that
is, keeping the upper angle open and making it granulate from
the bottom. The lower part of the wound was closed and a
dressing of iodoform gauze applied.
There was a slight rise of temperature for several days, but
there was no evidence at any time of other than a local perito-
nitis at the site of the purse-string suture. The opening at the
upper angle of the wound continued to discharge, and was slow
in filling up on account of the thick layer of abdominal fat. I
irrigated it with Thiersch's solution, and latterly with one of
weak permanganate of potassium. It is now completely closed,
and there is a fine cicatricial boss with a broad base over the
site of the former opening. The ligature came away on the
twenty -fifth day. Of course, it is too soon to even conjecture
what the ultimate result will be, but the patient says her " stom-
ach " feels as firm as ever, and that sho never felt better.
The amount of omentum removed must have weighed nearly
three pounds, but, unfortunately, it, with the sac, was thrown
away before I could secure it.
January 29, 1892.
578
LEADING ARTICLES.— MINOR PARAGRAPHS.
[N. Y. Med. Jouh.,
THE
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by Edited by
D. Appleton & Co. Frank P. Foster, M. B.
NEW YORK, SATURDAY, MAY 21, 1892.
DR. LAUDER BRUNTON ON HEMORRHOIDS.
Dr. Lauder Brunton lately read before the Medical Society
of London a practical paper on the causes and treatment of
haemorrhoids and allied affections. According to the report of
the discussion, as given in the Medical Press and Circular for
March 16th, it was contended that this "lowly complaint,
piles," should receive a larger degree of medical attention than
was commonly the case, in order that in the end the surgeon
should have to be called upon less frequently; and that, in fact,
only when persistent neglect had increased the severity of the
disorder beyond ordinary limits should there be recourse to
surgical means. Unfortunately, the term " piles " is often ap-
plied to pathological states of the anal region that have little in
common. The prophylaxis of the disorder has for this reason
been clouded by discrepant views. Dr. Brunton seeks to put
anal prophylaxis and rectal medication on a clearer and more
even basis. He especially magnifies the causative influence of
" chill." There are four regions of the human body that are
particularly susceptible to cold — the nape of the neck, the ab-
domen, the shins, and the feet. The shins are a weak point
seldom considered. There are many persons who would not
think of going out into the cold, unless properly clad, who pass
comparatively long periods in cold, sometimes damp, water-
closets with important parts of their bodies entirely unpro-
tected. Reflex contraction of rectal muscular tissue prevents
the blood from finding its way back through the haemorrhoidal
veins, the obstruction taking place at the point where the veins
pass through the muscular walls of the rectum.
The question of treatment with cathartics was discussed,
reference being made first to the benefit derived from mercurial
purgation followed by salines in the reduction of hepatic con-
gestion. The author next showed that certain cathartic drugs
— aloes, for example — would in large doses conduce to pile
formation by unduly stimulating the muscular coats of the
rectum ; whereas in small doses they acted in a contrary way.
Hepatic congestion from chill might also be relieved by apply-
ing hot-water bags to the back of the neck and over the liver.
Persons who had piles might be benefited by accustoming
themselves to emptying the rectum after supper, in order to se-
cure rest in the recumbent posture afterward. The use of
water for cleansing and at the same time allaying irritation
was preferable to that of the somewhat harsh fabrics sold for the
closet, but unsuitable for vigorous application to sensitive or to
irritated parts. Dr. Brunton often advises the use of a pledget
of absorbent cotton, dipped in a liquid preparation of hama-
melis, since it both supports the parts and acts as a topical
medication. The official extract and tincture, he thinks, have
not been so serviceable as some of the tradcmarked articles.
The anal pad has been a means of great relief in some obstinate
cases. The compound called "listerine," when suitably diluted,
has been found by some practitioners an advantageous appli-
cation.
MINOR PA II A GEA PUS.
AWAY WITH THE HOLLOW PESSARY.
A hollow Hodge pessary is an innocent-looking thing, and
it is undoubtedly somewhat lighter than a solid one; but the
weight of a hard-rubber Hodge pessary is not worth consider-
ing, whether hollow or solid, and the hollow article may do
damage, as the writer of this article has reason to believe from
an occurrence that is within his recent experience. Having re-
moved a hollow pessary, when he was about to reinsert it, he
found that, although it had been lying for several days in a dis-
infectant solution, it was decidedly odorous. Knowing that
hard rubber ought not to acquire an odor incapable of being
dissipated by washing with water, he was for the moment puz-
zled. He soon observed, however, that, although the instru-
ment had been carefully dried on its exterior, it felt moist on
further handling. On closer inspection, it was found to present
a pin-hole opening, and it was evident that through this open-
ing the secretions of the vagina had gained access to its inte-
rior. This conclusion was further confirmed by applying the
test of succussion ; on shaking the pessary, the presence of the
liquid within it was abundantly evident. It was at once re-
turned to the instrument-maker, and a solid pessary was substi-
tuted for it. The hollow Hodge pessary is not often met with
in commerce, and, considering the danger to which, as this inci-
dent shows, a patient may be subjected by its use, it should no
longer be put upon the market.
A REMEDY FOR CHRONIC RHEUMATIC ARTHRITIS.
According to Mr. Hugh Lane, in his recent wrork on Rheu-
matic Diseases, the following prescription was found of such
service among the pensioners of Chelsea Hospital who suffered
from chronic rheumatic arthritis that Lord Anson gave three
hundred pounds for the liberty to give publicity to it : R Honey,
§ xvj ; sulphur, §j; cream of tartar, §j; rhubarb, 3iv;gum
guaiaci, 3j; nutmeg, No. j. Misce. The patient took two ta-
blespoonfals in a small tumbler of hot white wine and water
when going to bed, and the same quantity before rising in the
morning, remaining in bed until any perspiration that was oc-
casioned had subsided. The treatment was continued until a
perceptibly good effect had ensued, when only one teaspoonful
was administered at a dose until the mixture was used up.
THE WOMAN'S HOSPITAL AND THE ALDERMEN.
The Board of Aldermen have a deep interest in the pros-
perity of the Woman's Hospital in the State of New York.
This is shown by the following report of proceedings at a regu-
lar meeting last week: " A resolution was passed by the alder-
men permitting the sale of the property at Lexington Avenue
and Fiftieth Street, now occupied by the Woman's Hospital, on
condition that the hospital authorities in their new location set
aside fifty free beds to be at the disposal of the aldermen."
After the meeting adjourned, one of the friends of the hospital
suggested that at the next session the City Fathers should vote
that the twelve signs of the zodiac should be " set aside " at the
disposal of the aldermen. It is a new feature in the politician's
evolution for him to " strike " a hospital for " free beds."
May 21, 1892.]
MINOR PARA GRAPHS. — ITEMS. — LETTERS TO THE EDITOR.
579
EPISPADIAS SUBSEQUENT TO INJURY IN COPULATION.
The fourth annual report of the 8eney Hospital, of Brooklyn,
contains a brief note regarding an alleged acute gangrenous in-
flammation of the penis due to injury during coition. The
corpora cavernosa took on violent inflammatory action, and the
greater part of their substance sloughed away. The treatment,
by incision, removal of necrotic tissue, and iodoform dressings,
was followed by a gradual repair. Deformity and epispadias
marked the condition of the penis at the time of the patient's
discharge. A plastic operation has been proposed for the relief
of the man's embarrassment from the flow of his stream of
urine from the top of the deformed member, but he has not yet
returned to accept the offer.
DEATHS BY INFLUENZA.
Db. Baloh, the secretary of the State Board of Health, esti-
mates that 10,000 deaths, in New York State, were chargeable
to influenza and its sequels in the winter quarter of 1892. The
local diseases appear to bear the brunt of a largely increased
mortality, but influenza is probably the genuine cause.
THE DIGNITY OF THE PATIENT.
It is reported that a physician in Germany has lately been
sentenced to imprisonment for an indignity offered to a patient
affected with hysteria. The incident serves to illustrate the
principle that, while it may often be necessary to shock a pa-
tient, either physically or mentally, nothing ever warrants an
affront from physician to patient.
ITEMS, ETC.
The New York State Medical Association. — At the eighth annual
meeting of the Fifth District Branch, to be held in Brooklyn on Tues-
day, the 24th inst., under the presidency of Dr. H. Van Hoevenbcrg, of
Kingston, papers are to be presented as follows : The Limitations for
Vaginal Hysterectomy in Malignant Disease of the Uterus, by Dr. J. E.
Janvrin (the discussion to be opened by Dr. George T. Harrison) ; Re-
tention of Menstrual Blood from Imperforate Hymen, by Dr. J. R. Van.
derveer ; Voluntary Patients in Asylums for the Insane, by Dr. W. D.
Granger ; Acute Catarrh of the Middle Ear as a Complication of la
Grippe, by Dr. Samuel W. Smith ; and Brown-Sequard's Paralysis re-
sulting from Syphilis, by Dr. S. T. Armstrong.
The Medical Society of the State of New York. — The business com-
mittee for the meeting of February, 1893, has been organized by the
appointment of Dr. Seneca D. Powell, of No. 12 West Fortieth Street,
New York, as chairman, and Dr. William Maddren, of Brooklyn, and
Dr. John 0. Roe, of Rochester, as associates. The programme for the
scientific work of the session is said to be already well advanced in its
preparation.
The New York Society for the Relief of Widows and Orphans of
Medical Men celebrated the fiftieth anniversary of its organization at a
dinner at the Academy of Medicine on Saturday evening, the 14th inst.
The secretary read a summary of the work done by the society, showing
it to be an exceedingly well managed and useful organization.
The New York Polyclinic. — Dr. Christian A. Herter has been ap-
pointed lecturer on the anatomy and pathology of the nervous system.
The Northwestern Medical Society of Philadelphia, which has been
in existence two years, meets on the second Tuesday of each month.
Change of Address. — Dr. C. H. Althaus, to No. 1024 Bushwiek
Avenue, Brooklyn.
The Death of Dr. Butson Maury took place on May 5th, after less
than a week's illness of pneumonia. He was born in North Carolina
thirty-seven years ago. Nearly all his life had been spent in New York.
He was an alumnus of the College of the City of New York of the
class of 1883, and of Bellevue Hospital Medieal College of the class of
1887. At the latter institution he passed at the head of the class, and
availed himself of an interneship at Bellevue. About two years later
he entered practice, being associated with Dr. W. T. Lusk. His death
took place at St. Luke's Hospital.
Society Meetings for the Coming Week :
Monday, May 23d: Medical Society of the County of New York ;
Boston Society for Medical Improvement ; Lawrence, Mass., Medi-
cal Club (private) ; Cambridge, Mass., Society for Medical Improve-
ment ; Baltimore Academy of Medicine.
Tuesday, May gjjth : New York State Medical Association, Fifth Dis-
trict Branch (annual — Brooklyn) ; Connecticut Medical Society (first
day — New Haven); Association of American Physicians (first day —
Washington) ; New York Academy of Medicine (Section in Laryn-
gology and Rhinology) ; New York Dermatological Society (private) ;
Buffalo Obstetrical Society.
Wednesday, May 25th: Connecticut Medieal Society (second day) ; As-
sociation of American Physicians (second day) ; New York Surgical
Society ; New York Pathological Society ; American Microscopical
Society of the City of New York ; Metropolitan Medical Society (pri-
vate) ; Medical Societies of the Counties of Albany and Monroe (an-
nual— Rochester), N. Y. ; Auburn, N. Y., City Medical Association ;
Berkshire, Mass., District Medical Society (Pittsfield) ; Philadelphia
County Medical Society.
Thursday, May 26th: Connecticut Medieal Society (third day); Asso-
ciation of American Physicians (third day) ; New York Academy of
Medicine (Section in Obstetrics and Gynaecology) ; New York Ortho-
paedic Society ; Brooklyn Pathological Society ; Roxbury, Mass., So-
ciety for Medieal Improvement (private).
Friday, May 27th : Yorkville Medical Association (private) ; New York
Society of German Physicians ; New York Clinical Society (private) ;
Philadelphia Clinical Society ; Philadelphia Laryngological Society.
Saturday, May 28th : New York Medical and Surgical Society (pri-
vate).
fetters to tbc €bitbr.
THE POLYSCOPE AND THE DIAPHANOSCOPE.
[Translation.]
14, rue Vivienne, Paris, April 11, 1892.
To the Editor of the New York Medical Journal :
Sir: In the Revue illustree de potytechnique medicale et
chirurgicale for March 31, 1892, I read a letter addressed to the
New York Medical Journal by Dr. Max Einlmrn, who seeks to
establish priority over Dr. Hugo J. Loebinger for an electrical
apparatus making it possible to illuminate the stomach and even
the large intestine in man.
The French journal comments upon its translation of the
letter into our language. It asks justly how the observer can
procure any information from illumination thus produced, and
it remarks that experiments in diaphanoscopy were long ago
made in France without any appreciable positive results.
Will you allow me, Mr. Editor, to join in the discussion and
to furnish Dr. Loebinger with the historical data that he de-
sires? Perhaps I am competent to do it, for, being perfectly
familiar with the chief fruitless attempts that had been made in
Europe, in 1869 I invented certain electrical appliances which I
called polyscopes, which not only illumined the interior of the
stomach, the large intestine, and certain other natural cavities
of the human body, but allowed of viewing the interior of these
organs directly, and not hy transparency. My polyscopes were
580
PROCEEDINGS
OF SOCIETIES.
[N. Y. Med. Jor/K.,
honored with the medal of progress at the Vienna International
Exposition in 1873. They were briefly described in your coun-
try by the Scientific American for September 21, 1878.
I do not wish to insist on the services that my electrical
polyscopes have rendered in the domain of biology ; I will only
say, in order to show that these appliances really exist and that
for many years they have rendered signal services to medicine,
that with them Professor Guyon has shown to his pupils the
normal and morbid states of the mucous membranes of the
rectum and bladder ; that Professor Lallier and the illustrious
Professor Pean have made use of them for illuminating deep
cavities from which they have removed tumors ; and that Pro-
fessor Collin, of Alfort, since 1876, with the aid of my poly-
scope, has been demonstrating to his pupils the interior of the
ox's stomach in order to teach them the digestion of that rumi-
nant. Introducing successively a frog and a leech into the
organ, he has shown them the disorders caused by the latter
animal.
I shall not further insist upon the experience, now classical
in France, Germany, and Austria, of my luminous fishes. Dr.
Georges Barrall's work (chapter vii, second part, pp. 291 to
320), which I have the honor of sending you, will give you the
amplest data on all these subjects. Les nouvelles decouvertes en
electricite (such is the title of the work) will also show you
how the use of my electric polyscopes has been extended even
to extra-organic investigations. It is thus that they were found
of service in inspecting and testing the bores of cannon and
shell at the arsenal St.-Thomas d'Aquin, the interior of casks,
the slides of steam-engines, hydraulic elevators, and bore-holes,
(in which case they are called orygmatoscopes).
They are still used daily in the national powder magazines
of Sevran-Livry and Ripault, in the schools of practical ar-
tillery and engineering at Versailles, Toul, Belfort, Verdun,
and Epinal, and the foundries and ship-yards of the Mediterra-
nean, etc.
Dr. Loebinger's pelveoscope, therefore, was long ago — more
than twenty years ago — preceded by the Trouve electric poly-
scope, which, used upon the rectum, has for many years been
known as the rectoscope. My electric gastroscope also leaves
Dr. Max Einhorn's gastrodiaphane just twenty years behind it.
There is no further occasion, evidently, to speak here of
diaphanoscopy. As a diagnostic procedure, it was long ago
condemned. In 1867 Mr. Bruch, of Breslau, illuminated the
interior of the mouth with his stomatoscope ; at that time, also,
Dr. Millet made experiments in Paris in diaphanoscopy upon
the stomach of animals. In 1868 Dr. Lazarevic, of Karkoff,
published a brochure upon the subject. No undertaking in this
direction has succeeded, and none could succeed.
Such being the case, I certainly believe that I was the first
not only to illumine the bodily cavities in a really practical
way, but also to see directly and distinctly what I illumined.
As the Revue illustree de poly technique medicale et ckirurgicale
justly says, Dr. Einhorn seems to have wholly forgotten to take
this last, but chief, precaution.
Dr. Bardet, the author of a Traite d' 'electricite medicale
(1884) very much esteemed in France, recognizes as follows
the progress achieved from the point of view of medical diag-
nosis by my polyscopic apparatuses: " M. Trouve, auquel on
doit tant de decouvertes precieuses autant qu'ingeniuses, est
certainement celui des electriciens qui a le plus fait pour la
medecine. Ses appareils ont ete copies plus ou moins servile-
ment a l'etranger ; mais c'est a lui seul que revient l'honneur
d'avoir le premier reus^i a eclairer les cavites profondes de
l'economie en portant le foyer lumineux au sein meme de
l'organe, marquant ainsi un grand progres sur tous les autres
nppareils precedemment imagines." G. Trouve.
ijproceebings of jfocuties.
NEW YORK SURGICAL SOCIETY.
Meeting of November 25, 1891.
The President, Dr. Arpad G. Gerster, in the Chair.
Osteosarcoma of the Jaw. — Dr. Charles McBurnet showed
a man, sixty-two years of age, who had come to him two weeks
and a half before with an osteosarcoma of the left upper jaw.
He had felt some hesitation in operating because of the exten-
sive encroachments of the tumor. The operation was, how-
ever, done in the usual way. The growth, being too soft to re-
move en masse, was taken away piecemeal with scissors and
curette. The speaker wished to urge the advantage of prelimi-
nary tracheotomy when operating upon such very vascular tu-
mors, as this proceeding allowed one to pack the lower pharynx
with sponge and so entirely avoid the entrance of blood into
the trachea. Etherization also went on uninterruptedly through
the tracheal tube. It seemed to him that the plan he had fol-
lowed was simpler and better than that dependent upon the use
of the tampon of Trendelenburg. The preliminary tracheotomy
was rapidly done, and there was no irritating cough, such as
usually occurred when one made use of the tampon of Trende-
lenburg. As to the method of nutrition for these patients, the
speaker again urged consideration for rectal alimentation ex-
clusively for a period of some days after such operations about
the air passages. In this old man it had been carried on for
three days without any evidences of weakness from lack of food.
He had been thus fed every four hours, and had been given an
ounce of whisky, an egg, half a drachm of salt, and four ounces
of water each time.
Osteoplastic Resection of the Upper Jaw for Naso-
pharyngeal Polypus. — Dr. MoBurxey also reported the case
of T. E. W., twenty -five years of age, who, eight months previ-
ous to treatment, had first noticed the signs of his disease, the
first indication being stiffness of the articulation of the lower
jaw and pain on the right side of the head. Severe neuralgia
followed, then obstruction of the nares and difficulty in swallow-
ing. Severe epistaxis occurred on several occasions. The right
nostril was found occluded and the right infra-orbital region
was slightly prominent. "With the finger behind the soft palate
a large smooth tumor could be felt high in the pharynx. This
could also be seen with the rhinoscopic mirror. Believing that
the tumor was one of naso-pharyngeal origin and not one in-
volving the upper jaw, and appreciating that much room would
be required to remove it successfully, the speaker determined to
do an osteoplastic resection of the right upper jaw. As haemor-
rhage from such vascular tissue was to be feared, preliminary
tracheotomy was done in order that the lower pharynx might
be plugged during the operation. The superficial incision ex-
tended along the lower border of the orbit, then downward be-
side the nose into the nostril, and again through the upper lip.
The flap was turned back and then a section of the hard palate
made in the median line with the knife through mucous mem-
brane and periosteum. Also, transversely from the posterior
end of this incision, an incision was made to a point near the
last molar tooth. An incisor tooth was drawn and the bone
divided with the chisel at all points except its upper outer angle.
The right upper jaw was then easily pried outward, fully dis-
closing the naso-pharyngeal space, which was filled by the large
tumor. The tumor was readily removed with scissors from its
base of attachment to the extreme upper pharyngeal roof.
Bleeding was active, but was readily controlled by pressure,
and, the pharynx having been been previously packed at its
ower end with sponges, no blood entered the trachea. The
May 21, 1892.]
PROCEEDINGS OF SOCIETIES.
581
base of the tumor attachment was cauterized and the jaw swung
l)ack into place .and stitched at various points. Primary union
ltook place throughout, but on the fifth day a sharp secondary
hemorrhage occurred, which was promptly stopped by partially
•separating the jaw and packing the upper pharynx with gauze.
After this, recovery was rapid and complete.
Dr. J. A. Wyetu thought that there was little merit in dis-
cussion when a case was so successful. Perhaps he should ques-
tion whether there had existed the necessity for preliminary
tracheotomy. He had many times removed the jaw for malig-
nant and non-malignant disease, and had never had to resort to
tracheotomy. He held, as he had before urged, that, by giving
a position of lateral declination to the patient's face without
the head being pitched over the back of the table, the blood
would run out effectually and there would be no danger.
Dr. J. D. Bryant said that, in considering what operation
should be done, it was well to recall the fact that the dangers
from loss of blood were comparatively trifling. He had col-
lected two hundred and fifty-four cases of excision of the jaw.
There were two hundred and thirty cases of excision of a single
jaw, and one hundred and eighty-eight of the patients had made
a perfect recovery. Thirty-three had died from haemorrhage,
but only nine from primary haemorrhage. In twenty-four cases
in which both jaws or the principal portions of both were re-
moved none of the patients had died. In the operations the
speaker had done, to expose pharyngeal growths or for disease
of the jaw itself, he had ligated the external carotid. The fact
that Dr. McBurney's patients were present and that tracheoto-
my had acted so well was evidence in its favor. Still, the ob-
ject was to get rid of the blood and insure against its entrance
into the air passages. Ligation of the external carotid did this
and avoided the additional danger of opening the trachea. Ic
the operations he had done the haemorrhage had been trifling.
Dr. McBurney explained that he was by no means a be-
liever in preliminary operations of any kind, unless they were
required. In the case of a large tumor with soft and very ex-
tensive attachments, such as he had described, he thought the
method he had followed advisable.
Fracture of the Temporal Bone involving the Petrous
Portion; Extradural and Subdural Haemorrhage; Fistu-
lous Communication with the Lateral Ventricle; Opera-
tion; Recovery. — Dr. G. Briddon presented a man, aged
twenty-six, who had been admitted into the Presbyterian Hos-
pital in his service. The man had fallen from a hay-loft, a dis-
tance of twelve feet, alighting on his head. It was thought
that at the same time he had been struck on the head with a
heavy piece of iron. On his admission his temperature was
100-5° F. ; his pulse 80, full and regular; and his respiration 34.
He was in a condition of stupor, but could be aroused, and was
irritable. The pupils were equal, but dilated. There was a
sero-sanguinolent discharge from the right ear. Examination
of the scalp revealed a superficial contused wound in the right
post-parietal region, but no evidence of depression. There was
no paralysis. The reflexes were preserved. The head was
shaved and an ice-cap applied. On the following day the tem-
perature was normal, the serous flow from the ear continued
profuse, and the mental condition was sluggish. There were
noted dilatation of the left pupil, deviation of the tongue to the
left, obliteration of the right naso-labial fold, left conjugate de-
viation of the optic axes, and marked weakness of the left arm.
The mental condition improved somewhat, but the memory was
impaired, and the flow from the ear persisted up to the morning
of September 7th, when he complained of a severe pain in the
right side of the head and neck, and had become stupid. Thus,
after a lucid interval of eight days, there supervened manifesta-
tions of compression, the patient lying as if in a tranquil sleep,
except during paroxysms of delirium, lasting sometimes an hour,
and followed by excruciating pain in the head. The pulse was
slow and regular, except on exertion, when it would reach 130.
When aroused, he would open his eyes and mutter. The respi-
rations were slow and deep, sometimes stertorous. The left
facial paralysis, the inequality of the pupils, the optic deviation,
the partial paralysis of the left arm, and the progressively in-
creasing stupor, with a temperature of 105°, all seemed to justi-
fy an immediate operation. On September 7th he was operated
on under ether narcosis and with antiseptic precautions. By a
curved incision the squamous portion of the right temporal bone
was exposed. There was found a V-shaped fracture, the apex
pointing downward, and the arms extending upward to the
sqnamo-parietal suture ; the apex was depressed about an eighth
of an inch. This was elevated and removed, exposing a clot.
The opening was enlarged to the extent of an inch and a half
and the clot removed. Examination showed a fissure extend-
ing downward through the root of the zygoma into the petrous
portion, but it could not be followed farther. The dura was
opened and the brain substance found lacerated and contused.
Several small clots and a good deal of broken-down brain
material escaped. There was a considerable protrusion of cere-
bral substance through the opening. Two drainage-tubes were
introduced, and the wound was dressed open. On the follow-
ing day the patient responded intelligently to questions, but was
delirious at times. The tubes were removed at the end of ten
days. There was a protrusion of brain substance. Facial
paralysis was still present, and there was complete deafness of
the right ear. There was a continuous flow of cerebro-spinal fluid,
the pillow being constantly soaked, and the liquid to be seen
distilling from a small fistulous opening, situated in the center
of the granulations covering the exposed brain. The amount
that escaped every day was estimated at about two ounces and
a half. On October 8th an aluminium probe was allowed to
pass by its own weight into the sinus, a distance of two inches
and a half, evidently entering the ventricle. The fluid was
quite limpid and, after continuing for about two weeks, the
flow gradually diminished, and in three weeks had ceased en-
tirely. Pari passu with these changes the brain receded and
cicatrization ensued. At the present time the wound was en-
tirely healed, but the cicatrix was tender, and pulsation of brain
could be detected over the area of the operation. No paralytic
conditions remained except some obliteration of the naso-labial
fold. One feature of extreme interest remained unexplained.
Before this accident the patient had been the terror of the
neighborhood in which he lived, frequently coming in contact
with the police. Since his recovery his character had entirely
changed ; he had lost all his aggressive traits, or they were in
abeyance, he was amiable and, as a convalescent, occupied him-
self in ministering to the other patients in the ward.
Dr. L. A. Stimson thought that the depression at the apex
of the fracture and the existence of a small clot did not point to
such a change in the relations between the cranium aud the con-
tents as to constitute depression and compression. He would
like to point out that the active processes had ceased soon after
the accident. For some unknown reason certain cerebral symp-
toms had developed which were not those of late hemorrhage
or compression. The speaker did not believe that the depres-
sion of the temporal bone or the clot had caused sufficient com-
pression to call for the operation ; the operation had done the
patient good, but not by relieving compression.
Dr. Briddon said that, as he had read the history, compres-
sion either by bone or by blood had not been regarded as the
cause of the trouble. There were active inflammatory processes
present for seven or eight days, as shown by the temperature of
105°.
582
PROCEEDINGS OE SOCIETIES.
[N. Y. Mkd. Jock.,
Vaginal Hysterectomy. — Dr. A.J. MoOosh showed a wom-
an, thirty-eight years of age, who had suffered from prolapsus
uteri for eight years. He said his experience with plastic opera-
tions for this kind of trouble had been rather unsatisfactory.
In this case he had decided that extirpation of the uterus was
the best procedure. For some time the improvement had been
marked, and no descent of the mass had occurred until a few
weeks ago, four months after the operation. Now, however,
the patient was in very much the same condition as before the
operation, minus the uterus. The operation, so far as effecting
a cure was concerned, had proved a complete failure. From
his experience with four cases he had come to the conclusion
that the ultimate results of this operation were far from satis-
factory.
Experience in the Treatment of Buboes by Excision and
Injection was the title of a paper read by Dr. MoBurney.
Dr. Briddon thought that when the glands situated beneath
the cribriform fascia were involved the dissection was difficult
and there was always danger of injuring veins. He had twice
divided the saphenous vein as it passed through the cribriform
fascia to join the femoral vein and had been obliged to tie the
femoral vein.
Dr. L. S. Pilcuer said that he had looked with a good deal
of skepticism upon the method of attacking large suppurating
buboes with vaseline, and, indeed, no method of dealing with
these conditions short of radical surgical methods had seemed
to him worthy of acceptance Evidence to the contrary had
been given at this meeting and had come in such a way that it
was impossible to refuse it credence. Some years ago he had
made a series of observations on double buboes. On one side
the gland was extirpated as a tumor and primary union sought
for. On the other side the suppurating region was freely opened
and curetted, the cavity packed, and secondary adhesions en-
couraged. The latter method had yielded the best results, and
since that time he had used it as a rule.
Dr. Stimson could confirm the statement as to the frequency
with which only partial success followed excision of the inguinal
glands. He had no experience of any accidents following the
operation. He thought it best always to search at once for the
femoral vein, and thus, by knowing where it was, be able to
avoid it.
Dr. Robert Abbe said that the treatment with vaseline im-
pressed him as a method to be tried. His own experience had
been favorable after excision and packing for thirty-six hours
and then allowing the edges of the wound to fall together and
secure union. He had never sutured the skin over the incision
made in getting out the glands.
Dr. Willy Meyer said he always tried to first free the pack-
age of glands from all sides and then let the saphenous vein^
where it entered the femoral, form the pedicle. He had invaria-
bly been able to do so. In two instances he had been obliged
to leave a portion of the gland adherent to the vein, but no harm
had resulted. He had in two cases of glandular abscess tapped
with a large needle, and, after antiseptic irrigation of the cavity
injected a ten-per-cent. solution of iodoform in ether. A per'
feet cure without the necessity of an additional cutting opera,
tion had ensued in both instances.
Dr. F. W. Gwyer asked if Dr. McBurney had ever tried to
prevent buboes by local treatment of the chancroid. Success
had followed the use, at Chambers Street Hospital, of salicylic
acid spread thickly over the chancroid. In one case in which a
bubo had existed as a fluctuating tumor this treatment had re-
sulted in the disappearance of the tumor.
Dr. MoBuenky said, as to accidents during excision of these
glands, that none had occurred. Hasmorrbage from the vessels of
the region could be attended to or prevented by previous ligation.
Perforating Ulcer of the Bladder.— Dr. Wtbth reported
the case of a man, aged forty-three, of good family history, who
had always enjoyed robust health. For twelve years he had
had a hernia which he said had always been reducible. He had
had no injury. About twenty hours before his admission he
had passed a large amount of bloody urine, but had had no pain
in the bladder. Since then he had had constant pain in both
shoulders, behind. There had been no other symptoms. He
was admitted on November 17, 1891, at 1.30 p. m. He com-
plained of nothing but pain in the back of the right shoulder.
His temperature was 98°, his pulse good. He had a peculiar
facies (intestinal). The abdomen was lax and not painful on
pressure. He was given a warm bath, and passed a moderate
amount of urine containing no blood. He was ordered fluid
diet, also five grains of sodium benzoate every four hours. Dur-
ing the night he urinated twice, the amount passed being small.
The urine was dark in color, of neutral reaction, and contained
no albumin or sugar. At 8 a. m. on the 18th he complained of
pain in and fullness of the bladder. A soft-rubber catheter was
passed, withdrawing, first, clear urine and, finally, a little bloody
urine. He had a loose stool. At 11 a.m. he was examined
thoroughly. Rectal examination was negative. The abdomen
was apparently normal. There was a large left inguinal hernia,
doughy to the feel and not reducible. The stone-searcher passed
easily into the bladder. The walls of the bladder were ex-
amined in all directions. The interior felt as if it contained
about six ounces. The searching was done very carefully.
Ruga? were distinctly felt. No pain followed the examination.
The foot of the bed was elevated. At 0 p. m. four ounces of
bloody urine were withdrawn. Pulse, 104 and good; respira-
tion, 30 ; temperature, 99°. He had a stool, with no urine.
Ordered suppositories of extract of opium, half a grain, and ex-
tract of belladonna, a quarter of a grain, one every four hours.
At 8 p. m. he had a stool and vomited several times. At 4 a. m. on
the 19th he was catheterized, and eighteen ounces were drawn,
the first part clear, followed by a large amount of bloody urine.
Pulse, 108; respiration, 30; temperature, 98°. The bladder was
washed out with hot Thiersch's solution, four ounces at a time,
three times. All the fluid seemed to return, and was bloody.
An ice-bag was applied over the bladder. At 8.30 a. m. he
vomited a green fluid. Pulse, 104; respiration, 30; tempera-
ture, 98°. His condition was about the same as on the day be-
fore. The abdomen was not distended. At 12 m. he was feel-
ing badly, vomiting. A high enema was given, and caused a
small movement. At 2 p. m. he was still vomiting a green fluid.
Pulse, 116; respiration, 33; temperature, 100°. Five drops of
Magendie's solution were given hypodermically. The abdomen
was tense and tympanitic, and the hernia was tense. At 6 p. m.
he had gradually grown worse. He had been stimulated freely
by the rectum and hypodermically. Morphine had had but lit-
tle effect, upon the vomiting. At 4 p. m. thirteen ounces of urine
were withdrawn with the catheter. x\t 9.15 p. m. he was an?es-
thetized with chloroform and kelotomy was performed. The
knuckle of intestine was found to be normal. The peritonaeum
was washed out with warm Thiersch's solution. The patient was
freely stimulated during the operation, and reacted fairly well,
but gradually collapsed during the night. He died early on the
morning of the 20th.
At the autopsy the intestines were found loosely adherent.
There was a small amount of bloody fluid in the abdominal
cavity. The kidneys were normal. There was an opening be-
tween the cavity of the bladder and the free peritoneal cavity
of about the size of half a dollar, with irregular, jagged edges.
The adjacent part of the wall of the bladder was dark-colored.
Injury of the Wrist. — Dr. Stimson showed a specimen
taken from a man who had fallen from an electric-light pole
May 21, 1892.]
PROCEEDINGS OF SOCIETIES.
583
two days before. The injury was to the left wrist. There was
dislocation together with an irregular form of fracture of the
scaphoid bone. The injury had been produced by excessive
dorsal flexion combined with some ulnar flexion. The semi-
lunar bone had remained attached to the radius, and the scaphoid
which joined it had been broken off by avulsion.
Appendicitis. — Dr. F. Kammerer showed a perforated ver-
miform appendix that lie had tied off on the third day of a peri-
typhlitic attack. The patient, a boy of thirteen, when seen,
had a very anxious expression and a temperature of 101°. The
respiration and pulse were accelerated, and the abdomen was
tympanitic, but the only symptom pointing to the affection on
the right side was increased tenderness in the iliac region. Aft-
er opening the peritoneal cavity by an incision along the ex-
ternal border of the rectus, the slightly adherent intestines were
separated and the appendix was discovered lying behind and to
the inner side of the caput coli. Around it there was a small col-
lection of pus. After its removal the wound cavity was packed
with iodoform gauze. The boy did well at first, although the
temperature never was normal. Then the abdomen began to
distend, occasional vomiting set in, and the patient died of sep-
tic poisoning on the seventh day. At the post-mortem no gen-
eral peritonitis was found, but immediately adjoining the wound
cavity, and separated from it by a thin wall of agglutinated gut
only, was another collection of pus, about half a cupful, secure-
ly shut off from the rest of the peritoneal cavity by inflamma-
tory adhesions. This, although lying in the true pelvis, had
escaped detection by rectal palpation. Reviewing the case, the
speaker thought this was one of those in which it was impossi-
ble to determine the course at the outset. He had assumed that
a beginning general peritonitis was present, and had operated
upon this indication, but the post-mortem examination had dem-
onstrated that this was not so. Considering the difficulty in
prognosticating perityphlic attacks, the speaker did not believe
that an absolute condemnation of exploratory puncture, as it
had lately been uttered, was entirely justifiable. If all surgeons
agreed that all cases of perityphlitis demanded surgical interfer-
ence, then, of course, exploratory puncture would be a useless
procedure. But this was not the case. As regarded the dan-
gers attending puncture, the speaker was convinced that practi-
cally they did not exist. In the last few years he had frequent-
ly resorted to it, and had never seen an untoward symptom fol-
low the use of the needle under the necessary precautions. The
presence of pus was an absolute indication for operative inter-
ference, of whatever character that interference might be in
the individual case. The speaker gave it as his conviction that
the greater part of the cases that ended fatally did so from an ex-
tension of a localized inflammatory process to the general peri-
toneal cavity. This accident, he argued, could almost always be
prevented by early operative interference. In conclusion, he
now thought that in most cases exploratory puncture could be
dispensed with, especially when the surgeon had determined to
operate whether he drew out pus or not. But, where a small,
deep-seated tumor was discovered in the iliac region during the
first week of an attack, with no general symptoms except
perhaps a rise of temperature, he confessed the withdrawal of
pus was occasionally for him the signal to operate. To do away
with all risk, the operation might follow puncture immediately.
Dr. MoBurney said that, while not able to state directly
from personal knowledge the dangers likely to accrue from the
use of the exploratory needle in these cases, he quite believed
that such dangers did exist and he objected to its use on theo-
retical grounds. A considerable number of cases called urgently
for operation, such as those in which the vermiform appendix
was already gangrenous and yet no pus existed. A great deal
of harm could be done in such cases if the operator did not suc-
ceed in finding pus after a number of punctures aud therefore
deferred the operation.
Meeting of December !), 1891.
The President, Dr. Arpad G. Gerster, in the Chair.
Deformity of the Leg relieved by Fracture and Wiring.
— Dr. R. F. Weir presented a boy of six years who had had,
three years previously, an extensive necrosis of the left tibia.
An operation for its removal some six months later had resulted
in a very loose false joint at the junction of the lower and mid-
dle thirds of the bone. This had caused the weight of the body
in walking to be borne by bending at the false joint on the outer
side of the foot and on the end of the fibula, which bone had
hence become much bowed outward. When the limb was thus
bent the shortening amounted to nearly three inches. The de-
formity was relieved by cutting away the false joint, which
separated the tibial surfaces nearly an inch, and, after fracturing
the fibula with a chisel, the broken ends of this latter bone were
forced between the ends of the tibia and secured there by wir-
ing. A good result had followed this procedure; the limb was
now straight and firm, with a shortening of but three quarters
of an inch.
Nephrectomy for Nephrydrosis. — Dr. Weir also showed a
patient, aged eleven, from whom he had removed a large multi-
ple cystic or hydrotic kidney in May last. The boy had noticed
for some six or seven mouths that the right side of his belly had
gradually increased in size, and on examination it had been only
with some difficulty that a flaccid tumor, apparently anterior to
the kidney, could be made out. This had yielded, on lumbar
aspiration, a clear fluid, free from urinary salts. An incision
was made into the tumor from the loin by Dr. Bull, who thus
ascertained it to be a nephrydrosis. No calculus was found, and,
jt might be stated, there had not at any time been a history of
calculous formation. The sac was stitched to the skin and
drained. The patient came under Dr. Weir's notice on May 1st.
The discharge was quite purulent and very free, and the pa-
tient's general condition was deteriorating. Injection of water
into the cavity showed it to be still very large, holding twenty-
four ounces of fluid. It was determined to withdraw, if possi-
ble, as much of the thinned walls of the kidney as might he
done, hoping that a certain portion of good kidney tissue would
show itself and be saved with the ureter, in accordance with
Tuffier's views of kidney regeneration. But, as the cyst walls
were separated and withdrawn, which was easily accomplished
by a T-shaped incision, it was seen to be a multiple distention
of the whole kidney, of which only small scattered portions of
the secreting tissues were left. The pedicle was a slight one
and easily secured, and the tumor was removed. The ureter
was seen to be occluded about an inch below the pelvis of the
kidney, probably from a congenital cause. No calculus was
found. Recovery was uninterrupted, but rendered tardy by the
persistence of a sinus, which was so often due to a retained silk
ligature. This had been the cause in this case. A curved probe
had recently withdrawn such a retained portion of silk. The
speaker had often found help in the extraction of such ligatures
by the ordinary crochet-needle.
Luxation of the Internal Meniscus.— Dr. L. A. Stimson
showed a patient who had suffered from recurrent pain in and
locking of the knee. The last attack had occurred about the
middle of October, after immunity for six months, and had been
caused by sudden outward rotation of the leg. The patient
was completely disabled when seen by the speaker, the day
after the last attack. There was inability to flex the knee
more than 10°. Any attempt to go beyond this angle would
give intense pain. On the inner side of the left knee could bo
584
PROCEEDINGS
OF SOCIETIES.
[N. Y. Mkd. Joue.,
felt a firm mass occupying the anterior and outer aspect of the
joint. The mass seemed to be cartilaginous, and gave the im-
pression of a displacement of the internal meniscus. On cut-
ting down, this was found to be the case. The detached ante-
rior half of the cartilage was removed by division in front of its
posterior attachment. The wound was closed and healing had
been prompt. He showed the case because it was rare that
active interference had been undertaken for such a condition.
Dr. Weir said that there not infrequently existed rare
troubles in the knee joint the nature of which could only be re-
vealed by exploratory incision.
Stimson said that in most of his cases an accurate diag-
nosis had been possible. One point was constant — namely, the
movement of the leg by which the attack was provoked ; it was
partial flexion of the knee combined with outward rotation of
the leg. Subluxation of the meniscus was now well recognized
as a surgical fact, and deserved to be classed and spoken of by
its appropriate title, to the exclusion of the term "internal de-
rangement of the knee joint."
Excision of the Elbow Joint.— Dr. F. Langk presented a
patient on whom he had performed excision of the elbow joint
seven weeks before. He presented the case to illustrate his
technique and after-treatment. Otherwise the case did not pre-
sent any extraordinary features. The process had gradually
developed within two years, and was tuberculous osteitis. The
speaker had made three incisions — one main incision on the
posterior aspect over the inner side of the olecranon as usuab
but, besides that, two lateral incisions over the epicondyles, and
downward, and this in order to get an easy access to those im-
portant points where the strong ligamentous and tendinous at-
tachments of the joint normally existed, which, according to a
proposition of Professor Veit's, of Greifswald, were left in con-
nection with a thin shell of bone, which was chiseled off the
cortical substance. The same was done on the attachment of
the triceps. The after-treatment was by loose tamponade of
the joint, and drainage through the wound over the internal
epicondyle, but at the end of the second week everything was
.allowed to close, no purulent secretion being then present.
About four or five weeks after the operation the patient got an
apparatus which he still used. It fulfilled the following indica-
tions: First, by its being suspended from the shoulder to lift the
forearm, so that its weight would not exert traction on the new
joint; second, to keep the elbow at a right angle by elastic
straps. The muscular action was done by the patient's holding
weights in his hand just heavy enough to pull the hand slowly
down. Against the force of this weight his flexor muscles had
to battle. Extension was practiced without a weight against
the action of the elastic straps. Third, to bring the bones at
the new elbow into such relation to each other that those of the
forearm were slightly pushed behind that of the arm. In this
way the physiological conditions of the elbow joint were imi-
tated. The splints were jointed with each other in such a way
that they would allow of a certain amount of slipping of the
forearm in an upward direction, and of their being pressed
against those of the arm through a lever action, the point of sup-
port being transferred to the points of attachment of the elastic
straps. The functional result was a very good one already.
Even without the apparatus the movements were already safe
and fairly strong. The patient could, in lateral elevation and
pronation, make extensive excursions in the elbow joint, There
would certainly not be a flail-joint as the result. There was a
distinct new formation of bone at the points where the soft
parts had been chiseled off. The patient's general condition
bad become excellent.
Excision of a Large Ulcer of the Stomach ; Adenoma. —
Dr. Lan<;e also presented a butcher, twenty-five years of age,
who bad begun to have pain in the region of his stomach about
two years before. The pain was mostly located in the middle,
sometimes more to the right or the left, and often radiating into
the back. It would mostly come on when the stomach was
empty, and was relieved by taking food, especially liquids, also
often by the recumbent posture. He had vomited only twice
during his illness and never discharged blood by the mouth or
with bis stools. He had been treated for various things — enlarge-
ment of the liver, gastric catarrh, rheumatic affection, neuralgia,
and finally supposed ulcer of the stomach. This last treatment
was maintained for several months, from the beginning of April
to the beginning of June of this year, but with no benefit at all.
In July the patient was examined under chloroform anaesthesia,
and a descended kidney was assumed as the probable cause of
the trouble by another surgeon. The speaker had seen him at
about the end of September. By palpation nothing certain could
be made out, and, the patient's suffering being very intense, pro-
batory laparotomy was proposed. Owing to the absence of
dilatation of the stomach or any symptoms pointing to the pres-
ence of an ulcer, the speaker had been inclined to assume the
gall-bladder as the seat of the trouble, especially since on deep
pressure that region had seemed to be painful. On the 26th of
October laparotomy was done. A longitudinal incision was
made over the gall-bladder. The latter was found in healthy
condition. Adhesions over the duodenum, which seemed to
compress it, were cut across. On passing the hand toward the
middle line, a hard disc could be felt on the anterior wall of the
stomach. A cross-incision to the middle line was made at a
right angle to the upper part of the existing opening. The mass,
which felt like a cancerous tumor, was pulled forward. The
omentum was tightly adherent. The hard disc and a good deal
of the apparently healthy neighborhood were excised. It meas-
ured from four to five inches in diameter, of which the ulcer it-
self occupied a central area about three inches in diameter. The
bottom of the central portion was formed by omentum and was
of about the size of a five-cent piece ; the wall of the stomach
seemed to be entirely gone. The edges of the ulcer were sharp
and abrupt. The stomach wall in the neighborhood was much
thickened, but microscopically did not appear like a carcinoma.
Several glands of the omentum were removed. The opening in
the stomach was enormous after the cicatricial traction of its
walls had ceased. At one point less than half of the circumfer-
ence remained, since here the operation had had to be extended
beyond the insertion of the omentum. To prevent narrowing
at this point the large wound was united partly in a longitudinal
direction on the upper edge, as well as on the lower. The main
line of suturing was from the left to the right, and the whole
line of suturing formed an irregular cross. The inner row of
sutures was done with iodoform catgut, the outer with silk
thread. On the points of crossing additional sutures were placed.
A loose iodoform-gauze packing was used over the lines of sut-
ure and at the point where the two abdominal sections met.
The operation lasted almost four hours. In spite of that, the
patient was in fairly good condition. He had lost considerable
blood from the wound in the stomach, where numerous vessels
had had to be tied, and several injections of wine and water were
given during and after the operation. There was continuous
vomiting during the first four days, with moderate elevation of
temperature. The patient was given enemata alone for about a
week, during the second week with small quantities taken by
the mouth. From the end of the third week all food was taken
through the mouth. The patient was kept in bed four weeks
and discharged two days later. His pain had not recurred since
the operation, and he was gaining strength rapidly. The micro-
scopical examination made it probable that the tumor was an
adenoma the center of which was ulcerated and digested, while
May 21, 1892.]
BOOK NOTICES.
585
the peripheral part showed luxuriant adenomatous formations
and much chronic inflammatory infiltration.
Fracture of the Base of the Skull ; Cerebral Haemor-
rhage ; Death. — Dr. Briddos reported the case of a man, fifty-
five years old, who had been admitted into the Presbyterian
Hospital on November 19th. Family history negative. While
under the influence of liquor, he had fallen from a stairway a
distance of about eifrht or ten feet, landing upon the hard pave-
ment and presumably striking on the left side of the head, from
the existence there of a slight abrasion and a small haematoma.
On his admission he was in a mild degree of alcoholic stupor,
combined with concussion. His temperature was 97°, his pulse
70, and his respiration 17. His face was flushed, and his pupils
were contracted but equal. From the left ear there was a slight
bloody discharge. Over the left parietal boss there «ras a small
abrasion of the skin with a contused area about two inches in
diameter, but no evidence of depression or fracture could be de-
tected. Physical examination of the thoracic and abdominal or-
gans revealed nothing pathological, except that the liver was
somewhat diminished in size. There was slight oedema of the ex-
tremities. There was no paralysis. The head was shaved, an
ice-cap was applied, and ten grains of calomel were adminis-
tered. During the night and the following day the patient was
very restless and at times delirious. Some slight nervous twitch-
ings on the left side of face were noticed, but no other facial
symptoms were observed. On account of the bloody discharge
from the left external auditory meatus, which ceased at the end
of thirty-six hours, the ear was carefully cleansed, dusted with
boric acid, and treated with the strictest antiseptic precautions.
On the third day the delirium still continued and the tempera-
ture rose to 102°, the pulse being 76, and the respiration 20.
On the following day (four days after the accident) his mental
condition became more sluggish and stupid, and only with diffi-
culty could he be aroused. Convulsive seizures were now first
noticed. There were spasmodic twitchings of the left side of
the face, and of the left arm and leg, and violent clonic muscu-
lar contractions of the right arm. The optic axes deviated de-
cidedly to the left. The pupils were dilated, but equal. The
pulse was slow, full, and bounding. During the interval be-
tween the convulsions there was paralysis of the left arm and
leg, and the patient lapsed into a semi-comatose condition. In
the next twenty-four hours there were sixteen seizures similar
to those described, each lasting about two minutes. On the fol-
lowing day the temperature fell to normal, the pulse to 60, and
the respiration to 16. The functions of the left arm and leg were
restored and the patient rested quietly. There were now noticed
some slight ecchymosis and bagginess over the mastoid process of
the left side. During the following week there were no further
convulsions, there was no rise of temperature, and the mental
condition became much improved. Examination of the urine
now showed seven per cent, of albumin and a few hyaline and
granular casts. On the morning of the 30th there was noticed
a marked inequality in the pupils, the right being the larger.
This condition lasted, however, only twelve hours. On Decem-
ber 3d, two weeks after his admission, the temperature rose to
101-5°, the pulse to 118, and the respiration to 28, and he rapidly
grew weaker and more stupid. The urine and fasces were passed
involuntarily. On the next day there was a rapid rise of tempera-
ture, until at 11 p. M. it had reached 106-5°, the pulse being
146 and the respiration 40. Death occurred two hours later.
At the autopsy a fracture was found extending from a point
about half an inch below and behind the left parietal eminence,
Ibrongh both plates of the skull, to the external auditory meatus.
Inside, it ran along the upper surface of the petrous bone, about
an eighth of an inch in front of the edge. The fracture lay
close in front of the merubrana tympani, but did not involve it.
There was evidence of there having been profuse haemorrhage
beneath the dura, all over the convexity of the right hemi-
sphere. The clots were in part intimately adherent to the dura.
The brain was otherwise normal. In the lungs there were
found a few old adhesions, some fibrous nodules on the surface,
much congestion, and abundant muco-pus in the bronchi. The
kidneys were somewhat congested, the cortex was slightly
opaque, and the capsule was adherent. The remaining abdomi-
nal organs and the heart were normal.
'$5ooh flotkes.
Practical Midwifery : A Hand-book of Treatment. By Edward
Reynolds, M. D., Fellow of the American Gynaecological So-
ciety, etc. With One Hundred and Twenty-one Illustrations.
New York : William Wood & Company, 1892. Pp. xiv to
421.
This book, though intended for the medical student, contains
many practical hints which might be of service not alone to the
"busy practitioner," for whom so much is nowadays done, but
to the every-day practitioner whose cases do not come so fre-
quently that his knowledge is at his fingers' ends. Although as
a rule the author steers a safe middle course, and hence is a safe
guide, there are not a few points which call for criticism : for
instance, the advice to make frequent examinations in the first
stage of labor, to ascertain the exact position of the head, and
in the second stage to ascertain the advance it is making. An-
other instance is the freedom with which injections of bichloride
of mercury (1 to 3,000 and 1 to 4,000) are recommended. We
are surprised to find that no mention is made of tamponing the
uterus with iodoform gauze in cases of severe post-partum haem-
orrhage. We think t hat, considering the importance of the mat-
ter, greater space might have been allotted to the subject of sep-
ticaemia. Apart from these criticisms, the book can be very
warmly recommended to the class for whom it was written.
Hospice de la Salpetriere. Clinique des maladips du systeme
nerveux. M. le Professeur Chakcot. Lecons du professeur,
memoires, notes et observations. Parus pendant les annees
1889-'90et 1890-'91, et publiessous la direction de Georges
Guinon, chef de clinique. Avec la collaboration de MM.
GlLLES DE LA ToURETTE, BLOCQ, HlJET, PaRMENTIER, SotJQUES,
Hallion, J. B. Charcot et Meige, anciens chef de clinique,
internes et interne provisoire de la clinique. Avec 47 figures
et 3 planches. Paris: Veuve Babe et cie., 1892. [Publica-
tions du Progres medical.'] Pp. iii-468. [Prix, 12 francs.]
This is the first volume of a collection of the lectures, ob-
servations, notes, and original researches made by Professor
Charcot and his pupils, and published in various journals be-
tween 1889 and 1891. The original publications are not always
accessible; and to those who are interested in neuropathology
this plan of reuniting scattered essays will be particularly con-
venient.
In the present volume are lectures on Morvan's disease, bys-
tero-traumatism, hysterical tremor, ophthalmoplegic migraine,
blue oedema in hysterical subjects, amyotrophic paralysis in the
popliteal region, external ophthalmoplegia, diabetic paralysis,
hysteria in the male, the gait in hemiplegics, cerebral syphilis,
aDd abortive types of sclerosis in patches, together with a con-
tribution to the study of hysterical yawning. Many of these
papers have been noticed in the Journal in the reports on the
progress of medicine and of neurology.
586
MISCELLANY.
[N. Y. Med. Jodk.,
The volume is an ipterestipg one, and will undoubtedly prove
to be of great convenience for reference.
BOOKS, ETC., RECEIVED.
A Text-book of the Practice of Medicine for the Use of Student? and
Practitioners. By R. C M. Page, M. D., Professor of General Medicine
and Diseases of the Chest in the New York Polyclinic ; Visiting Physi-
cian to Randall's Island Hospital, etc. New York : William Wood &
Company, 1892. Pp. x to 568.
Text-book of the Eruptive and Continued Fevers. By John William
Moore, B. A., M. D., M. Ch., Univ. Dubl., Physician to the Meath Hospi-
tal, Dublin, etc. William Wood & Company, 1892. Pp. xxv to 535.
Maladies des voies urinaires : uretre — vessie. Exploration, traite-
ments d'urgence. Par P. Bazy, chirurgien des hopitaux de Paris.
Paris: G. Masson, 1892. Pp. 7 to 187. [Encyclopedic scientifique des
aide-mimoire.]
Technique bacteriologique. Par le Dr. B. Wurtz, chef du labora-
toire de pathologie experimental ;\ la Faculte de medecine de Paris.
Paris : G. Masson, 1892. Pp. 9 to 192. [Eneyclopedie scientifique des
aide-memoire.]
Diseases of the Nervous System. By J. A. Ormerod, M. D., etc.,
Medical Registrar and Demonstrator of Morbid Anatomy at St. Bar-
tholomew's Hospital, etc. With Numerous Illustrations. Philadelphia :
P. Blakiston, Son, & Co., 1892. Pp. xiv-13 to 343.
On the Choice of Operation for Removal of Stone from the Bladder.
By L. Bolton Bangs, M. D. [Reprinted from the Ann ah of Surgery.]
A Peculiar Accident during Litholapaxy. By L. Bolton Bangs, M. D.
[Reprinted from the Maryland Medical Juama/.]
Four Cases of Orbital Traumatism resulting in Immediate Monocu-
lar Blindness through Fracture into the Foramen Optieum. In One of
these Cases the Blow was over the Left Orbit, causing blinding of the
Right Eye. By Peter Gallon, M. D., New York. [Reprinted f rom the
Journal of the American Medical Association.]
The Science and Art of Midwifery. By William Thompson Lusk,
M. D., Professor of Obstetrics and the Diseases of Women and Chil-
dren in the Bellevue Hospital Medical College, Consulting Physician to
the Maternity Hospital and to the Foundling Asylum, etc. New Edi-
tion, revised and enlarged, with Numerous Illustrations. New York :
D. Appleton & Co., 1892. Pp. xviii to 761.
The Electro-therapeutics of Gynaecology. By A. H. Goelet, M. D.,
Fellow of the New York Academy of Medicine and of the New York
Obstetrical Society, etc. Part I and Part II. With Illustrations. De-
troit: George S. Davis, 1892. [The Physicians' Leisure Library.]
History of the College of Physicians and Surgeons in the City of
New York ; Medical Department of Columbia College. By John C.
Dalton, M. D., President, and Professor Emeritus of Physiology. Pub-
lished by order of the College, 1888.
Trattato d'igiene pubblica. Del Dottor Carlo Ruata, Professore dell'
Universita di Perugia. Vol. I (parte generale). Castello: S. Lapi,
1892. Pp. x to 271.
De 1'inHuence du courant continu sur les microbes, et particuliere-
ment sur la bacteridie. charbonneuse. Par MM. Apostoli et Laguer-
riere. [Extrait du Repertoire de police sanifaire, veterinaire et a"" hygiene
publiquei]
The Fundamental Principles of Anatomical Nomenclature. By Burt
G. Wilder, M. D., Ithaca, N. Y. [Reprinted from the Medical News.]
Myelitis in a Case of Incipient Spinal Sclerosis. By J. T. Eskridge,
M. D., Denver, Col. [Reprinted from the International Medical Maga-
zine.]
Double Pyosalpinx ; Ovarian Abscess ; Curettement during Acute
Stage of Purulent Inflammation ; Subsequent Laparotomy ; Recovery.
By Florian Krug, M. D. [Reprinted from the Transactions of the New
York Obstetrical Society.]
The Treatment of Posterior Displacement of the Uterus with the
Utero-vaginal Ligature. By H. J. Boldt, M. D. [Reprinted from the
Medical Nems.]
Contribution to the Literature concerning the Normal Mucous Mem-
brane of the Uterus. By II. J. Boldt, M. I). [Reprinted from the An-
wds of Gynaecology and Padiatry.]
Suppurative Oophoritis. By H. 3. Boldt, M. D., New York. [Re-
printed f rom the New York Journal of Gynaecology and Obstetrics.]
Phthisis Bulbi and Artificial Eyes. By William Oliver Moore,
M. I). [Reprinted from International Clinics.]
Studies upon Injuries of the Kidney, Nephrolithotomy, and Nephror-
rhaphy. By Aug. Schraclmer, M. D. [Reprinted from the Annals of
Surgery.]
Eleventh Annual Report of the State Board of Health of Illinois.
Being for the Year ending December 31, 1888. With an Appendix
containing the Official Register of Physicians and Midwives, 1892.
Presbyterian Hospital in the City of New York. Twenty-third
Annual Report, 1891.
Thirty-first Annual Report of the Cincinnati Hospital to the Mayor
of Cincinnati, for the Year ending December 31, 1891.
Bl i s c 1 1 hi n n .
The Association of American Physicians will hold its seventh an-
nual meeting in the Army Medical Museum and Library Building,
Washington, on Tuesday, Wednesday, and Thursday, May 24th, 25th,
and 20th, under the presidency of Dr. Henry M. Lyman, of Chicago.
Besides the president's address, the programme gives the following
titles: The Cold-water Treatment of Typhoid Fever, by Dr. G. Wilkius,
of Montreal ; The Treatment of Follicular Tonsillitis, by Dr. G. M. Gar-
land, of Boston ; A Collective Investigation in Regard to the Value of
Quinine in Malarial Haematuria or Malarial Hemoglobinuria, by Dr. H.
A. Hare, of Philadelphia ; Alcoholism, by Dr. T. S. Latimer, of Balti-
more ; Practical Results of Bacteriological Researches, by Dr. G. M.
Sternberg, of the navy ; The Treatment of Experimental Tuberculosis
by Koch's Tuberculin, Hunter's Modifications, and other Products of the
Tubercle Bacilli, by Dr. E. L. Trudeau, of Saranac Lake, N. Y. ; Report
of a Case of Glanders, with Results of Bacteriological Study, by Dr.
William Pepper, of Philadelphia ; The Bacteriological Study of Drinking
Water, by Dr. V. C. Vaughan, of Ann Arbor, Mich. ; The Morbid Anatomy
of Leprosy, by Dr. Heneage Gibbes, of Ann Arbor, Mich. ; Discussion on
Dysentery (^Etiology and Pathology, by Dr. W. T. Councilman, of Balti-
more ; Symptomatology, Complications, and Treatment, by Dr. A. B. Ball,
of New York) ; The Treatment of Acute Dysentery by Antiseptic Colon
and Rectal Irrigation, by Dr. W. W. Johnston, of Washington ; A Con-
tribution to the Study of Hepatic Abscess, by Dr. W. C. Dabney, of Vir-
ginia ; Pulsating Pleural Effusions, by Dr. James C. Wilson, of Phila-
delphia; A Case presenting the Symptoms of Landry's Paralysis, with
Recovery, by Dr. F. T. Miles, of Baltimore ; A Case showing Symptoms
of Landry's Paralysis — Recovery, by Dr. A. McPhedran, of Toronto,
Canada ; The Areas of Anaesthesia in Spinal-cord Lesions as a Guide to
Localization, by Dr. M. A. Starr, of New York ; A Study of the Seasonal
Relations of Chorea and Rheumatism for a Period of Fifteen Years, by
Dr. Morris J. Lewis, of Philadelphia; The Significance of Intermission
in Functional Nervous Diseases, by Dr. W. H. Thomson, of New York ;
Misconceptions and Misnomers revealed by Modern Gastric Research,
by Dr. Charles G. Stockton, of Buffalo ; The Production of Tubular
Breathing in Consolidation and other Conditions of the Lungs, by Dr.
Charles Gary, of Buffalo ; The Different Forms of Cardiac Pain, by Dr.
Samuel G. Chew, of Baltimore ; The Late Systolic Murmur, by Dr. J. P.
Crozer (iriffitb, of Philadelphia ; Tube Casts and their Diagnostic Value,
by Dr. I. N. Danforth, of Chicago ; Studies in Hypnotism, by Dr. B. F.
Westbrook, of Brooklyn ; and Influenza and Some of its Present Aspects,
by Dr. Morris Longstreth, of Philadelphia.
Points in Uterine Therapeutics. — We are indebted to the Occid* ntal
Medical Times, of Sacramento, for proof-sheets of its excellent report
of the recent meeting of the Medical Society of the State of California,
Among the proceedings we find an interesting communication on The
Septic Origin and Antiseptic Treatment of Chronic Endometritis, by Dr.
W. A. Briggs, of Sacramento, the chairman of the committee on gynae-
cology, in the course of which he says: In my earlier gynaecological
May 21, 1892.]
MISCELLANY.
587
work, tincture of iodine was quite in vogue and gave me many a mau-
vais quart cTheure in my office. Repeated experiences with uterine colic
diminished my zeal as well as that of my patients for this form of treat-
ment The monotonous futility of the applicator, however, drove me to
the resumption of injections, with the previous result. Notwithstanding
this unpleasant and unsatisfactory experience, I have latterly resumed
intra-uterine injections, although in somewhat different form, with dif-
ferent purposes, and invested with greater precautions. I use them
now as but one element of a systematic and consistent whole — the anti-
septic treatment; and, I feel sure, with better results, immediate as well
as remote.
After considerable experimentation, I have found that camphor-
creasote is an excellent solvent for iodine, and, over alcohol, possesses
the following advantages : (1) It does not coagulate albumin. (2) Being
thick and oily and having no affinity for water, it does not come in
such rapid contact with the mucous surface, and hence is not so likely
to produce severe pain. (3) It dissolves by far the largest ratio of
iodine of any liquid with which I am acquainted — roughly estimated,
about twenty-five or thirty per cent, by weight — and hence can be used
in a correspondingly smaller quantity, and with marked immunity from
uterine colic. Occasionally, it must be confessed, it will provoke con-
siderable pain and even colic, but I believe much less frequently than
tincture of iodine, and, if properly used, very rarely.
The formula is as follows:
3 Camphoric gm. 16;
Creasoti fagi silvat c. c. 6.
M. solve et adde
Iodinii resub gm. 7.
If the orifice is not patulous enough to permit the ready outflow of
the injection it should be sufficiently dilated by Hegar's bougies. For
these injections I take a deep urethral syringe, with small terminal and
lateral perforations, wrap the last three inches of the nozzle with a thin
layer of absorbent cotton, dip it in the iodized camphor-creasote, pass
it quickly through the cervix to the fundus, and, expressing two or three
minims of the solution at a time, spread it thoroughly over the entire
mucosa. During this process careful watch should be kept to see if
the injection escapes freely, and, if not, the cause should be ascertained
and removed before proceeding further. Injections should be limited
to ten or fifteen minims, and repeated every second or third day, and,
as improvement manifests itself, every fifth or seventh day.
Having made the injection, we are now prepared for cataphoresis,
which is done by introducing into the uterus a platinum electrode,
whose active surface corresponds in length with the uterine cavity and
constitutes the positive pole of the utero-abdominal current, varying
from five to twenty milliamperes. The electrode is covered with ab-
sorbent cotton, saturated with iodized camphor-creasote, and made to
sweep the mucosa in its entire extent, not neglecting the cornua. The
sitting lasts from five to ten minutes and is repeated with each injection.
If the ease be a hasmorrhagic one of recent origin, the current is raised
to thirty, forty, or even fifty milliamperes, and the application repeated
if necessary weekly during one or two intermenstrual periods. The
uterine mucosa is capable of active absorption, and under the influence
of electricity we may introduce considerable quantities of iodine or other
remedy into the general circulation. This fact may be of importance
in uterine cataphoresis. After treatment, patients will often complain
of a metallic taste before leaving the office, and sometimes before leav-
ing the gynaecological chair.
In the algesic form of endometritis the positive pole produces seda-
tive effects that render it doubly valuable. Pain will be often marked-
ly relieved by three or four applications. Whenever the uterine cavity
is enlarged and the uterine tissue flabby, it will be advantageous to com-
bine the faradaic current with the galvanic, which is easily done by
means of double cords terminating in single electrodes, to continue it for
ten minutes, and repeat it every second day. This treatment is of
marked benefit, not only in the relief of pain, but also in the promotion
of uterine circulation and the absorption of inflammatory exudates.
In confirmed hiemorrhagic and hypertrophic endometritis it is diffi-
cult, if not impossible, to restore the diseased mucosa to its normal con-
dition ; nothing less than its destruction will produce a satisfactory re-
sult. For this purpose we have several means at command — chemical
cauterization, positive galvano-chemical cauterization, and curettage.
Nitric acid and chloride of zinc are undoubtedly efficient, but it is im-
possible to limit their action to the diseased structures, and so often do
they entail cicatrices, stenosis, and sterility that their use is altogether
indefensible. The same objections perhaps, although in a far inferior
degree, apply to galvano-chemical cauterization. But in recent cases,
or in inveterate ones, in which the patient will not consent to its use,
we have in positive galvano-chemical cauterization a sovereign remedy,
which, if used by the antiseptic method, is altogether free from danger.
By the cataphoric action of the positive pole the eschar becomes asep-
tic from absorption of iodine, and, in my experience, breaks down and
passes away without the slightest untoward result. Besides, the acids
generated at the positive pole are themselves more or less antiseptic
and assist in the general effect. For the purpose of a cauterant, the
current should vary from thirty to sixty milliamperes, and be main-
tained from five to eight minutes in weekly sittings. With the large
currents recommended by Apostoli I have had no experience in endo-
metritis, but I must confess to a prejudice against them, which must be
overcome, if overcome at all, by positive and indisputable evidence of
their freedom from untoward secondary effects.
Curettage, however, I prefer. My own experience leads me to con-
cur in the opinion that, properly done in properly selected cases, it is
one of the safest and not the least efficient of surgical procedures. In
hemorrhagic and hypertrophic endometritis the uterine mucosa is soft
and pulpy, and, moreover, it is an essential feature of curettage that it
leaves the terminal culs-desac of the mucous glands as a basis for the
regeneration of the membrane. The sharp curette of Sims, therefore,
and the cutting spoon of Simon, are out of place in this condition, and
I habitually employ the irrigating curette with an edge, as Pozzi says,
like that of an unfiled knife-blade. The irrigating current should be
turned on from a reservoir with a head not exceeding eighteen or twenty
inches. A bulb syringe should never be used, for it is difficult accu-
rately to estimate the force exerted on the bulb, and the intra uterine
pressure is liable to be raised to a dangerous degree. The curettage
should be systematic and thorough, especially in the neighborhood of
the tubal orifices. The irrigation should continue until the debris has
been completely removed and the fluid returns nearly or quite colorless.
The curette should then be withdrawn, and ten or fifteen minims of
iodized camphor-creasote should be introduced into the uterus by the
syringe-applicator and spread over the entire denuded surface.
Drainage is the next, and an important element of the antiseptic
treatment. In a large majority of the serious and annoying cases of
endometritis coming under my observation the uterus has been either
retroverted or retroflexed, or both retroverted and retroflexed. These
backward displacements are probably partly cause and partly conse-
quence of the inveteracy of the inflammatory condition. In the first
place, they prevent drainage, especially in the recumbent position. The
secretions stagnate, microbes multiply and maintain a constant irritation
of the endometrium. In the second place, they hinder the uterine cir-
culation, produce stasis and malnutrition, and thus furnish conditions
extremely favorable to the development and maintenance of inflamma-
tion. Such displacements, therefore, if possible, should be corrected
early in the course of treatment, and reposition, if necessary, be main-
tained by antiseptic cotton or lamb's-wool pessary. Artificial drainage,
I believe, is frequently advantageous and occasionally necessary. Iodized
candle-wicking, which is prepared by immersing the wicking in tincture
of iodine and drying it without heat, seems to me to answer a better
purpose than iodoform gauze. It should be introduced well within the
uterine cavity and be supported by an antiseptic tampon.
The uterine treatment, whether of injection and cataphoresis or of
curettage, having been completed for the day, we reach the question of
vaginal dressing, which, while always antiseptic, will be determined in a
measure by our views of the necessity or advantage of local depletion
As nearly every patient suffering with chronic endometritis becomes
more or less anaemic, blood waste in every form, even the menstrual
flow, should be restricted rather than promoted. For this reason, and
because I rarely witnessed any improvement even in the local condition
from the application of cither the natural or the artificial leech, I long
ago altogether discarded local bloodletting. But glycerin, by its high
specific gravity and affinity for water, as well as various hygroscopic
588
MISCELLANY.
[N. Y. Med. Jotjii.
powders, produce a free exosmosis from the engorged vessels, and thus
effectually deplete them without impoverishing the blood. They also
serve another useful purpose : By distending the vagina and inviting
the effusion of considerable quantities of liquid, secretions and microbes,
if unfortunately they escape all our previous precautions, are rapidly
carried out of the body. Tampons of glycerole of tannin possess other
advantages — they leave an astringent after-effect, which, in accordance
with the law of diffusion of liquids, extends well into the cervical canal
and probably into the uterine cavity itself ; they support the uterus in
case of displacement, and thus promote drainage, the uterine circula-
tion, and the absorption of inflammatory exudates. The vaginal dress-
ing, therefore, by promoting antisepsis, drainage, the uterine circulation,
and the depletion, with subsequent contraction of the engorged uterine
vessels, is an indispensable element of the antiseptic treatment.
Should the support of a tampon be unnecessary, and the astringent
effect of the tannin undesirable, or should there be vaginal leucorrhoea,
dry packing with boric acid and sulphur (9 to 1) will be an excellent
substitute. This dressing, whether of liquid or of powder, will produce
considerable discharge from the vagina. A napkin, therefore, is neces-
sary, for the purpose of cleanliness as well as to furnish the final element
of the antiseptic treatment. It should be made of antiseptic gauze,
worn constantly, and changed twice daily, after the vaginal injections.
An Act to Kegulate the Practice of Midwifery in the State of New
Jersey was approved on March 28th. The text is as follows :
1. Be it enacted by the Senate and General Assembly of the State
of New Jersey, That every person practicing midwifery in any of its
branches shall possess a certificate from the State Board of Medical Ex-
aminers as hereinafter provided.
2. And be it enacted, That every'person now practicing midwifery
in cities of the first and second classes in this^State shall, within thirty
days after the passing of this act, personally present to the State board
of medical examiners an affidavit setting|forth the name, nationality,
age, authority, location, and length of practice, together with a certifi-
cate of good moral character from some registered physician, resident
of the same district ; whereupon the board, on receipt of a fee of one
dollar, shall issue a certificate, signedjby its president and secretary and
bearing the seal of said board, entitling the person named therein to
practice midwifery in this State.
3. And be it enacted, That every person hereafter beginning the
practice of midwifery in this State shall appear before the State board
of medical examiners and submit to such examinations in midwifery as
the board shall require, and if such examination is satisfactory to the
examiners, the said board shall, upon the receipt of a fee of five dol-
lars, issue a certificate the same as provided in section two of this act.
4. And be it enacted, That the person so receiving said certificate
shall file the same or a true copy thereof with the clerk of the county
in which she resides, and said clerk shall file said certificate or a copy
thereof, and enter a memorandum thereof, giving the date of said cer-
tificate and the name of the person to whom the same is issued, and
the date of said filing, in a book to be provided and kept for that pur-
pose ; and for which registry the said county clerk shall be entitled to
demand and receive from each person registering the sum of twenty-five
cents.
5. And be it enacted, That the State board of medical examiners
are hereby authorized and empowered to execute the provisions of this
act, and shall hold examinations of candidates for certificates in mid-
wifery at such times and places as may be deemed expedient.
6. And be it enacted, That the State board of medical examiners
may refuse licenses to persons guilty of unprofessional or dishonorable
conduct, and may revoke licenses for like cause, or for neglect to make
proper returns to the various health officers, of births, and the cases of
puerperal and other contagious diseases occurring in their practice.
7. And be it enacted, That any person shall be regarded as prac-
ticing midwifery within the meaning of this act who shall publicly pro-
fe.ss by advertisement, sign, card, or otherwise to be a midwife, or who
shall, for a fee, attend to women in childbirth ; but nothing in this act
shall be construed to prohibit gratuitous service in case of emergency,
nor to the legally qualified physicians or surgeons of this State.
8. And be it enacted, That any person practicing midwifery in this
State without first complying with the provisions of this act, shall lie
guilty of a misdemeanor and shall be punished by a fine of not less than
ten dollars nor more than fifty dollars, or by imprisonment in the county
jail for not less than ten nor more than thirty days, or both, in the dis-
cretion of the Court.
9. And be it enacted, That all acts or parts of acts inconsistent
herewith be and the same are hereby repealed, and that this act shall
take effect immediately.
The New York Academy of Medicine. — The special order for the
meeting of Thursday evening, the 19th inst, was a discussion on The
Causes and Treatment of Endometritis, opened by Dr. W. R. Prvor.
At the next meeting of the Section in Laryngology and Rhiuologv.
on Wednesday evening, the 25th inst., Dr. J. E. Newcomb will report a
case of Adenosarconia of the Fauces, Dr. J. W. Wright will present a
case of Carcinoma at the Base of the Tongue, and Dr. J. E. Nichols will
read a paper on Disease of the Frontal Sinus.
At the next meeting of the Section in Obstetrics and Gynaecology,
on Thursday evening, the 26th inst., Dr. C. A. von Ramdohr will read
a paper on The Treatment of Puerperal Fever, and Dr. F. Krug will
read A Report of Some Interesting Cases of Extra-uterine Pregnancy.
To Contributors and Correspondents. — The attention of all who purpose
favoring us with communications is respectfully called to the follow-
ing:
Authors of articles intended for publication under the head of " original
contributions " are respectfully informed that, in accepting such arti-
cles, we always do so with the understanding that the following condi-
tions are to be observed: (1) when a manuscript is sent to this jour-
nal, a similar manuscript or any abstract thereof must not be or
have been sent to any other periodical, unless we are specially notified
of the fact at the time the article is sent to us ; (2) accepted articles
are subject to the customary rules of editorial revision, and will be
published as promptly as our other engagements will admit of — we
can not engage to publish an article in any specified issue ; (3) any
conditions which an author wiihes complied with must be distinctly
stated in a communication accompanying the manuscript, and no
new conditions can be considered after the manuscript has been put
into the type-setters' hands. We are often constrained to decline
articles which, although tliey may be creditable to their authors, art
not suitable for publication in this journal, either because they are
too long, or are loaded with talmlar matter or prolix histories of
cases, or deal with subjects of little interest to the medical profession
at large. We can not enter into any correspondence concerning our
reasons for declining an article.
All letters, whether intended for publication or not, must contain the
writers name and address, not necessarily for publication. No at-
lention will be paid to anonymous communications. Hereafter, cor-
respondents asking for information that we are capable of giving,
and that can properly be given in this journal, will be answered by
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respondent informing him under what number the answer to his note
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under the author's name are treated as strictly confidential. We can
not give advice to laymen as to particular cases or recommend indi.
vidual practitioners.
Secretaries of medical societies trill confer a favor by keeping !« in-
formed of the dates of their societies' regular meetings. Brief notifi-
cations of matters that are expected to come up at particular meet-
ings will be inserted ichen they are received in lime.
Newspapers and other publications containing matter which the person
sending them desires to bring to our notice should be marked. Mem-
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All communications intended for the editor should be addressed to him
in care of the publishers.
AU communications relating to the business of the journal should be ad-
dressed to the publishers.
THE NEW YORK MEDICAL JOURNAL, May 28, 1892.
' Original (Communications.
SOME SURGERY OF
THE LIVER AND GALL-BLADDER.*
By J. C. REEVE, Ju., M. I).,
DAYTON, OUIO.
These organs dispute only with the intrameningeal and
intestinal tissues the claim of being the latest regions to be
invaded by our art. Their surgery, though differing in no
general way from other surgery, or rather in no particular
way from other abdominal surgery, requires, nevertheless,
in its more difficult features, a greater command of technique
than that of any other part of the body. The making of
delicate seams in the ducts, lying as they do deep in the
abdomen and at times almost out of reach, must often be
difficult beyond accomplishment. But the object of this
paper being the practical presentation of some points, and
its form but the hasty collection of actual material, we will
pass at once to the consideration of some cases.
Abscess of the Liver. — Fullness in the hypochondrium
and difficulty in lying on the right side, pain in the right
shoulder, dyspepsia, nausea, vomiting, rigors, fever, sweat-
ing, irritability of the nervous system, cough, local enlarge-
ment, dysentery, jaundice rarely — these make up the com-
plete picture of this trouble ; but that it is often announced
by much fewer symptoms is not necessary to state — in fact,
can exist without manifestation until another cause brings
the subject to the dead-room. In order of frequency, these
may be placed in this sequence : First, digestive disturb-
ances ; second, pain ; third, fever ; while jaundice is so rare
as to weigh rather against than for abscess. The fever,
with its chills, sweats, and intermissions, so like that from
malarial cause, is often mistaken for it. The following
will fairly represent the subject in hand :
Case I. — A strong German, fifty-eight years of age, and a
stone-cutter, had been complaining of pain in the abdomen and
slight diarrhoea for several months before entering the hospital.
His temperature was then fluctuating between 99° and 101°,
with the higher figure usually in the evening. The pain was
in the liver region, but whether extending to the shoulder we
are unable, after several years, to recollect. The diarrhoea was
considerable and not lessened by the usual remedies ; the stools
were thin, but not lacking color. It was not long after his admis-
sion until increase in liver dullness appeared, and the diagnosis of
abscess was made and an operation suggested ; but, as this diag-
nosis was not supported at a consultation, the case was contin-
ued tentatively. At the beginning of the fifth week of observa-
tion the temperature was from 101° to 103°, and all the man's
symptoms were worse. Besides, he had chills, vomiting, much
sweating, and, on the thirty-ninth day of this record, cough-
ing began. On the next day a very long coughing spell. On
the forty-fourth day it was plainly demonstrated at a consulta-
tion held that day that the upper line of liver dullness was rap-
idly rising. (That it was the liver and not pleuritic dullness
was told by the method of percussing the highest line of dull-
ness during expiration and then seeing that it disappeared upon
* Being parts of a paper read, with specimens, temperature charts,
and diagrams, oeiore the Montgomery County, Ohio, Medical Society.
full inspiration.) A few days later widespread pain, and on the
fiftieth day a circumscribed flush on the most prominent part ot
the distention that occupied the upper right part of the abdo-
men— in fact, all the conditions which Greig Smith calls " signs
of the abscess bursting of its own accord," and he adds : " Red-
ness, tenderness, and some swelling at any point over a hepatic
tumor, which is probably suppurating, may be taken as an indi-
cation that the matter is forcing its way to the surface. In such
cases there will be adhesions between the liver and the overly-
ing peritonaeum, and an opening may be made with safety. It
need scarcely be said that such a tendency to point is neither
to be waited for nor encouraged, . . . and before the signs of
pointing appear the patient will have been reduced to a very
low ebb." But it was not until two days later, four weeks after
the diagnosis was first made, that agreement with a consultant
was reached as to the need of evacuation, and aspiration was
the means fixed upon.
And here we may consider the several surgical methods
of dealing with abscess of the liver, for medical there are
none.
First, aspiration. It has the disadvantage of uncertain-
ty in finding a small collection of matter, and, in common
with its use in all abscesses, the impossibility of removing
all material. The later exclusion of air is almost sure to
fail, and hence the conditions for hectic are perfect — the
accession of the atmosphere to retained pus. Further, the
danger of leakage into the peritoneal cavity is great.-
Puncture by trocar has the same disadvantages, except ad-
hesions are known to exist, when danger of leakage is ab-
sent. Opening by caustics is bungling and inhuman, and
by thermo-cautery of application only in late stages. Open-
ing by " direct incision " would be attempted only when
pointing, as above described, existed, and " by incision in
two stages " only when ample time was to be had. The latter
operation consists in incising the parietes to the peritonaeum,
packing the wound in order to excite enough inflammation
to cause the viscus to adhere to the parietal fold, and, a few
days later, incising the liver through the peritonaeum. Final-
ly, there is hepatotomy — that is, by means of laparotomy.
Here we have the advantage of sight, possibly, in detecting
the position of the abscess, in detecting other abscesses, and
in avoiding omentum and bowel, which might have suffered
in the making of puncture or adhesions, and the advantage
of protecting the peritoneal cavity. Though some choice of
thsee means lies certainly in the demands of the case, it is
to the last we must look for best results, and it has already
given us these in the hands of such operators as Tait and
others. The incision is over the most prominent part of
the tumor, four or five inches long. If in exploration suit-
able adhesions are found to exist, the collection is punct-
ured through the parietes by a large trocar. If not, the
abscess is incised, and its edges stitched to the parietes..
This is much easier if the case is from a suppurating hy-
datid cyst, because there is then a distinct limiting mem-
brane. Several operators have presented in late numbers
of the British Medical Journal their methods of aspira-
tion, and with most siphon drainage to the floor is adopted.
With this and several other details this operation has not
all of the above disadvantages, and that it is efficient the
results of these gentlemen show.
590
REEVE: SOME SURGERY OF THE LIVER AND GALL-BLADDER. [N. Y. Mkd. Joub.,
But to return to our patient. His tumor was aspirated at
the point of most prominence in the right hypochondrium, and
several quarts of grumous pus obtained — gruraous from shreds
of liver tissue. The tube was not withdrawn for four days,
during which time large quantities of pus continued to flow,
with no improvement, however, in his condition, except that
the pain had disappeared. When the needle was withdrawn,
the matter continued to discharge four days longer, when the
patient died from exhaustion. To-day we would refuse to treat
this case except by free incision, and in its earlier stages except
by laparotomy.
Tumors of the Liver. — From its extreme vascularity and
friability, no tissue in the body has the surgeon attacked
with more trepidation than that of the liver. Yet every
week brings new accounts of neoplasms removed from its
embrace, and even portions of the organ excised. The
frightfully abundant haemorrhage from its cut surface can,
however, be checked — usually by the cautery, but often,
in meeting the larger vessels, the ligature itself must be ap-
plied, a procedure which certainly must be difficult and un-
satisfactory from the above features of the liver substance.
Even lesser means will suffice, as will be seen by an instance
below.
Cholelithiasis. — Though usually very easy of diagnosis,
the presence of gall-stones is at times so unsuspected that
we tarry only long enough on diagnosis to present two cases
in point. They were mentioned to the society last winter,
but we venture to report them fuller. At that meeting a
member read a paper on gall-stone colic and the favorable
results he had had from phosphate of sodium, a remedy
which, together with olive oil, we do not reject. But the re-
sults were so favorable that we ventured to doubt to some
extent the diagnoses.
Case II. — Annie E., aged thirty-nine, had been incapaci-
tated for work by pain for five years. The trouble began sud-
denly with abdominal pain and the appearance of a tumor in
the right lumbar region of the abdomen, which tumor was de-
scribed as being hooked or J-shaped, about an inch in thick-
ness. There were various remissions, and upon one exacerba-
tion a quantity of pus was said to have been passed by the rec-
tum. The pain, though varying, was continuous and never
agonizing. When first seen, the tumor was cylindrical to the
touch, extending from the right inguinal region to beneath the
ribs, movable, and feeling like a tense cyst. There was con-
siderable stagnation of gas and, faeces in the larger bowel, but
the stools were of natural color. A distended appendix or colon
was diagnosticated, and, from what she said, her attendant in a
neighboring city had thought the same, and yet upon operation
a distended gall-bladder was found.
A man, dying at sixty, had during the last ten years of his
life paroxysms of pain over the region of the liver, but no other
symptoms aided at finding a cause, and palpation was prevented
by bis fat. Still, for years he and his attendant took it for
granted that gall-stones were the sole trouble, and operations
were talked of. An attack of sickness brought to the patient
thin abdominal walls, when was revealed an unexpected tumor.
It was very movable, often below and to the left of the umbili-
cus, and from there moved to every part of the upper right
quarter of the abdomen. In size, consistence, and form, as felt
through the parietes, it was very like a kidney, and what a per-
fect picture of floating kidney the case presented ! Occasional at-
tacks of hematuria or suppression of urine following paroxysms
of unusual pain, so strongly suggesting twisting of the pedicle,
the tumor movable, even to being elusive, in size and feel so de-
ceptive— these led us to attempt to replace the lump in the loin,
where it easily went, and when kept there by a binder seemed
to give the patient some ease. Nephrorrhaphy was presented,
but the patient in his exhausted state doubted his powers of
endurance, and after many months of most awful suffering he
succumbed. His last attendant was so kind as to let me make
the autopsy, and he has in his possession the tumor — this gall-
stone. It is pyriform, weighs two ounces and a half, is two
inches and three quarters in length, and six inches and a quarter
in its equatorial circumference. Two inches below it, in the
duct, this smaller stone, the size of a large cherry, was found.
Five facets make up the entire surface of the latter, one of
which is polished and fits the facet in the point of the larger
stone, and the two placed together make the pyriform shape of
the gall-bladder. They were plainly at one time in contact if
not in union. The sac, when found, was not much elongated,
the stone resting just below the edge of the liver. The stone
made a visible projection of the abdominal walls after death.
These two cases, it is trusted, will show how deceptive excep-
tional cases of cholelithiasis may be.
In cases like these which have resisted all remedies,
what is to be done ? Plainly, operate. The ideal opera-
tion is this : Open the abdomen, incise the bladder, re-
move the stones, suture the opening in the bladder and
drop it back, close the abdomen after it, leaving the patient
eventually in the full possession of his organs. This, of
course, can be done only when the cystic and common ducts
are perfectly patent ; otherwise the local back pressure of
the bile would destroy the delicate seam in the fundus of
the cyst. Circumstances have permitted this to be done
very seldom. Very often the stone, or some of the
stones, can not be found in spite of the most diligent
search. Then to close the bladder, presuming it could be
safely done, is simply to place the patient where he was
before beginning the operation. So it has been advised to
stitch the margins of the bladder to the margins of the
parietes, thus establishing a biliary fistula for the escape
of this calculus or of regurgitant bile, or for assisting the
onward movement of the stone by the probe. The follow-
ing case will illustrate :
Case III. Gholeeystotomy. — The patient, M., was a strong
man of forty-one, who for two years bad had occasional attacks
of what was called dyspepsia, accompanied by tenderness in
the right hypochondrium. These attacks increased in severity
till six months before the operation ; they assumed the char-
acter of biliary colic and occurred as often as every three or
four weeks. Gall-stones were never found, but the distended
gall-bladder was easily felt during the attacks and could not be
at other times. His condition was serious from excessive jaun-
dice, the persistent reflex vomiting, and the large amounts of
morphine necessarily given to lessen pain. Attacks were now
becoming so frequent that sometimes but four days intervened
between them, and the offers of an operation were about to be
accepted when a violent cystitis occurred, following a catheteri-
zation. The most terrible strangury, which nothing would
lessen, made still more morphine necessary, and these, with the
continued high temperature and loss of sleep, soon brought the
patient to a state of extreme emaciation and asthenia. He now
recognized the need of an operation to ward off a recurrence
of biliary obstruction, which might come on at any moment,
May 28, 18924 REEVE: SOME SURGERY OF THE LIVER AND GALL-BLADDER.
591
and appreciated also the probable insufficiency of his powers to
withstand either operation or attack. Under these critical
circumstances it was decided to defer operating as long as pos-
sible to give time for recuperation; but, in case obstruction
again occurred, to operate at once, as safer than to weather an-
other attack. There were but a few days to wait until colic
once more began, and accordingly, six hours late/, with a tem-
perature of 101-4°, the patient was placed on the table. The
incision, five inches long, was made parallel with the cartilages
of the ribs and three finger-breadths from them. The cyst was
but slightly distended, presenting an inch and a half below
the liver, which was somewhat enlarged. The former was
raised by two loops passed through it, and incised between
these for the length of an inch. Several ounces of clear mucus,
tinged straw-yellow by the bile and in places mottled-brown,
were evacuated, and with them a gall-stone the size of a mar-
rowfat pea. Though this bore facets, no other stones could
be found by the finger, either within or without the bladder,
nor by a probe; but as one was known (from the jaundice) to
be in the common duct at the time of beginning the operation,
it was decided to establish a fistula to allow of its possible es-
cape externally, and more because closing the sac securely
would, in the face of the back pressure, hardly be possible.
The opening in the latter was accordingly stitched by continu-
ous suture to the peritonaeum and transversalis fascia in the
outer end of the parietal incision, a large tube inserted, and the
rest of the incision closed. His temperature at once fell to
99-4°, and was not over that during his recovery. His colic,
however, continued three days and ended, not by the extrusion
of the stone, but by its entrance, as was to be supposed, into
the bowel.
This is of interest as showing that such concretions
are not advanced (through the duct) by fluid pressure
alone, for the bile was flowing freely externally, but possi-
bly by a peristalsis of the muscular coat of the duct. At
the end of the third day the most violent vomiting began,
induced, most likely, by the movement of the stone ; it
lasted all night, and before it was done consisted of gall,
thus showing that the common duct was once more free.
It did not stop until a very large evacuation from the bow-
els had been secured by a copious irrigation of castor oil
and soap. Alarming hiccough then began, and was stopped
in the same way after some hours. His emaciation now
increased until two weeks later he was all but a skeleton ;
this was to be attributed to his cystitis, which was, fortu-
nately, giving him less misery than before the operation. As
the disease subsided, he was taken with severe pains in the
lower limbs and joints in the nature of rheumatism, and
after a week of these, then with the appearance of three
mysterious, painful swellings in the axilla, on the scapula,
and on the shin respectively. What these were, in the face
of a normal temperature, no one could say. They slowly
enlarged, one to the size of the fist, approached suppura-
tion, and then declined. All these, it is unnecessary to
state, added much to the discouragement of both patient
and attendant, for the swelling in the axilla, together with
his emaciated condition, and then a badly inflamed bursa
over the third sacral spine, limited very much the position
in which he could lie. Next came an attack of subacute
bronchitis of a week's duration. Convalescence was, of
course, much prolonged by this fateful list of miseries, but
the fistula progressively diminished, and, in spite of the
copious discharge of bile, his weight reached, six weeks
after the operation, twenty pounds more than it usually had
been.
In case this stone, which was known to lie in the com-
mon duct, was found at the time of operating, what should
have been done with it ? First attempt to slide it back into
the open bladder by pressure on the outside of the duct by
the fingers ; failing in this, to slide it onward into the
duodenum, unless so large as later to hazard obstruction of
the bowels from its size. The probe can also be tried for
this purpose. If these are not successful, crushing the stone
by padded forceps on the outside of the duct must be at-
tempted, or the same thing by introducing needles into the
friable substance of the stone. These failing, the duct must
be incised and doubly sutured after removal of the obstruc-
tion ; or, if this is impossible or contra-indicated, and the
cystic duct and sac are still open, an anastomosis must be
made between the latter and some part of the bowel for the
diversion of the gall to its proper destination and the avoid-
ance of a fistula. Sometimes, when the stone lies near the
lower end of the duct, it can best be reached by an incision
in the duodenum. The technic of the last four procedures
will be neglected, as the intention is to write from personal
experience as much as possible
Case IV. Closure of Biliary Fistula. — The above patient*
M., was now up, and the fistula had contracted to the size of a
needle-hole, but all the bile ran out of it in spite of many appli-
cations and expedients in minor surgery, and the stools remained
perfectly white. It was feared the common duct bad closed by
some adhesive process following laceration by the last stone, or
through disuse, as Langenbuch suggests, and to determine this
the following test — an original one, it is believed — was made: A
warm saline solution was passed into the fistula under a " head "
of four or five feet. No current inward could be detected. The
trial was repeated with olive oil with no better results. How-
ever, there grew to be occasional hindrances to the external
secretion through granulations, and when these occurred the
fasces took on more color, thus proving to the patient's great
good fortune that there was an inward channel and that steps
could be taken to close the fistula permanently. Otherwise the
outcome would have been, to quote Langenbuch's words, "a
definite occlusion of the duct and a permanent fistula, two cir-
cumstances not promoting the comfort of the patient." But, in
spite of the harm to clothing which the leakage occasioned, an
operation was not considered until inflammation of the abdomi-
nal integument set in. Protectives and unguents had been care-
fully used, but still the inflammation grew until a large surface
was quite raw and the patient could only lie on his back in bed
with neither clothing nor covers on him. Thirteen weeks after
the first laparotomy the second was undertaken. The old in-
cision was opened an inch and a half just internal to the fistula,
the internal surface of the fistula and cyst curetted, four stout
silk ligatures drawn as tightly as possible around the elongated
fundus of the bladder, and the whole opening firmly closed.
The cyst walls were fouud so thick that sufficient constriction
could not be brought to bear upon them by means of the silk :
silver was not at hand, and the obstinate reappearance of the
fluid was hourly expected. Surely enough, on the third day a
drop of the clear mucus made its appearance, and two days
later the bile. This so discouraged the patient that he bravely
declared he would not leave his bed till he was well, and ac-
cordingly the hour was set for the third operation. Circum-
stances, however, caused him to change his mind, and he went
592
REEVE: SOME SURGERY OF THE LIVER AND GALL-BLADDER. [N. Y. Med. Jovh.,
walking on the street six days after the last abdominal section !
Only once again did bile appear, and the residual mucus of the
gall-bladder gradually diminished till seven weeks after, when it
disappeared, not, however, before two of the ligatures had been
extruded. Whether these ulcerated through the walls of the
bladder into the sinus or over its ends cemented in the parietes
can not be said, but their appearance greatly mystified the pa-
tient, who was something of a mechanic. Since then, during a
period of eij;ht months, he has been in perfect health, weighing
more than ever before and doing all his business.
Case II (Annie E., continued). — Cholecystotomy in two sit-
tings.* The patient would have nothing but an operation, so
in July, 1890, a vertical incision three inches and a half in
length was made just external to the right rectus and beginning
an inch above the middle of Poupart's ligament. Later this cut
was extended an inch upward. A distended gall-bladder was
discovered, glistening and pyriform, and extending to the lower
end of the incision. It was decided to stitch this to the parietes,
after the general rule with pancreatic cysts waiting for adhe-
sions, and at a second sitting to evacuate the organ. The walls of
the cyst appeared as tense and thin as a toy balloon — a sufficient
•objection, it seems, to the suggestion made to this society by a
member to produce always in gall-stone colic vigorous vomit-
ing. This condition made stitching through its serous coat diffi-
cult, but an oval upon the lower end of the tumor, an inch and
a half in length, was, by continuous suture of fine silk, attached
to the parietal fascias at the lower angle of the wound and the
remaining part of the incision closed. The open wound was
packed. No rise of temperature followed above what had pre-
vailed for a month previous — viz., 99"5°. The second operation
was undertaken on the morning of the sixth day. Without
auresthesia the cyst was incised after passing a securing loop,
and over a pint of clear serum resembling white of egg evacu-
ated. It may here be desirable to explain that the natural secre-
tion of the lining of the bladder is a clear mucus, and being here
unmixed with bile, showed that communication with the com-
mon duct had been long cut off. Upon exploring, an ovoid
stone an inch and a sixteenth in length was found resting
against the under side of the anterior border of the (enlarged
and locally inflamed) liver. Here a suppurative process had
begun, probably toward extrusion as an end. The calculus was
extracted after a little trouble by cutting in two by a penknife.
Large drainage-tubes were used for a week. The mucous
•discharge progressively lessened for three weeks, when the fist-
ula closed. Th is stone, of the "mulberry" variety, weighs one
hundred and five grains and measures two inches and five
eighths in its smallest circumference, is radial in structure, and
floats in water. In the light of the second sitting it is plain
that it would have been advantageous to have opened the cyst
at once, the plan generally followed, we find, by other opera-
tors.
Case V. Cholecystotomy for Second Stone. — Annie E. re-
mained well for a few months, during which time the fistula
occasionally opened and discharged a little clear mucus, and
upon these occasions she felt somewhat better, as other patients
similarly circumstanced have reported. But pain and tender-
ness returned, and at the end of five months she was again un-
able to do housework. Not only pain, but extreme tenderness,
extended in the form of a girdle around her left loin, from near
the middle line behind to the middle line in front, and the same
existed over the site of the operation. It will be remembered
that the gall-bladder was fastened within an inch of Poupart's
ligament; and could tension from retraction cause this ? Hardly
the pain in the left side, but neither would residual gall-stones
* Reported before in the Cincinnati Lancet Clinic
seem to do so. An examination under ether failed to explain.
When occasionally visited over a period of six months, she was
plainly seen to be declining, and eventually took to her bed.
Anxious to have anything done, she was offered a cholecystec-
tomy with uncertain prospects, when a probing of the fistula
revealed another stone, and her second operation was at once
undertaken, thirteen months after the [first. It was necessary
to open the abdomen in the line of cicatrix, but only to a limited
extent. Numerous adhesions were expected, but, in spite of the
utmost care and deliberation, the liver was incised to the extent
of an inch and a half by an inch. The hemorrhage was alarm-
ing even from this small cut, and the Paquelin was in use else-
where. But a packing of gauze dipped in a solution of chloride
of zinc, twenty grains to the ounce, effectually removed this in-
terruption. After opening the bladder enough to admit the
finger the stone had disappeared, and it required considerable
search, both within and without, to find it, and it is believed a
sacculated dilatation of the duct (not a rare condition in these
cases) concealed it both then and at the first operation. The
stone was of the same variety as the first, somewhat smaller but
weighing a little more. Cholecystectomy was now indicated to
prevent any more intruders, but, from the dense adhesions, this
was not attempted. In lieu of it, the following scheme was
adopted, apparently without a precedent, and how wisely re-
mains yet to be seen : In place of removing the viscus, why not
ligate its duct, thus cutting it off from taking any part in the
transference of bile ? This was not easy, working almost against
the vertebrae and including no other structures, but it was fin-
ished with two stout silk ligatures. A drainage-tube was placed
within the lips of the cut in the liver and surrounded by a little
gauze. The fragments of the fundus of the bladder were
gathered together and stitched in the wound, a silver wire being
placed between them and reaching to the outside to conduct
out the mucus which it was expected would still be secreted
from the mucous lining. The night of the operation showed a
temperature of 103°, but this was but one degree more than three
days before. This quickly fell, and seven days later tube and
stitches were removed, and on the twelfth day she abandoned
her bed. But her new-found ease was not to last. Pain and
tenderness, very much as already described, again appeared, and
again the question, from what cause ? This time, however, the
deep-lying and heavy ligatures might be suspected. After some
months of discouragement electricity was applied, in the hope
that the pain was neuralgic. The first application of the fine
coil rapidly interrupted gave much relief, and three weeks of
daily applications, made between the sacrum or flank and the
incision, so helped the patient that with occasional applications
she began again the whole work of a large house and has con-
tinued it till to-day — two mouths — with comparative vigor and
little pain. She still wears the silver wire, and still feels indis-
posed and uneasy when its removal allows the fistula to close.
Vivisection in Germany. — " The Education Committee of the Prus-
sian House of Representatives has lately had under consideration a pe-
tition from the 1 International and Hanoverian Association for the Sup-
pression of the Scientific Torture of Animals,' urging the absolute pro-
hibition of vivisection. Both the House of Representatives and the
Reichstag have already had the question before them, and the late Cul-
tus-Minister, Dr. von Gossler, imposed certain restrictions on scientific
investigators in respect of experiments on animals with the object of
preventing any abuse. The majority of the committee were of opinion
that science could not dispense with vivisection, and that abuses had
only been proved to have occurred in a few isolated instances. Such ex-
ceptional cases did not, however, in the opinion of the committee, justify
the total prohibition of vivisection. The House was therefore recom-
mended to pass to the order of the day." — British Medical Journal.
May 28, 1892.]
ELLIOT: DERMATITIS HERPETIFORMIS.
593
- SOME CASES OF THE
DERMATITIS HERPETIFORMIS OF DUHRING,
WITH REMARKS ON THEIR ETIOLOGY.
By GEORGE T. ELLIOT, M. D.,
ATTENDING DERMATOLOGIST TO THK DEMILT DISPENSARY AND
THE NEW YORK INFANT ASYLUM ;
ASSISTANT PHYSICIAN TO TUB NEW YORK SKIN AND CANCER HOSPITAL, ETC.
In a recent article on Dermatitis Herpetiformis * I re-
ported two cases, in each of which the origin of the disease
eould be traced directly to the reception of a severe mental
and moral shock. Owing to this fact, and also because in
their entire pathological course and history, they showed a
profound subjection to influences of all sorts, which in one
way or another expended their effects upon the nervous sys-
tem, the conclusion was drawn that the raison d'etre of the
process on the skin was a disturbance of some kind brought
about in the nervous system by the serological factors in ex-
istence, and from thence transmitted to the cutaneous sur-
face. For these same reasons I also expressed my belief
that the cases ought to be regarded as dermatoneuroses, and
I stated that not they alone, but also all other examples of
the disease, should, in my opinion, be included in the same
category.
In support of this confession of faith, I would record
the following cases :
Cask I (private practice).— Male, aged forty-five, was kindly
referred to me for treatment on November 26, 1889, by Dr.
Blundell, of Paterson, N. J. His disease had begun a year pre-
viously, and for many months prior to its inception he had been
subjected to severe overwork, business worries and anxieties,
and grave responsibilities. These circumstances had finally in-
duced great nervousness, he suffered from severe neuralgic at-
tacks, constant insomnia, and he became generally unstrung
and neurasthenic. He could not say that any special determin-
ing factor immediately preceded the first appearance of the cu-
taneous disease beyond a qualitative and quantitative increase
in his mental strain, but be had observed during its existence
that new outbreaks had occurred whenever any fresh worry or
anxiety arose or after any slight or severe nervous shock or dis-
turbance. In fact, he even stated that regularly, a few hours or
the next day after connection with his wife, a relapse of varia-
ble severity and extent would be manifested.
The eruption had first appeared in the lumbo-sacral region,
but later quite generally over the entire body, though more es-
pecially over the extensor surfaces of the extremities. From
the beginning he had never been free from the manifestations of
the process, but relapses occurred continually, at times of lim-
ited extent, at others covering a wide territory. Pruritus had
been a constant and severe symptom, not only on the site of the
lesions, but also generally over the entire surface. Occasionally
burning pain would also be experienced. During the existence
of the disease the bowels had been regular and the appetite good.
Once in a while he suffered from slight indigestion. A "brick-
dust " deposit in the urine had been frequently observed.
Status Prcesens. — The patient was slight, wiry, and of medium
height. His functional health was good. The urine contained
urates, uric acid, and oxalate of calcium to a marked degree.
The eruption occupied the lumbo-sacral region, the extensor sur-
faces of the arms, especially about the elbows, and extended over
the shoulders. The buttocks and external aspects of the thighs
and legs were affected, but the lesions were aggregated together,
* Journal of Cutan. and Genito-urin. T)it., September, 1891.
more abundantly about the knees. It was noticeable that almost
perfect symmetry was followed in the distribution of the lesions
and patches. On the surfaces mentioned papules, papulo-vesi-
cles, and vesicles were met with. These were occasionally dis-
crete, but for the most part arranged in groups of variable ex-
tent upon a reddened, somewhat elevated base, and they varied
in size from that of a pin-head to that, of a small pea. The vesi-
cles were tense, deep-seated, rounded, stellate, or flattened, and
contained a clear, slightly yellow fluid of neutral reaction. The
papules resembled somewhat those of urticaria, as also did larger
erythematous patches, which were distributed here and there,
but, in contradistinction to the lesions occurring in that disease,
they were persistent in character, only disappearing gradually
and then leaving pigmentation. Abundantly distributed over
the surface were dark pigmented spots and areas, the residua of
previous lesions, and there were also crusts and scratch marks.
The itching was bitterly complained of and was said to be most
severe at night, at times paroxysmal in character and accom-
panied by a sensation of heat and pain.
While the patient was under ray care, the course of the dis-
ease at first was one of alternate improvement and relapse. The
relapses and recurrent outbreaks followed regularly after any
worry, anxiety, or increased mental work. Several times, the
day following a coitus, I was able to observe on him more or
less abundant new lesions and patches, and he complained of
increased pruritus. The character of the eruption varied in the
relapses, at times papular and vesicular, or purely vesicular, or
the latter and bulbous, or again a mixture of all three forms of
lesions with, in addition, erythematous patches of variable
extent.
At the end of a few mouths, there being still no cessation of
the mental worry, the overwork, etc., the treatment also being
ineffectual, the patient was ordered to take an entire rest and to
go away for some weeks. He remained in the country for six
weeks, and on his return reported that the outcropping of lesions
had ceased at the end of the first week; the pruritus had dimin-
ished greatly. The insomnia also had been relieved, he gained
flesh and strength, and on his return felt better than in several
years. He could now attend better to his business, but still got
tired easily. A week, however, after taking up his old cares and
responsibilities and worries, pruritus began about the ankles,
and groups of papules appeared around the knees and on the
legs. He was ordered to take a long rest and went away from
business and work of all kind. He regained his general health
completely, the eruption disappeared, and since May, 1890, he
has remained well.
Case II (private practice). — J. H., male, aged forty-two, an
electrical machinist, consulted me October 5, 1890. He stated
that he had always been of a nervous temperament, excitable,
prone to worry and to restlessness. The nature of his work
had also necessitated constant watchfulness and anxiety, owing
to its dangerous character. In 1876 a falling window shutter
struck him on the right shoulder, fracturing the clavicle and
four ribs, and for more than a year after he was unable to use
the right arm or leg. In 1883 he had a severe attack of dysen-
tery and, when barely recovered, he failed in business. In 1884
he lost his four children inside of a few weeks. His wife's ill-
ness began in the following year and has persisted ever since,
but it was severer for him during the first year, as, owing to his
poor circumstances, he was obliged to work during the day-time
and take care of her during the night. lie thus had little rest
and sleep, and this, conjoined to his mental suffering, the severe
moral shocks he had experienced, and the harassing anxiety of
poverty and debt, operated an entire change in his character,
causing him to become gloomy, despondent, and melancholic.
In 1887 ho broke his left leg, and his circumstances became still
594
ELLIOT: DERMATITIS HERPETIFORMIS.
[N. Y. Med. Joch.,
more precarious, but, finally recovering, he began work again.
During May and June, 1889, he worked in a damp cellar con-
taining pools of stagnant water. Early in May attacks of quo-
tidian malarial fever began, and at the end of two or three
weeks he felt a most intense pruritus over the buttocks. When
he examined himself, he found that they were covered with an
eruption of "small water blisters and bumps" (vesicles and
papules?). A week later the face became swollen, very itchy,
and a similar outbreak ensued upon it, and extension of the
process to the trunk and extremities gradually took place.
Since that time the patient has never been free from the dis-
ease, but crop after crop of lesions have appeared, vesicles,
papules, bullae, and large "hives" occurring simultaneously, or
the one form or the other predominating in successive out-
breaks. The pruritus has always been most intense, interfering
with his rest, causing loss of appetite and flesh, and even at
times forcing him to abandon work for days in succession. Dur-
ing the course of the disease the patient constantly observed
that severe itching invariably preceded an outbreak of lesions
on any part of the surface, lasting for an hour or more, but abat-
ing somewhat with the appearance of the objective manifesta-
tions. Symmetrical distribution of the lesions was also noted,
and when an outbreak occurred on one side of the body it was
invariably followed within twenty-four hours by a similar crop
on the opposite side. An increase in the degree of the itching
and in the amount and intensity of the eruption followed regu-
larly after the reception of any shock, or with any accession of
worry, or when his work demanded more watchfulness than
usual — in other words, whenever, from any cause whatever, an
additional mental strain or effort was required of him. Con-
tinuous pressure upon any portion of the body was also followed
upon that part by an outbreak of lesions. Clonic spasms and
jerkings of the legs, but especially of the arms, were also com-
plained of as occurring when in bed, and lately, after a severe
wetting, a numbness of the extremities had developed and lasted
for several weeks. Shooting neuralgic pains had also begun at
that time and still occurred, being invariably followed by a crop
of lesions.
When seen by me the patient still suffered from occasional
attacks of quotidian malarial fever, but they did not appear to
be followed by any outbreaks of the cutaneous manifestations.
He was thin, much run down, anaemic, and very constipated.
Anorexia, but no gastric derangement. Urine abundant and
normal.
The entire surface was occupied by the eruption, except
over the abdomen and flanks. Very marked symmetrical ar-
rangement was observed. The morbid phenomena consisted of
vesicles, papules, and pustules grouped in patches and also oc-
curring discretely, covering more or less large areas, lying con-
tiguous to each other or separated by intervening masses of
crusts or by pigmented spots and surfaces of variable extent.
Every stage and grade of the process was apparent on the skin
from the fresh vesicle or papule or other lesion to the crusted
one, or the pigmented spot, or in many places to the superficial
cicatrix, the result of the wounding and tearing of the skin by
the nails in the patient's endeavor to obtain relief from the itch-
ing. The body presented in consequence a most peculiar ap-
pearance, which, however, bore testimony to the severity of the
disease and the suffering entailed by it. While the patient was
under treatment there was no cessation in the outbreaks of the
process, but crop aftercrop appeared, consisting of lesions of all
forms. Occasionally large erythematous patches developed,
upon portions of which numerous vesicles would be aggregated,
or tense bullae would arise suddenly upon an intensely itchy or
burning surface, or groups of papules would appear and remain
as such, or become transformed into papulo-vesicles. The most
protean course was shown by this case ; but yet the tormenting
and implacable itching persisted unchanged and uninfluenced
by the condition of the patient, by the paucity or multiplicity
of the new lesions, or by any treatment made use of. After
being under observation for some months, the patient disap-
peared from view, being still in statu quo ante.
Case III (dispensary practice). — L., male, aged forty-five, con-
sulted me in September, 1890, giving the following history : Two
years before the eruption began he experienced severe family
troubles, and these still continue. At the same time he suffered
business reverses, and he has never recovered his former posi-
tion in life. As a result, he became greatly depressed, the pe-
riods of depression alternating with others of severe nervous
excitement and restlessness; he suffered from insomnia and
sudden and unaccountable feelings of oppression and night ter-
rors. The patient had had several years ago malarial fever, and
also an attack of pneumonia. His functional health had been
good* but the new occupation he followed caused him consider-
able excitement and necessitated exposure to cold during the
winter months.
The eruption first manifested itself two years before I saw
him, beginning as an outbreak of pustules on the inner side of
the right upper arm. The same manifestations soon appeared
on the left arm and gradually implicated the trunk, and later
on the lower extremities. From the first appearance of the
lesions he has never been free, though their type shortly changed
to the existing one. The pruritus and burning sensation, which
had been always a prominent symptom, has increased greatly in
degree. When the patient was examined he was found quite
well nourished, bowels regular, stomach in good order, urine
normal. His habits were good ; he drank beer with his dinner,
but did not over-indulge in stimulants. The eruption was dis-
tributed quite generally over the face, arms, and legs and trunk,
consisting of erythematous, slightly elevated, sharply defined
patches of all shapes and sizes. They were round or oval, or
irregular in outline, and from a silver dollar to a whole hand in
size. Their color was for the most part of a purplish-red ; some
had become purpuric. Besides these, there were groups of
papules, here and there small crusted areas, and more or less
large pigmented surfaces, the sites of former lesions. The pru-
ritus was intense. While the patient was under observation it
was seen that the erythematous patches began as small lesions,
the size of a thumb-nail perhaps, and then gradually enlarged to
a silver dollar or much larger size, no involution of the central
portion taking place. The patches were not transitory in exist-
ence, but remained persistent for weeks and months, only slowly
disappearing and then leaving pigmentation. There were no
outbreaks of vesicles or pustules or bullai while under my care ;
only a few groups of papules. In December the patient was
much improved by his treatment, and was not seen again until
March, 1891, when he presented himself with a new but slight
relapse. It subsided shortly, but he returned in June with an-
other and similar erythematous outbreak. In September he
again presented himself with a new relapse, affecting especially
the face. The lesions were symmetrical on both tempies, fore-
head, and cheeks, consisting of thickened, elevated patches on
which were papules, vesicles, and crusts. The pruritus was very
severe. This relapse has persisted without material change up
to the present day (February, 1892), having become general over
the body.
From the clinical histories of these three cases it can
be seen that each possessed, in common with the others,
certain prominent and striking characteristics, which would
immediately" suggest their intimate relationship, and tend
to establish the fact that each constituted an integral part
May 28, 1892.]
ELLIOT: DERMATITIS HERPETIFORMIS.
595
of one and the same process. It can not be said that there
was an absolute quantitative and qualitative identity in their
objective and other symptoms, but yet all were character-
ized by chronicity and long duration, by frequent relapses,
multiformity of lesions, excessive subjective disturbances —
pruritus and burning pain — and by rebelliousness to treat-
ment. Possessing, therefore, these essential features, it
would be impossible to regard these cases as any other form
of disease than dermatitis herpetiformis, if we accept the
writings of Dr. Duhring and are familiar with the superb
analysis of the subject made by Brocq. If, however, we
base our diagnosis upon the objective lesions alone and do
not take the entire course of the disease into consideration,
then certainly difficulties will be met with at every step, for
at one time the eruption could be regarded as an eczema,
at another a herpes, or an urticaria, or some other process.
It scarcely seems necessary to me, however, to point out
the differential characteristics of Cases I and II, when their
entire clinical histories and course are duly valued, and the
same may be said, in my opinion, in regard to Case III.
Yet, for the reason that, when I presented the patient be-
fore the New York Dermatologieal Society, some of the
members present were inclined to regard the eruption in
this case as a chronic urticaria, I would point out those
points which appeared to distinguish it from that of derma-
tosis. There was not observed during the entire time that
the patient had been under observation any sudden and
daily outcropping of wheals, which, after short duration,
would disappear, but the lesion began as a small erythema-
tous patch, which gradually enlarged to the size of a silver
dollar or much larger, and then persisted for weeks and
weeks, finally and gradually fading and leaving pigmenta-
tion. The lesions in no instance resembled those seen in
urticaria, but were sharply defined, slightly elevated, and of
a dusky-red color. In addition, there was not any of the
irritability of the skin seen in urticaria ; no wheals or lesions
could be evoked by rubbing, scratching, or by other means.
Finally, sections of the newer lesions under the microscope
showed distinct inflammatory changes, such as do not exist
in urticaria.
Cask IV (New York Skin and Cancer Hospital, Dr. Bulk-
ley's service). — A man, aged thirty-eight, entered the hospital on
November 16, 1889. His general health had always been good.
He had never had syphilis or any other disease; had always
been temperate, though accustomed to drink a few glasses of
beer at night, but no whisky. For months before the cutaneous
process began he had been subjected to excessive mental worry,
anxiety, and fatigue, superinduced by certain duties in connec-
tion with one of the more or less large secret societies of the
country, and the nervous strain had led to insomnia and a gen-
eral lowering of his physical and mental powers. While iu this
condition he observed, toward the end of July, 1889, immedi-
ately after experiencing a keen disappointment, the appearance
of an elevated, reddened, somewhat scaly patch, as large as the
palm of the hand, over the middle portion of the sternum. It
was accompanied by severe itching and burning pain, and per-
sisted until the middle of September, when an outbreak of simi-
r lar lesions occurred over the shoulders and back, at the flexures
of the elbows and at the wrists, over the knees, and on the
palms and soles. The latter burned and tingl«d, while the rest
of the surface itched intensely. He stated positively that the
lesions were dry, pointing out some similar to them ; in other
words, papules, except on the soles, where they consisted of
bulla? the size of a small pea. All treatment seemed to be with-
out effect, and the nervous strain he was under continuing and
increasing in degree, in a few weeks (October) bulla?, pea-size
to that of a hen's egg, formed about the ankles, and the legs
became cedematous from the knees down. At the end of a
couple of days subsidence of the oedema occurred, and bullae
began cropping out all over the legs. At the end of a week the
thighs had become similarly affected, and a little later the but-
tocks and forearms. Over the remainder of the body only few
bullae formed, papules largely predominating. The outbreak of
these lesions had invariably been preceded by the most intense
pruritus, which would cease when the bulla? had been ruptured.
The mucous membranes had at no time been affected. The on-
set of the bullous eruption had been accompanied by more or
less elevation of temperature and constitutional disturbance.
Status Prasens. — Patient medium height, slight build, of
energetic nervous temperament. Appetite and digestion good,
bowels regular. He can walk only with great difficulty, not,
however, from any loss of power, but on account of the inflam-
mation about his ankles and the pain therefrom. On the flexor
surface of the left wrist and on the upper portion of the right
arm, as well as on the penis and scrotum, are large patches of
vitiligo, which have developed since the inception of the cuta-
neous disease.
The entire surface of the body, except the forearms and legs
from the knees Jdown, is deeply pigmented, 'and quite thickly
distributed over it are small crusts and groups of firm papules.
On the legs and forearms are bulla?, in size from that of a large
pea to that of a pigeon's egg ; some tense ; others flaccid, grouped,
and discrete. Some large ones had been evidently formed by the
confluence together of smaller lesions, which, in some instances,
were seen grouped around and about the bullous elevation.
Their contents were clear yeilow, or had become turbid or even
purulent. Where the fluid had dried, thin, yellowish, and
blackish crusts were seen, but occasionally, instead of these, a
ragged, irregular loss of tissue bad been produced by the pa-
tient's scratching. About the ankles the crusting was very
marked, the skin beneath deeply fissured, denuded, and bathed
in a sero-purulent fluid, having a most offensive odor of de-
composing pus. Acute inflammatory reaction had been set up,
and the pain, as already mentioned, prevented him from walk-
ing. That no other cause produced the apparent inability to
walk was later distinctly demonstrated by the fact that, when
those morbid symptoms had been removed by proper antiseptic
treatment, the patient was able to get up and go about with
ease.
The record of temperature was not begun until November
18th. It was then 101'2°, and up to December 1st it varied be-
tween 99° and 102-2°, evening exacerbations and morning re-
missions. The pulse was rapid and small — 98 to 144. These
conditions of pulse and temperature can not, in my opinion, be
ascribed to the disease dermatitis herpetiformis, but rather to
septicemic infection from absorption of the products of decom-
posing pus. The source of infection having been completely
removed by November 28th, it was seen that the temperature
full to normal, and remained there during his stay in the hos-
pital, except for a few days, when the temperature again rose
to 100°, in consequence of a neglect of antiseptic precautions.
While the patient was under observation, numerous out-
breaks occurred, and crops of bullae, or papules, or papules and
vesicles, or of all combined, appeared in more or less rapid suc-
cession. Bulla), however, developed only on the legs, below the
knees, or occasionally on the backs of the hands or on the
' wrists. Usually singlo and discrete, at times they were small
596
ELLIOT: DERMATITIS HERPETIFORMIS.
[N. Y. Med. Joub.,
and grouped, or again around a central large one would be ar-
ranged a row of smaller bullae.
The vesicles varied in size from that of a pin-head to that of
a small pea, tense, rounded, or flat, or angular or stellate. They
formed small groups and also large patches, the latter being
composed of papules and vesicles arranged and aggregated
together without regularity. The papules were firm and ery-
thematous, occurring as above mentioned, and also in more or
less large groups and patches.
These various lesions, when left to themselves, underwent
involution in a few days, the vesicles and bulla forming crusts,
and the papules leaving marked pigmentation. A group of
vesicles appeared at one time on the left check, near the nose,
which, however, did not subside in xitu, but progressed over the
surface, and in a few days had the appearance of a reddened and
infiltrated patch, bounded by a scalloped elevated border, upon
which was a row of small vesicles and crusts.
The outbreaks of the eruption, of whatever character or ex-
tent, were always preceded by the most intense itching, and the
pruritus persisted until the bullae or vesicles had been ruptured,
or the tops torn off from the papules. The patient remained in
the hospital for some months, leaving February 8, 1890. He
was then in good functional health, and had gained flesh and
strength. The cutaneous surface, with the exception of deep
pigmentation, was free from disease. Here and there were a few
crusts and excoriated places, but no new lesions or crops had
appeared in some time, and the itching had ceased entirely. He
remained under observation for some months, and occasional
bullaa cropped out on the legs, and small groups of papules and
vesicles an the arms. These outbreaks finally subsided and no
new relapse had occurred up to the end of 1890.
Whether he will or will not experience a return of the
disease it is almost impossible to say. Possibly not, as he
is no longer subjected to those influences which appear to
have been active in the production of the primary attack of
the process. Before this patient entered the Skin and Can-
cer Hospital he had been seen by Dr. Piffard. He has
made a brief reference to the fact in an article on Pemphi-
gus Pruriginosus, accompanied by two photographs of the
case, which he published some time later. In this paper be
says that while he does not believe that this and similar
cases are in any way related to pemphigus vulgaris, while he
denies their relationship to either of the affections termed
herpes, though granting that Dr. Duhring would include
the case in question in his dermatitis herpetiformis, he yet
prefers to use the term pemphigus pruriginosus for want
of a better one and until some correct title and more defi-
nite knowledge of the aetiology and nature of such processes
is obtained. I would agree with Dr. Piffard that the affec-
tion has no relationship with pemphigus vulgaris, and.
though this case would undoubtedly have been termed
pemphigus pruriginosus by the older writers, in view of the
presence of bulhe and pruritus, yet that alone is not a rea-
son why we should persist in the use of a designation mis-
leading and unsatisfactory. Because it has been handed
down to us from former times, is no guarantee of its correct-
ness any more than bulla, accompanied or not by itching,
always constitute a pemphigus, qualified or not by the
term pruriginosus, and no other cutaneous disease. In the
case in question here (Case IV), as well as in other similar
ones, moreover, the diagnosis should not be based upon
the objective lesions seen at only one and a single consulta-
tion, but the whole course of the process — the various pict-
ures presented by it, the morbid phenomena of all kinds
which arose — should all be taken into consideration and
properly estimated in reference to each other before the
case is definitely catalogued. This patient, who was under
my immediate observation for months, presented, as pre-
dominant lesions, frank inflammatory papules, persisting for
days, some becoming papulo-vesicles, and finally disappear-
ing, leaving marked pigmentation. Pure vesicles were at
times present, but only exceptionally bullae, and these latter
limited to the surfaces below the knees and to the wrists.
In other words, we found that the sine qua non of a
pemphigus — bullae — were greatly in the minority and
limited in distribution, and under those circumstances it
would seem only to cause confusion more confounded to re-
gard it as in any way connected with pemphigus vulgaris.
When, on the other hand, the case conformed in its course
and clinical history so closely with the others recorded here,
then its inclusion in the category, dermatitis herpetiformis,
would appear to be perfectly justifiable in my opinion — one
supported likewise by Dr. Bulkley, in whose service the
patient was.
The clinical features presented by these four cases do
not appear to me, however, to possess as much importance
as do the aetiology and the pathological course of each,
owing to the fact that from the former many facts could be
gleaned which, taken in conjunction with the latter, pointed
very suggestively, and in truth strongly, to an intimate con-
nection of the cutaneous disease with some disturbed state
or condition of the nervous system. We thus find that
each of the patients had been subjected for a more or less
long period of time before any outbreak had occurred on
the skin, to varying degrees of physical, but more especially
of mental, overwork, or grave cares and responsibilities,
severe worries and anxieties, and grief. The influence of
these* factors upon the individual was demonstrated by
the production of such evidences of general nervous and
cerebral exhaustion as neurasthenia, insomnia, night ter-
rors, depression alternating with periods of excitement, at-
tacks of melancholia, severe neuralgias, etc., and it was
during the existence and continuance of the state of nerve
exhaustion that the process developed on the skin, although
there was no evidence that these conditions acted directly
and causatively in the production of the disease. On the
contrary, and as will be shown presently, entirely different
factors immediately preceding the appearance of the
dermatosis, and apparently ushering it in, they could be ac-
cused as the direct causes of its development.
Besides the four cases (I to IV) contained in this
paper, there ai-e four others which I would also include in
my analysis, for the reason that in them the various influ-
ences, agencies, causes, etc., which made up their setiological
history and which participated in the origin of the disease
could be obtained from the patients. Of these four, two (V
and VI in my analysis) have already been reported by me,
while the remaining two (VII and VIII) are as yet unre-
corded.
The investigation of the histories of these four patients
(V, VI, VII, VIII) showed the following factors to have
May 28, 1892.]
ELLIOT: DERMATITIS HERPETIFORMIS.
597
been in existence prior to the development of the dis-
ease :
Cases V and VI. — Both neuropathic from worry, anxiety,
mental and physical excesses of longer or shorter duration, run
down in health, and debilitated.
Case VII. — A woman, aged forty-eight, a sufferer from in-
tense neuralgias for twenty years, nervous, hysterical, and easily
frightened, subject to attacks of melancholia.
Case VIII. — A woman, aged fifty-three, of nervous tempera-
ment and nature, having a lacerated cervix and excessive leucor-
rhcea of twenty-five years' duration, anaemic and debilitated,
accustomed to take cold baths every day during menstruation,
but not at other times.
If we analyze the serological facts presented by these
eight cases as having preceded the development of the
cutaneous disease, we find that they may be summed up
and separated into the following two categories :
I. Excessive mental and physical work, mental and
moral emotions, anxieties, cares, responsibilities, grief, etc.
(Cases I to VI inclusive) — six cases.
II. Nervous temperament and nature, hysteria, intense
neuralgias, anaemia and debilitating conditions, etc. (Cases
VII and VIII) — two cases.
From the histories of the patients we furthermore
found, as already mentioned, that the effects of the factors
contained in the first category were shown in I to IV by
the production of neuropathic states of the general system
— neurasthenia, insomnia, etc. — while in V and VI there
was in addition a debilitated, run-down condition of the
general economy. In VII and VIII the consequence of the
facts mentioned in II were systemic debility, great in-
crease in nervous and hysterical condition, in frequency of
neuralgias and other evidences of disturbed innervation, a
more or less apathetic state of the mind, the conditions ex-
isting pointing in general to lowered nerve tone, without
any special feature being demonstrable. The morbid
symptoms and states having been produced in these patients,
they persisted for various periods of time — from a few
weeks to years ; but, nevertheless, every one of the cases,
during their existence and continuance, however long it
might have been, enjoyed complete freedom from any cuta-
neous process. Upon the supervention of an additional or
new factor, however, which apparently swept away the
last remaining barrier to its production, then the catastro-
phe was precipitated, the dermatitis herpetiformis de-
veloped, and the usual train of symptoms characterizing
the process became immediately manifested. These we
find to have been in three cases severe mental and moral
shock and emotion; in two (V and VI) from a death; in
one (IV) from a keen disappointment ; in one (I) a great
increase in mental and moral strain ; in another (II) mala-
rial intermittent fever; in two (VII, VIII) the menopause.
In the two last the process developed almost synchronously
with the cessation of menstruation, in the one (VII) having
been preceded for a month by the most intense pruritus, and
the cutaneous disease has lasted now in Case VIII two years
and a half ; in Case VII, two years. Case III was unable
to furnish any positive or definite data in regard to the in-
ception of the process, though possibly some occurrence in
his profession — he was a sheriff's officer — may have ushered
it in.
If we make a brief resume of the histories of these pa-
tients prior to the development of the dermatosis, we find,
therefore, on the one hand, a whole series of factors acting
detrimentally upon the general system, but not provoking
the disease, and on the other, in seven of them the occur-
rence of some new and different one immediately followed
by the process. The question which therefore arises is,
What role does each of these play in the origin and pro-
duction of the dermatitis herpetiformis ?
In disease in general, whenever it has been possible, a
most material difference has always been made between
those influences, conditions, etc., which, not productive of
a process, act only as favoring or contributive factors, and
those others which, immediately followed by the disease,
can be regarded as the exciting and determining causes ;
and, in my opinion, the same course should be followed in
dermatitis herpetiformis. Therefore, since all the factors
contained in Case I, notwithstanding their existence and
continuance for more or less long periods of time, were
productive of a neuropathic condition, an increased nervous
susceptibility, a generally lowered systemic stability alone,
but in no instance, as we have seen, of the cutaneous dis-
ease, then they would have to be regarded as occupying
the position of favoring or contributive causes — those which
produced in the patient that state to which the term pre-
disposition may be applied. On the other hand, however,
since the cutaneous disease developed immediately upon
and after the supervention of some new and additional
occurrence independent of those which had been for a more
or less long time in existence, and represented in my cases
by the mental and moral shock, the malarial fever, the
menopause, etc., then these should, under the circumstances,
be considered as the active and exciting causes of the pro-
cess— the ones which were directly and actively productive
of its development.
From the aetiological data furnished by these eight
cases, it seems to me that we can properly make the above
division, and we thus have on the one hand certain factors
which predisposed the individual to the development of the
skin affection, and on the other hand certain others which
directly caused its appearance, presumably, however, in
virtue of this state or predisposition already in existence.
Of the two, it is the " predisposition " which would seem
to be the most important portion of the subject. What is
the predisposition, what are the conditions which constitute
it, and what actual changes take place in the general sys-
tem in its production '. are questions of pre-eminent interest,
but, unfortunately, to-day not any more facile of explana-
tion in dermatitis herpetiformis than in many other dis-
eases, local as well as general. With our present knowledge
and as yet limited opportunities for ultimate investiga-
tions, it is utterly impossible to precise the actual patho-
logical changes produced in the patient by the a>tiologieal
moments which held sway prior to the development of
the process, and we can only judge from clinical data what
portion of the general system has been affected by the in-
fluences at work and where the disturbances, whatever thev
598
ELLIOT: DERMATITIS HERPETIFORMIS.
[N. Y. Med. Jocb.,
may be, are probably located. It is upon clinical grounds
alone, therefore, that I have based the opinion I hold that
whatever the actual changes are which arise and are pro-
duced in the general system and thus constitute the predis-
position to the dermatosis, they are resident in and inti-
mately connected with the nervous system. I would locate
them there for the reasons that in all those of my cases
from whom an intelligent history could be obtained, the
aetiological factors which preceded the disease were such as
exerted their influence only upon the nervous system, or the
patients were by nature neuropathic, or owing to some
pathological systemic condition presented more or less well
marked indications of disturbed nerve tone. When, in
addition, there were not any other moments which could
be accused as participating in the production of the state
of the individual, and the results of the aetiological data
mentioned were seen and shown by the various neuro-
pathic conditions which developed in each — the neuras-
thenia, etc. — then it appears to me that, though there
is no actual demonstration of nerve changes, yet the
clinical histories of the cases furnish sufficient grounds
•for the belief that the predisposition was constituted by
some condition other than normal of the general nervous
system.
Regarding the predisposed condition of the patient as
•the most important, then the character of the exciting or
determining cause would not be of such incisive moment,
nor would it need to be a constant one. On the contrary,
it seems to me that under those circumstances almost any
occurrence, agent, or factor would be sufficient to precipi-
tate the production of the process, and th.s is precisely
what was seen in my cases, in seven of which the exciting
cause was of the most various nature, character, and inten-
sity. I do not think it worth while here to speculate upon
the manner in which these exciting causes acted in bring-
ing about the dermatosis ; we know nothing whatever in
regard to this portion of the subject, and possibly we
never will, for though, in some cases, evidences of peripheral
nerve degeneration may be found, in others, graver central
changes, yet when the clinical history and course of the
.great mass of the cases are considered, it can not but be
surmised that the changes presiding at the birth and exist-
ing during the continuance of the disease must be for the
most part transitory, probably functional, and certainly not
organic.
The analysis of the eight cases of dermatitis herpeti-
formis contained in this paper and the data furnished by
their clinical histories allow me, however, I believe, to
formulate the following conclusions :
1. That in the production of the dermatosis there are
two factors in operation — a predisposition of itself not pro-
ductive of the process, and an exciting cause capable of
provoking the disease on account of the existence of the
former.
2. The predisposition, present by nature or acquired
through the influence of various causes, is constituted by a
state or condition other than normal of the nervous sys-
tem.
3. The exciting factor need not be a constant one, but
may be of the most various character, nature, or intensity,
its power to call the disease into existence being, however,
dependent upon the state of predisposition of the patient.
As a result of these conclusions, I would therefore regard
dermatitis herpetiformis not as a specific disease, always the
product of a single or specific agent or cause, but as the
outcome of any number of causes of the most various char-
acter acting upon an individual possessing a certain degree
of predisposition.
It appears to me that if we take the dermatosis upon
this broad pathological basis, we can understand the contra-
dictions in origin met with in successive cases and their ap-
parent entire want of agreement. It can not be expected
that the predisposition would always be of the same degree,
but it probably varies within wide limits, so that in one case
an intense exciting cause, while in another only a slight one,
would be necessary to produce the disease. We see, for
example, among my own cases that V and VI, in whom the
influences producing the predisposition were of compara-
tively short duration and it was slight, a severe and intense
shock developed the process, while in Case I, the predis-
posed condition being of long existence and marked, a mere
increase in mental and moral strain was sufficient. In Case
II, again, we see a man undergoing and resisting for years
mental and moral shocks, grief, etc., sufferings of various
kinds, and finally succumbing to an attack of malarial fever.
It is in view of such facts that the opinions expressed by
me have been formed, and they are advanced for the reason
that they appear to me to suggest a satisfactory explana-
tion for the various and divergent modes of origin seen in
the disease and the want of agreement manifested in the de-
velopment of the individual cases. I must confess that my
views do not apparently seem to be borne out either by all
of my own cases or by those recorded in the literature of
the disease. Still I do not believe that this is due to the
absence of predisposing and exciting causes in the genesis
of the other examples of the process, but rather, to judge
from my own experience, to the ignorance and forgetfulness
or intentional concealment of facts on the part of the pa-
tient. This is met with in a large number of cases, while
in others the aetiological factors may have been of such slight
grade as not to have excited special attention, and certainly
in some it may have been due to the observer, who failed
to investigate carefully the antecedent history of a case com-
ing under his care. I do not, however, intend to analyze
from this point the literature of dermatitis herpetiformis,
having preferred to base my opinion upon my own cases
alone, of which ten — eight in this paper and two others un-
recorded— out of sixteen furnished facts such as have al-
ready been related, and I would rather take up the cpiestion
of the nature of the process, whether it is a dermato-neuro-
sis or not. In view of the data derived from the study of
the aetiology of the cases conjoined with the clinical and
pathological course of each, I do not see what other con-
clusion could be made by me but that the process is a der-
mato-neurosis. While the patients were under my care and
observation, it was constantly shown that the cutaneous phe-
nomena were peculiarly" and altogether subservient to every
influence which acted in any way upon the nervous system,
May 28, 1892.]
ELLIOT:
DERMA TITIS HERPETIFORMIS.
599
or which produced a nerve disturbance of some kind or
other, and that it was independent of those which acted
upon other portions of the general economy. Every mental
or moral shock or emotion of whatever grade, worry or anx-
iety, excitement or fatigue, mental activity and work, etc.,
were regularly followed by an increase in the objective and
subjective symptoms or were productive of a fresh relapse.
Some of them, especially Cases I, V, and VI, would be en-
tirely free from any and all traces of the process, but would
have an outbreak immediately after the occurrence of some
one or other of the factors just mentioned, and yet during
the intermission there had been functional disturbances,
gastric or intestinal or of other nature, but nevertheless no
reappearance of the eruption. Other factors, which can be
mentioned, and which acted in the same manner as those
above, were coitus, the excitement and fatigue of the theatre
or of any social gathering, the occurrence of neuralgias,
shooting pains, hemicrania, etc. In regard to these latter,
it was also observed that, together with a great increase in
the subjective symptoms, there would be an outcropping
of lesions over the surface which had been the seat of
the neuralgia, pain, etc., and not over some other por-
tion of the body. As it has been my experience to
make these observations continually and repeatedly, to
see on the one hand that the cases offered in their aeti-
ology facts and data all pointing to the nervous' system,
and on the other that the process once instituted was
entirely under the control of that system, it therefore
seems to me that any other conclusion but that the
process is a neurosis, or, since all its phenomena occur
in connection with the skin, that it is a dermato-neurosis,
is impossible.
In conclusion, I would add a few words in regard to
the treatment of the disease. My experience has certainly
demonstrated to me that there is no remedy, drugs, or
forms of treatment which exercise any specific influence
over the process. On the contrary, the few good results
obtained by me have been only in those cases in which
there was an opportunity of either removing or of counter-
acting the aetiological influences which had been at work,
and it appears to me that the course of treatment adopted
should be based upon that principle. I have not seen any
particular benefit derived from dietary changes, from inter-
nal remedies, or from the routine administration of alkaline
treatment, or nerve sedatives, or tonics, etc., as long as the
primary influences operating upon the patient continued.
But when, as in Case I, the individual was able to go away
and be free from all his cares and responsibilities, etc., or,
in Case IV, all his mental and physical overwork, etc., were
replaced by rest and freedom, or, in Case V, the patient
was protected in her business and family life from emo-
tions, shocks, etc., or, in Case VI, recuperation of the gen-
eral normal tone was obtained and retained by constant
care, then the patients got apparently well — that is, enjoyed
entire freedom from the disease, though this freedom lasted
only as long as the primary causes were absent ; but, as was
seen in all of them, the eruption returned in some degree
when they again came into play. On the other hand, no
improvement was seen when the aetiological causes were
still in existence, notwithstanding the use of arsenic, atro-
pine, ergot, strychnine, valerianate or phosphide of zinc,
potassium salts, mercury, etc., and the hygienic and dietetic
and other means employed. This was seen in Case II,
whose mental sufferings continued ; in Case III, who, from
his occupation and family troubles, was incessantly exposed
to shocks, mental and moral, to excitement, etc. ; in Cases
VII and VIII, whose nervous conditions and states and
systemic disabilities remained in existence. In these four
cases the patients' circumstances, surroundings, etc., pre-
cluded the removal of the detrimental influences primarily
operating in the production of the disease, and, in conse-
quence, it is still in existence, varying in degree from time
to time, but yet never absent. From this experience, the
course of treatment which should therefore be followed
ought, in my opinion, to be based upon the broadest prin-
ciples and, as far as possible, guided and directed toward
removing all of those influences which apparently produced
the disease in any given case, and which brought about the
occurrence of relapses. If this can be done by appropriate
internal treatment, then the remedies indicated should be
exhibited, or, if it requires change of scene, surroundings,
occupations, etc., then recourse should, as far as possible,
be had to these. At the same time, any functional or
other systemic disturbance should be attended to, and the
patient's condition be brought as far as possible up to the
normal. In other words, the therapy of every case will have
to be based upon the indications and conditions existing in
each, and can therefore in no particular be a specific one or
consist of any specifics.
The external or local treatment is also of great impor-
tance, and should be combined with the one just mentioned.
Its principal object, in my estimation, is to give relief to-
the subjective discomfort, to remove the lesions already ex-
isting, and to prevent septic infection, which, on a surface
presenting so many points of entrance as the scratched and
torn and denuded skin of a case of dermatitis herpetiformis
would occur most easily [vide Case IV). I have tried to
attain these ends with the tars, carbolic and salicylic acids,
camphor, resorcin, menthol, chloral, ol. hyoscyami cocti,
etc. ; the sulphur treatment recommended by Dr. Duhring
has also been used by me ; but none gave results in any
way commensurate with that obtained from ichthyol, and
the majority failed altogether to be of any use. The ich-
thyol in ointment form did not act as well as when used as
a lotion — twenty-five grains to fifty grains in an ounce of
water ; but the best effects were observed when it was com-
bined with ol. amygdal. dulc. and lime-water : B IchthyoL
ammon., gr. xxx to xl ; ol. amygdal. dulc, aq. calcis, aa
3 ss. This was rubbed in thoroughly several times daily
and allowed to remain on the surface, or sheet lint saturated
in it was wrapped around and retained in place by band-
ages. The treatment was also combined with frequent
baths of starch, or of starch and bicarbonate of sodium, to
which, in case there was much hyperidrosis, as was at times
observed, a decoction of white-oak bark was added. By
these means the patient obtained at least considerable com-
fort, even though they did not act as distinctly curative
agents.
eoo
CHAPPELL: HINTS ON COUGHS.
[N. Y. Med. Joue.,
HINTS ON COUGHS:
THEIR CAUSES AND TREATMENT.
By WALTER F. CHAPPELL, M. D., M. R. C. S.
No symptom of a disease befogs the young practitioner
more than the varieties of coughs which he is called upon
to treat. No symptom receives more random guesses or
more shot-gun prescriptions. It is not my intention to wade
through the ancient history and literature of coughs, but
simply to give some practical hints on the varieties, causes,
and treatment of coughs as they occur in every -day prac-
tice.
A cough, as we all know, is a symptom of some irrita-
tion, mechanical or sympathetic, affecting the respiratory
tract or organs. It is Nature's effort to remove the cause
of irritation.
When thinking over the best way to present this sub-
ject, I found it difficult to make a classification which would
separate and at the same time include the important forms
of cough. A division based on their relative frequency
seemed to make the subject fairly distinct.
First Class. — No doubt in this country the morning
cough to remove the accumulation of mucus, caused by nasal
obstruction, post-nasal catarrh, the different forms of phar-
yngitis, general enlargement of vessels and glandular tissue
of the pharynx, base of tongue, and upper respiratory pas-
sages, is by far the most frequent.
These conditions sometimes occur singly, but often all
are present in the one patient and constitute what is called
" common catarrh." They cause increased secretion, which
is disposed of almost as soon as it is formed during the day,
but at night it accumulates in the post-nasal space, lower
part of pharynx, and superior laryngeal region. These pa-
tients, on rising in the morning, have a feeling of fullness,
sometimes dryness, in the throat. It causes them little an-
noyance at first, but after moving about and taking break-
fast their trouble begins. The act of mastication and swal-
lowing increases the blood supply to these regions and calls
into activity the normal function of the glands. The result-
ing secretion liquefies the mucus which has accumulated dur-
ing the night and causes it, as the patient will tell you, to
rise in his throat. At first there is little difficulty in get-
ting the mucus into the mouth and expectorating it. In
half an hour or so, however, the hypersecretion seems ex-
hausted, but some thick sticky mucus still adheres to the
walls of the throat. The effort to get rid of this produces
a violent hawking and gagging and a succession of short
coughs before it can be dislodged.
In mild cases, after the throat has been cleared in the
morning, there is little annoyance for the rest of the day.
In more severe cases, however, the efforts to clear the throat
and post-nasal space are most distressing. They come on
after every meal, after exercise, or when the atmosphere is
moist, or the patient excited. The feeling that something
is slipping down behind the soft palate causes a deep inspi-
ration through the nose, followed at once by a violent cough
which usually brings relief ; if not, there is a succession of
coughs and gagging, and relief is obtained by vomiting.
Men frequently smoke, especially a cigarette, on rising
or after breakfast, as they find that by this means they are
able to relieve themselves more easily and rapidly of the ac-
cumulation. Of course the smoking produces a hyperstiinu-
lation of the glands and consequent secretion, and gives tem-
porary relief ; it, however, leaves a dry and irritable feeling
in the throat. To fully appreciate these symptoms one has
only to be a passenger in any of our public conveyances
when people are going to business in the morning. If not
a sufferer himself, he will at least soon realize what a sym-
pathetic nervous system is. This form of cough, while less
dangerous than any other, is most troublesome and annoy-
ing to the patient and his friends and difficult to treat.
Second Class. — The cough resulting from what we call
a common cold may be classed as next in frequency. The
symptoms in these cases usually begin with acute rhinitis or
influenza and travel down to the trachea and bronchial tubes
a day or so later. Some people have their first symptoms
of an approaching cold in the chest, and the throat and
nose are attacked subsequently, while in others the cold
begins on the chest, and does not invade the upper respira-
tory passages at all. In those which begin as an influenza
the nasal symptoms and general febrile condition last from
two to three days, when some irritation is noticed in the
laryngeal region and a slight cough appears ; this increases
daily until about the fourth or fifth day, when the nasal
symptoms will be relieved and the patient tells you that the
cold is now entirely on the chest.
The cough is often severe and comes on in paroxysms,
especially when speaking, eating, taking exercise, or when
changing from one temperature to another, or during any
excitement. There is more or less of an aching or tight
feeling under the sternum, and if the person is a frequent
sufferer from colds, or, as he will tell you, " catches cold
easily," you find he often complains of a distinct sore spot
near the ensiform cartilage. Somebody has suggested that
this is caused by a semi-inflamed condition of the mucous
membrane at the bifurcation of the trachea. This place, of
course, receives the direct current and pressure of the air
at every inspiration. The expectoration is very scanty at
first and consists of white mucus. A few days later the
mucus becomes more profuse, and its character will depend
a good deal on the history and age of the patient and the
severity of the attack.
In young people, if it is only a mild attack, the mucus
is rarely prof use and only slightly yellow. In older persons,
or when there is a history of repeated attacks and some
chronic bronchitis or a syphilitic history, the mucus is thick
and yellow in appearance and abundant. The respiration
is little interfered with in young people, but in older per-
sons, where the mucous membrane is thickened, there is a
good deal of shortness of breath whenever they take cold.
Third Class. — We next consider the different forms of
coughs encountered in the various stages of phthisis. In the
early stages of the disease we are consulted for a short, dry,
hacking cough, which the patient can not refer to any spe-
cial cause or place ; he simply has a desire to cough. It is
not violent, and attention is only called to it by its persist-
ence. It is caused, in the opinion of many physicians, by a
May 28, 1892.]
CHAP PELL: HLNTS ON COUGHS.
601
deposit of tubercular material around the terminal branches
of the pneumogastric nerves. Its course is insidious and
often so short that the physician is not consulted until the
disease has advanced to another stage, when the cough be-
comes loose and more bronchial in character. This change
in the cough is due to a catarrhal condition of the mucous
membrane of the bronchial tubes and terminal bronchioles,
the result of localized bronchitis. The expectoration at first
is white mucus tinged with yellow ; a little later it becomes
thick, yellow, and tenacious, and requires a good deal of
coughing to get it up. This is most troublesome during
the night and in the morning — in fact, during the day there
is often little coughing. The increased cough at night is
probably due to the change in position of the body, as then
the mucus is made to occupy different parts of the bronchial
tract, and until the mucous membrane becomes accustomed
to this change it resents the intrusion.
In a still later stage of this disease, when softening is
going on and a portion of the lung separating, the cough
is violent and continuous ; also, when cavities have been
formed, they fill with mucus during the night ; in the morn-
ing there is violent coughing until the cavity is emptied.
The coughs in the later stages of phthisis are the result of
such large accumulations of mucus and necrosed tissue that
they are kept up night and day and wear the patient out.
The mouth and throat are frequently tender and covered
with a watery mucus at this stage of the disease, which
adds to the frequency and severity of the cough.
Fourth Class. — Many persons complain of a cough
which leaves them during the warm weather, but returns
on the approach of winter. This " winter cough " may be
due to several conditions — viz., bronchial catarrh or thick-
ening of the bronchial mucous membrane, chronic bronchi-
tis, and quiescent or arrested phthisis.
There is usually a history of previous severe colds,
which for several winters had been most intractable to
treatment ; then the patient has noticed that the cough re-
turned with the cold weather, probably without his having
any special symptoms of having taken cold.
The disease is sometimes hereditary, occurring in chil-
dren whose parents have been sufferers from winter cough
for years. These persons are usually pale and anaemic. All
their mucous membranes are flabby and prone to catarrhal
inflammations, and their recuperative powers are weak.
Women, especially blondes, suffer more frequently than
men.
The initial symptoms develop in early life, when the
child takes cold in the chest on the slightest change of
temperature. The symptoms are slight and catarrhal in
character at first, but become more marked and persistent
as age advances. The mucous membrane of the lower part
of the trachea and large bronchial tubes is the chief seat of
the trouble. This becomes thick and tumid, and the ves-
sels permanently enlarged. As age advances, especially in
neglected cases, the tubes become dilated, and in some
cases small, pouch-shaped depressions are found in the walls
of the bronchial tubes and trachea. When the cough
comes on, the patient has a feeling of slight oppression or
wheezing over the sternal region, some aching between the
shoulders, and a sore or tender feeling through the chest,
mostly on the right side.
This sore feeling is often complained of during the
warm weather if there is a sudden change of temperature.
Hot flashes of the face and upper extremities are common,
also cold perspirations. Excitement, exercise, and sudden
changes from one temperature to another aggravate the
symptoms, and in some produce an asthmatical attack.
The cough in the early cases is not severe or paroxys-
mal, and would be called a slight bronchial cough. It is
worse at night and during the early morning hours. The
mucus expectorated is white and frothy. As age advances,
the cough becomes violent and paroxysmal in character,
and troublesome during the day as well as at night. The
mucus is abundant, thick, yellow, and tenacious.
If this condition lasts for years, as it sometimes does,
and nothing arrests its progress, the right heart becomes
enlarged, and the general venous system sluggish. The
thickened condition of the bronchial mucous membrane ex-
tends to the lung tissue and produces contraction and
hardening, until both lungs are in a fibroid state, re-
sembling, if not identical with, that of true fibroid phthisis.
This, of course, is an extreme picture, and would proba-
bly only occur in a few predisposed or neglected cases.
The great majority, however, end in chronic bronchitis,
which continues for years, and death may result from some
other disease.
Fifth Class ; Nervous Coughs. — This class is probably
more common here than in any other country. It causes a
great deal of trouble on account of its persistency and from
its nature being frequently overlooked. Its nature is
sometimes only discovered after many cough mixtures and
other remedies have been employed for its relief. Scarcely
an organ in the body has escaped the accusation of origi-
nating a nervous cough, and many of them have certainly
been guilty.
In one class of cases it is the general nervous system
which is at fault, while in others some particular organ
originates the trouble. These coughs are characterized by
short, dry hacks, which the patient takes in rapid succes-
sion. They are paroxysmal, and sometimes violent and
barking in sound. During excitement they become almost
continuous, and the sufferer complains of a fear of strangu-
lation. If this continues for any time the laryngeal mucous
membrane becomes red and the muscles of the neck and
chest have a sore, tired feeling. Sometimes there is a dry,
burning sensation through the throat. There is always a
history of nervous troubles of various kinds extending over
some period. Some cases entirely recover, while in others
the cough extends through life and is spoken of as a habit.
There is also the hemming cough of puberty, so well de-
scribed recently by Sir Andrew Clarke.
It is sometimes difficult to trace the reflex form of nerv-
ous cough to its origin, and every organ may have to be
examined before determining this. I think, however, when
we decide that we have a refiex cough to deal with, there
are usually symptoms which point to its probable origin.
Sixth Class. — We are all familiar with the following-
history : A short, plethoric person calls and tells you that
602
he has a bad cough, which attacks him in paroxysms, that
he can not bring up any phlegm, has a full, stuffy feeling
over the trachea, a little shortness of breath, and is husky
at times. Appetite not good. Tongue very red or large,
white, and flabby, and marked with the indentations of the
teeth. Bowels probably constipated, although they may be
loose. Urine high-colored, scanty, and thick. Morning
nausea common. He has probably had the cough some
time and taken a good many things for it without benefit.
On examining this patient's throat, you find the mucous
membrane of the fauces and walls of the pharynx mostly
of a deep-red color, but in places it is dark blue, relaxed,
and bathed in a watery mucus.
This condition extends to the laryngeal region and as
far down the trachea as we can see. The congestion of
these regions is produced by over-indulgence in food and
alcoholic beverages. In people with a rheumatic or gouty
tendency it takes very little to produce this result, while in
others it comes on after a spree or steady drinking, extend-
ing over a long period.
Treatment. — When consulted about a cough, the first
thing to decide is whether it originates in the respiratory
tract or is due to some nervous disturbance.
If the former is at fault, the next decision is whether
the cough is a useful or useless one, or excessive for the
amount of good we might expect from it. If it is evi-
dently doing good service, our object should be to assist it
to complete its work as soon as possible. In useless
coughs we consider whether they are so excessive as to re-
quire a sedative, and then direct our efforts to remove the
cause. It is easy to see how important it is that all these
points should be made out before we write our prescription
or decide on a course of treatment. If we reply to this cry
for relief by the indiscriminate use of sedatives, we may carry
our patient into a dangerous position from which we can
not extricate him. It is a wise course never to give opiates
until you have found the cause of the cough and are satis-
fied that it is so excessive that it is wearing the patient out
or is endangering the lung tissue. The latter is most
likely to happen in the very young and in advanced life.
Some of the milder forms of sedatives may be em-
ployed with less caution, but we should always make the
selection with care, as certain sedatives are specially suited
for a certain class of cases and patients. In every cough
resulting from acute disease an aperient will be of serv-
ice, with a reduction in the quantity of nitrogenous food
and a liberal supply of fluids, especially of alkaline waters.
Another general direction is the matter of dress.
Probably no country in the world is subject to greater
and more sudden changes than this ; especially is this true
of this vicinity. It would seem that in so changeable a
climate the people would, as a national custom, wear next
their bodies a material which would be a poor heat con-
ductor. Some do protect themselves with woolen garments,
but the vast majority wear underclothing of a material
which does not retain the surface heat of the body as well
as wool. Thick overcoats and other thick external gar-
ments are supposed to keep in the warmth, but this is a
mistaken idea, as the warmth needs to be next the skin.
[N. Y. Med. Jooh.,
As a class, no people wear thinner boots than Ameri-
cans. Women especially indulge in thin boots or slippers
at times when only the thickest should be worn. Tbeir
hosiery, too, is often of the thinnest material.
It is extremely important that in persons subject to
catarrhal affections of the respiratory tract special attention
be given to their clothing ; otherwise no amount of medi-
cation will prevent taking cold.
The treatment of the cough described under the first
class would, of course, differ according to the cause of the
accumulation of mucus or the pharyngeal irritation. When
the mucous membrane of the nasal passage is at fault, as in
hypertrophies, etc., there are many methods for its re-
duction— viz.: electric cautery, cutting, removal with
snare, and various caustics. Of the latter, chromic and
monochloracetic acid are the most useful, as physicians
with ordinary experience and care can use them. Mono-
chloracetic acid seems preferable, as it can be applied in
the mild cases to the surface of the membrane, and does
not make a deep scar and soon heals. When the mucous
membrane is very much hypertrophied, monochloracetic
acid is also the most useful, as by submucous injection
sufficient tissue can be destroyed to make the reduction
permanent.
If deviated sa?ptum, spur, or any form of growth ob-
structs the nasal passages, only operative measures can give
relief. Enlarged tonsils and hypertrophied glandular
tissue at the base of the tongue must also be treated ; the
latter, either by the galvano-cautery or the instrument I
have suggested for this purpose.
It is impossible to lay down a strict rule for the treat-
ment of the different forms of chronic pharyngitis, but the
following has given me good results. Every night spray
the nose and throat, and inhale while spraying with —
B Acid, carbolic gr. ij ;
Sodii biborat gr. vj ;
Aqua? ad 3 ij. M.
After the parts have been well cleansed with this solu-
tion, I spray them with —
B Liq. hydrastis 3 ij \
Benzoinol ad 3 ij. M.
The following morning use spray Xo. 1 before break-
fast and No. 2 after breakfast. Every sixth or seventh day
I direct the patient to paint the post-pharyngeal wall with —
B Iodine gr. v ;
Pot. iod gr. x;
Glycerin ad § j. M.
This can easilv be done with a long brush, the patient
standing before a looking-glass.
Internally give one tablet sulphur co., which is com-
posed of —
Sulphur gr. v ;
Cream tartar gr. j,
twice a day after meals. When the follicles in the phar-
ynx are much enlarged, touch them once in two weeks with
a cautery point or the nitrate-of-silver stick. Of course,
every case treated in this way is not cured, but it gives
very satisfactory results. To obtain success, the treatment
must be carried out for from three to six months. Sum-
CHAPPELL : HINTS OX COUGHS.
May 28, 1892.]
CHAP PELL: HINTS ON COUGHS.
603
mer is the most suitable season for treatment. If the
patient shaves, I frequently advise him to wear a beard
This may seem trivial, but it is only by the closest atten-
tion to details that a successful result can be expected.
When the pharyngeal irritation and accumulation of
mucus are due to atrophic rhinitis in the stage when there
is a great accumulation of dried mucus, I direct the patient
to spray the nasal cavities night and morning with alkaline
spray No. 1, and at night introduce, by means of a camel's-
bair brush, an ointment of —
R. Europhen 3 ij ;
Ung. aquae rosae ad 3* j.
M. Ft. ung.
During the night the ointment finds its way into the
posterior nares and pharynx and keeps the mucus from
getting dry and hard, and acts as a stimulant and disin-
fectant. After breakfast I direct the patient to blow into
each nostril a small quantity of powdered europhen.
We next consider the coughs arising from a common
cold. Any one can tell when he has taken cold before any
symptoms are apparent to others. This knowledge, when
possible, should be treated by a good rubbing with a rough
towel over the entire body, a saline purge, and as much rest
as possible. In a few hours more definite symptoms ap-
pear, and the indication will then be to quiet the excite-
ment of the central nervous system, to soothe local con-
gestion and hyperassthesia of the nasal mucous membrane,
and arrest the discharge. There is nothing, in my opinion,
which acts so promptly as the tablet triturates recom-
mended by Dr. Lincoln. If used in the proper way, no
one can fail to be impressed with their action. They con-
sist of —
B; Quininae sulph., ) x
Camphors, f aa gr. ¥ ;
Ext. belladon. fl gr. M.
One of these should be given every fifteen minutes un-
til there is beginning dryness of the mouth and throat, and
then one every hour or two, as required. Besides this, I
direct the patient to inhale from boiling water —
Pi Mentholi, ) _
i r aa 3 ss.
Campnorae, )
M. Sig. : One teaspoonful to a quart of water.
Also to hold a sponge, wrung out of hot water, over the
bridge of the nose. If seen early, four hours of this treat-
ment will positively stop the sneezing and running from the
nose ; twenty-four hours completes the cure. If rest is not
possible, I advise the patient to exercise very little, dress
warmer than usual, drink little, avoid change of tempera-
ture, and continue the inhalation twice a day.
Should a bronchial irritation appear, I give —
R. Potassii nitratis 3 ij ;
Ammonii bromid 3 iij ;
Syrup, simplicis 3 j ;
Aquae ad § iij.
M. Sig. : One teasponful every three hours in Vichy.
If the patient is not seen until the rhinitis has been
present forty-eight hours, the tablets are not so efficacious,
and we have to rely more on the inhalation and ammonium-
bromide mixture.
The third variety, or coughs of phthisis, requires differ-
ent treatment according to the stage of the disease.
The short, dry, useless cough of the initial period of
phthisis is not often troublesome enough to require treat-
ment ; when it is, one four-hundredth of a grain of sulphate
of atropine, or ten drops of tinctura gelsemii, twice a day,
will afford relief, or one two-hundredth of a grain of hy-
oscyamine is equally efficacious. Later, when there is
bronchitis and considerable coughing and expectoration,
creasote, taken internally and by inhalation, gives some re-
lief. I have not had the uniform success with creasote
which Dr. Beverley Robinson reports from its use. On ac-
count of its effect on the stomach, it is impossible, except-
ing in rare instances, to give the large doses of creasote
which some observers recommend. The largest dose I have
given was ten minims three times a day.
Dr. William H. Flint's creasote pill is an excellent
method of administration. Hot milk, lime water, and whis-
ky, added together, make a good vehicle. No one remedy
can be relied upon for these coughs, and the gieatest suc-
cess may be expected from a judicious change from time
to time of the remedies. Menthol, given in three-grain
doses an hour after meals, is useful when the expectoration
is excessive. In the latter stages, when rest is greatly dis-
turbed, opiates are our best remedies. When the cough is
due to efforts to empty a filled cavity, it should not be for-
gotten that the position of the patient will materially assist
in doing this, and trials should be made to determine the
most favorable position. Change of climate is one of our
most certain remedies for the relief of these coughs, and
great care must be exercised in determining what climate
would be most suitable in each case.
Treatment of Winter Coughs. — The conditions which
cause winter coughs are usually well established when the
physician is consulted. The first step will be to take an
inventory to determine what damage the respiratory tract
has sustained,' also if there is any emphysema or other lung
trouble and the condition of the heart. We also inquire
for any hereditary diathesis. On the result of the exami-
nation and inquiries our course of treatment will depend.
Climatic conditions influence these coughs more than
anything else, and must always be considered in their treat-
ment. A warm, dry, even temperature, free from high
winds — in other words, where there is summer weatlu r the
year round — is most favorable for a cure. When this can
be obtained without too great a sacrifice, it should always
be taken advantage of.
Many persons, from business or other reasons, can not
avail themselves of the advantages of change of climate?
and we have to do the best we can for these patients at
home. They should wear flannel the entire year, thin in
summer and thick during the winter. Sponge the chest with
cold water morning and evening, and follow it up with dry
friction. Thick-soled boots should be worn, and the night
air avoided as much as possible. Cold sleeping-rooms and
breathing through the mouth must be guarded against ; also
sudden changes of temperature. Should these precaution-
ary measures prove useless and the sufferer finds he has
taken cold, or that the cough is simply returning, we must
KINO: RESPONSIBILITY IN THE TREATMENT OF FRACTURES. [N. Y. Med. Joub.,
601
endeavor to give as much relief as possible. This is best
done by daily inhalations of vaporized Dobell's solution, or
some other soothing vapor. The whole list of balsams are
more or less beneficial, but their effect on the stomach is so
disastrous that they can not be taken for any length of
time. Each case will require a special selection of drugs.
Terpin hydrate and creasote have given me the most satis-
faction. The soreness and aching over the trachea and
sternum are greatly benefited by —
Olei sinapis sem tt),x;
Spt. vin. rect ad | ss.
M. Sig. : Apply with camel's-hair brush twice a day.
Attention must be paid to the physical condition, and
the organs kept in the best possible health.
Success with these cases depends more on the general
management of the patient and persistency in treatment
than on internal administration of drugs directed to the
cough.
Nervous coughs must be treated according to their kind
and cause. The accompanying symptoms and general his-
tory will decide this. When there is a local or reflex
cause, the treatment must be directed to allay or remove
the irritation. In one case I removed a piece of coal, weigh-
ing five grains, which had been imbedded in the external
auditory canal against the tympanum for thirteen years.
This cured the cough and asthmatical attacks from which
the patient had suffered.
Abrasions of the nasal mucous membrane and also press-
ure in the nose frequently causes reflex coughs. It is usu-
ally not difficult to relieve these coughs, if the diagnosis has
been correct.
The neurotic cough in girls with chlorosis and boys at
the age of puberty is successfully treated with iron and sul-
phate of magnesia. Judicious bathing, exercise, and fric-
tion of the skin must also be employed. Counter-irritation
in the ovarian region is sometimes useful, and a sea voyage
may be necessary in some cases.
In adults, when the cough is due to a general neuras-
thenic condition, many plans may be tried without success.
Tonics, combined with prolonged rest or a sea voyage, is
the most satisfactory. Oxalate of cerium, if kept up for a
long time, has relieved some cases. When the cough seems
to have become a habit, there is little use of trying to
stop it.
The coughs resulting from excessive indulgence in food
and alcoholic beverages are benefited by a moderation of
the cause.
Aperients and plenty of alkalies and alkaline drinks
must be given. Spraying the throat twice a day with —
fjl Acid carbolic gr. j ;
Liq. hydrastis 3 j \
Benzoinol ad § j. M. —
allays the irritation. If there is any rheumatic or gouty
history, it must receive attention in the treatment.
22 East Forty-second Street.
The Manhattan Dispensary. — A new hospital building, at West One
Hundred and Thirty-first Street and Tenth Avenue, was opened to in-
spection by an invited company on Thursday afternoon of this week.
THE PHYSICIAN'S RESPONSIBILITY
IN THE TREATMENT OF FRACTURES*
By GEORGE W. KING, M. D.,
SURGEON TO THE MONTANA COMPANY (LIMITED), HELENA.
Every one who practices the healing art is expected to
assume the responsibility of treating fractures ; and no
matter how serious or complicated the injuries, or under
what adverse circumstances they occur, the exacting public
require him to conduct his cases to a successful issue in
every instance.
Accidents involving fractures are of common occurrence ;
and the majority of these cases naturally fall into the hands
of the nearest or most available physician. He can not
avoid them if he would. If he attempts to shirk the re-
sponsibility, when called upon to take charge of a broken
limb, his skill in other lines of practice is questioned, and
the inference quickly drawn that he is not a safe man to
trust in any event. There is, therefore, no choice upon the
physician's part — he must do the best he can, even though
he knows he will be held personally liable for any defect in
the healing of the injuries he undertakes to treat.
While the management of broken bones is usually re-
garded by the non-professional as a very simple affair, it is
in reality one of the most difficult duties we have to per-
form. There are no other class of cases which furnish so
many suits for malpractice, none in which the physician is
so unjustly persecuted. There is certainly a wrong senti-
ment prevailing in every community in regard to the extent
of the physician's liability. Who is to blame for this
error ? The physician himself, in so far as he fails to deal
candidly with his patient, is to blame for promising to do
what the ablest surgeons in the profession, with all the
facilities at their command, have declared their inability to
do — to blame for claiming more than the resources of his
art will warrant. The consequences of so unwise a course
are injurious in the extreme.
The patient who has been deceived by his physician in
regard to the prognosis of his case becomes dissatisfied, and
believes that he has been unskillfully treated, and very likely
seeks advice elsewhere, and is probably told that better re-
sults could have been obtained by proper treatment. Are we
not all too ready to encourage the public in believing that
perfect results ought to be obtained after simple fracture,
and that anything short of a complete cure is the physi-
cian's fault ?
This belief, shared in a measure by physicians them-
selves, imposes an unnecessary hardship upon us all. When
we come to understand, and are willing to admit, that de-
formity, with more or less impairment of function, is a
common result after simple fracture under the most skillful
treatment, less will be expected of us and impossible cures
no longer required at our hands.
Unfortunately, in the treatment of fractures, the defi-
ciencies of our art become more apparent than in other de-
partments of our work. A failure to cure diseased condi-
* Abstract of a paper read before the Medical Association of Mon-
tana, May 29, 1891.
May 28, 1892.]
KING: RESPONSIBILITY IN THE TREATMENT OF FRACTURES.
605
tions of the human system by medical means is never con-
sidered sufficient ground for damages against the physician ;
but whoever is so unfortunate in his practice as to get a
badly deformed limb, is doomed to be ever shadowed by its
possessor (for he never dies, but remains waiting and watch-
ing in the hope that the doctor will accumulate property
enough to make it worth while to bring a suit for damages).
What can the surgeon really do in the treatment of
fractures ? What are the limitations of his art ? These are
important questions, and have a direct bearing upon the
physician's responsibility in law. Men of limited experi-
ence, who may have had the good fortune to treat a few
cases of simple fracture, without displacement, and who
have obtained good results, are misled by their success, and
imagine themselves authorities upon the subject ; and by
their ignorance of the real conditions to be met with in
more complicated cases, are capable of doing harm when
they attempt to dictate to juries what should have been the
proper treatment in a given case. Such evidence is mani-
festly incompetent ; but it often has greater weight with
the court and jury than the highest authorities in the land.
It is not to the ignorant and inexperienced that we look
for guidance, but to those men whose opportunities for ob-
serving and experience in treating fractures give them the
right to be heard. They all agree that shortening, with
some deformity, after the fracture of long bones is the rule
in practice, regardless of any of the plans of treatment now
in use. Such statements from recognized authorities indi-
cate what we may expect under the most improved methods
of treatment, and we have only to refer to our individual
experiences to confirm this statement in full.
It is certainly discouraging, after applying all the im-
proved methods, to find that, somehow or other, broken
limbs will unite with deformity when we have done our
best to keep them straight, and, after all our care and
anxiety, very likely involve us in costly litigation, because
we were unable to restore the part to its original perfec-
tion. Were it possible to join broken bones as the artisan
does wood and steel, by mathematical rule, there might be
some excuse for so rigid an enforcement of the law. But
instead of that we have a human being to manage, diseased
conditions to treat, muscular action to overcome — condi-
tions that in many instances are absolutely beyond our con-
trol. The more common deformities following fractures,
such as are liable to occur in the practice of any one, are
the cases that are paraded in court and exhibited to juries
to enlist their sympathies and influence them to return a
verdict against the physician.
Perfect results are seldom obtained by any or all meth-
ods now in use ; but the law requires impossibilities of no
man, only a reasonable performance of what he undertakes.
The same rule applies to lawyers, engineers, machinists,
and all other classes who transact business requiring special
skill. The requirements of the law, as applied to the physi-
cian, are : First, that he possess " that reasonable degree of
learning, skill, and experience ordinarily possessed by others
of his profession " ; second, that he use ordinary care in
the treatment of the cases committed to him ; third, that
he use his best judgment in matters of doubt. He is not
responsible for want of success unless it is proved to result
from want of ordinary skill or ordinary care. He is not
responsible for errors in judgment or mere mistakes in
matters of reasonable doubt.
These are the principles of common law, and if strictly
adhered to would protect the medical profession from un-
just and malicious persecution. We admit the fundamental
principles of the law, but have a right to complain at the
unjust discrimination in its practical application to physi-
cians. Individuals of all other trades or professions can
be guilty of negligence or want of skill, and are never pun-
ished. Should disease invade your home by reason of de-
fective plumbing, should your carriage collapse suddenly
from faulty construction and cripple you for life, would you
expect to recover damages ? Certainly not ; such a case
would be ruled out of court. Quacks and impostors ply
their vocation in every community unmolested, while the
skilled physician, who has spent years of study to qualify
himself for his work, is held strictly accountable for every
act, and his treatment overhauled in a court of justice upon
the slightest provocation.
The facilities for bringing suit for malpractice are so
great that no physician, however eminent, is safe. A
pauper, a hungry attorney, and a quack doctor can get a
case into court without the expenditure of a dollar.
The whole system by which the physician is tried is
prejudicial to his interests. The jury is usually composed
of ordinary men who think only upon ordinary subjects, and
can not be expected to judge correctly upon matters per-
taining to medical science. The attorney for the prosecu-
tion summons as experts those who will swear for his side,
regardless of their standing in the profession — men who
care nothing for truth or science, but who can, with as-
sumed wisdom, assert their opinions with a positiveness
that, in spite of all evidence to the contrary, is apt to se-
cure a verdict for the plaintiff.
It is certainly an unsatisfactory application of law that
compels the members of an honorable profession to suffer
the indignity of being confronted in courts of law by igno-
rant pretenders, their good names tarnished, and the earn-
ings of a lifetime squandered in defending themselves.
How can we, as an association, remedy this evil, or, at
least, secure a better recognition of our rights ? I believe
that by united effort much may be accomplished. Do you
know that every case of malpractice that comes into court
is instigated by physicians or so-called doctors, who really
prosecute the case for the plaintiff ? This ought not to be ;
rather should each one strive to elevate the profession to
which he belongs, and gladly lay aside all local jealousies to
rally to the aid of a fellow-physician when unjustly assailed.
During the past year a verdict has been obtained
against a member of this association. Of its injustice
there is not the slightest doubt. Competent physicians
testified as to the correctness of the treatment. There was
no proof of a want of ordinary care and skill. Having es-
tablished his innocence of these charges, nothing more in
the line of defense is possible. The law requires no more,
and yet the jury returned for the plaintiff, with damages of
$500. This is the kind of justice that physicians are con-
606
BREMNER: HOT BLANKET PACKS IN THE TREATMENT OF FEVERS. [N. Y. Med. Jooe.,
stantly receiving in our courts. Some modification in the
system of trying malpractice suits is imperatively de-
manded. A board of arbitration, consisting of physicians
and attorneys, men of scientific attainments, and, above all
things, honest, is the only proper tribunal. Legislation re-
- quiring plaintiff to give bonds for costs is only a matter of
simple justice to the physician. A committee, composed of
members of the association who are willing to devote the time
necessary to becoming thoroughly conversant with medico-
legal technicalities, and to assist in defending those who re-
quire such aid, would prove much more satisfactory than the
bungling manner in which these suits are usually conducted.
To one engaged in the unequal struggle of maintaining
his right before the law, the sympathy of his professional
brethren becomes a grateful assurance. It should be
freely given to every worthy physician. Those who prac-
tice dishonorably, whose ways are dark and mysterious,
have no claim upon us. These are the men who bring dis-
credit upon the profession, and by their sharp methods
create a feeling of distrust against all physicians.
In " the great conflict that is constantly going on be-
tween science and ignorance," it is to be hoped that the
Medical Association of Montana will take the aggressive,
and endeavor to protect the people and the profession by
enforcing a higher culture that shall make the distinction
so great that all may recognize the true physician from the
impostor.
HOT BLANKET PACKS
IN THE TREATMENT OF FEVERS.
By W. W. BREMNER, M. D.
There has lately been a considerable amount of discus-
sion in regard to the Brandt treatment of typhoid fever, by
which a patient is put into a bath of water of a temperature
of 70° F., and, while the reported results seem fairly favor-
able, yet the treatment is apparently harsh and often diffi-
cult of application.
As, week by week, the great number of febrile diseases
is reported by the Health Department, and with such a large
proportion of deaths, I have felt impelled to bring before
the profession a simple method of treatment for typhoid
fever and any other febrile disease (especially scarlet fever
and measles in children) which has been very successful in
my hands and which is perfectly safe, comfortable, and easy
of application, either in private or in hospital practice.
Take a blanket, just large enough to completely envelop
the patient ; fold it lengthwise twice ; then roll it up into a
moderately tight roll. Boil until dissolved two ounces of
good soap in two quarts of water. Pour the boiling solu-
tion slowly into the center of the ends of the roll of blank-
et, stopping at intervals to clap the outside of the blanket
to facilitate its thorough saturation. Either a cot beside
the patient's bed, or half of the bed on which he lies, should
be prepared by laying on it a Mackintosh sheet, over which
is placed a large double blanket dry, so arranged as to come
half-way up on the pillow, and thus be ready to completely
and thoroughly surround the patient's neck. The patient
should be undressed and have a loose blanket thrown over
him. All being in readiness, the roll should be laid at the
bottom of the bed and quickly unrolled from below upward
and spread out on the dry blanket. In about two or three
seconds, judging the heat by the hand, place the patient
upon the center of the hot wet blanket ; two ordinary at-
tendants can easily do this even when an adult is delirious.
Wrap him up, with the arms inclosed, from both sides ;
first with the wet blanket and then with the double dry one,
taking great care to make the dry one fit closely round the
neck, and fastening it in position with a safety-pin. The
feet must be well tucked up, and, if they are inclined to be
cold, a hot-water bottle should be applied and inclosed in
the outer coverings. If the room is cold, another quilt
may be thrown over these coverings. A handkerchief
squeezed out of cold water should be placed on the temples
and renewed every few minutes, or an ice-bag applied to the
whole head. The patient should be supplied with cold wa-
ter to drink as often as desired.
The pack should be continued from one to two hours,
according to the state of the temperature and the feelings of
the patient ; children often fall asleep during the applica-
tion. The temperature will usually fall after it has been
applied a little time, and, if the patient is delirious or coma-
tose, intelligence will return more or less completely. The
pack should be repeated twice or thrice daily until the tem-
perature falls permanently below 101° F. When it is re-
moved, the patient should be gently rubbed with a soft
towel and replaced in the ordinary bedding.
The medicinal treatment in typhoid consisted in small
doses of well-diluted hydrochloric acid, and the treatment
of any symptoms that arose according to their indications :
occasionally, when the diarrhoea was very troublesome, copi-
ous enemata of warm water were given once daily with
marked benefit. In some cases the temperature seemed to
be very little affected, but the same beneficial results fol-
lowed. One very severe case of typhoid fever treated in
this way in 1888 was that of a child fourteen months old.
The case was given up by one of the leading physicians.
The temperature was 105° F., and the child was comatose.
The first pack was put on very wet and left on for three
hours ; it reduced the temperature to normal, and restored
the child to sensibility. In about five hours the temperature
again rose to 105° F., and insensibility returned ; three
packs daily, averaging two hours each, were given for
eleven days before the temperature was reduced to stay be-
low 101°. This child made a good recovery.
In scarlet fever and measles, to commence their treat-
ment by one or two packs of this kind generally seems to
quite break up the disease, and in a large private practice I
can only recollect one death from scarlet fever during several
years, when treated in this way, though in some epidemics
there were very many deaths in the same district among
children not so treated. This method of treatment has all
the advantages of the cold-water applications without any of
their drawbacks. There is no shock to the patients, and
children have no fear of it ; in fact, rather seem to enjoy it.
The temperature can be lowered just as certainly as by the
application of cold water, evaporation takes place from such
a large surface.
May 28, 1892.]
LEADING ARTICLES.— MINOR PARAGRAPHS.
607
THE
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by Edited by
D. Appleton & Co. Frank P. Foster, M. D.
NEW YORK, SATURDAY, MAY 28, 1892.
ASCENDING GONORRHOEA IN WOMEN.
If gonorrhoea in the male still presents many points upon
which pathologists differ, the same affection in the female
scarcoly possesses a point upon which they agree. Ever since
the promulgation of Noeggerath's famous dictum as to the
relation existing between pelvic affections in women and latent
gonorrhoea in men, pathologists have busied themselves in the
attempt to trace the gonococcus of Neisser from its entrance
into the vagina up to the uterus, the Falloppian tubes, the
ovaries, and the pelvic peritonaeum, and to explain the patho-
logical processes found in these various organs as due to its
presence. Many obstacles have surrounded these investigations,
and some of them have appeared insurmountable. For in-
stance, it has generally been held that the gonococcus had not
the power of penetrating into pavement epithelium, and conse-
quently had no power of exciting disease in serous structures.
To explain, therefore, the pathological changes found in the
peritonaeum covering the tubes in cases of pyosalpinx un-
doubtedly due to the gonococcus, as shown by its presence in
the tubes, it was assumed that there was a "mixed infection,"
and that Staphylococcus aureus and Streptococcus pyogenes were
the pathogenic factors of the peritoneal affection. Experimental
researches on the lower animals, which are usually of such
great aid in similar investigations, were not resorted to, because
it was known that the mucous membrane of the lower animals
was not susceptible to the action of the gonococcus. The same
immunity was inferred to exist in the case of the peritonaeum.
If we are to accept Wertheim's investigations, published in
a recent number of the Archiv fur Gyndkologie, this inference
was erroneous. He has succeeded quite readily in exciting
peritonitis in mice and guinea-pigs by injecting pure cultures of
Neisser's gonococcus into the abdominal cavity. Rabbits and
rats were found to be less susceptible, and dogs quite insus-
ceptible. In two cases, after laparotomy done on women,
Wertheim found gonococci in the tubes, the ovaries, and the
peritoneal tissues. Previous to that, no one had succeeded in
finding gonococci in the inflammatory products of the peri-
tonaeum. The gonococci, according to this observer, pass to
the peritonaeum either directly through the walls of the Fallop-
pian tubes, or through their abdominal openings, lie has de-
tected gonococci in every layer of the tubal tissues, and thinks
he is justified in assuming that they may pass directly through
these tissues to the peritoneal surface. It has also been hither-
to maintained that the gonococcus was incapable of exciting
inflammatory action in connective tissue. Wertheim's re-
searches on the lower animals contradict this assertion. He
has succeeded in several instances in setting up a virulent in-
flammation by injecting pure cultures of the gonococcus
directly into the connective tissue of the lower animals experi-
mented upon. In a few cases of pyosalpinx and ovarian ab-
scess gonococci were the only bacteria found. On the strength
of his experiments and investigations, Wertheim concludes that
gonorrhoea in women does ascend to the uterus, to the tubes, to
the ovaries, to the peritonaeum, and into the tissues of the
broad ligaments.
MINOR PARAGRAPHS.
" SUNDOWNERS."
This term, as our readers have been informed, is applied in
Washington to physicians who, being employed during the day-
time in some of the Government offices, devote their evenings
to what medical practice they may succeed in picking up.
These gentlemen are accused of "cutting rates," and in that
and other ways they seem to have incurred the hostility of the
other medical practitioners of the city. Perhaps as a conse-
quence of this feeling, the Medical Association of the District
of Columbia, we learn from the Washington newspapers, has
incorporated in its by-laws the following declaration: "No
graduate of medicine shall be eligible to membership in the
association who shall not devote his entire time to the practice
of medicine." The association has, of course, a perfect right to
limit its membership in any such way as this, but it seems to
us that the limitation, if strictly carried out, will deprive the
association of the company of many gentlemen who would be
an ornament to any medical body, and it is quite imaginable
that some of the genuine "sundown doctors" might be of the
number.
OIL OF EUCALYPTUS.
This oil has grown into such great demand in Europe that
over twenty thousand pounds were exported from California in
1891. A sketch of the rather remarkable history of this com-
modity is given in the Independent, which dates the beginning
of the cultivation of the tree in California from 1869. In that
year fifty acres, near Hay wards, were planted, chiefly for lumber
purposes. Since then enormous numbers of the tree have been
planted. About ten years ago the discovery was made that a
decoction of the leaves of eucalyptus had the property of remov-
ing the scales of incrustation from boilers. While the engineers
were preparing their anti-scale fluid they appeared to be cured
of their ailments, such as bronchitis and asthma, and they started
a factory or works for the extraction of the oil at San Lorenzo.
From this, as a beginning, a very considerable industry has
sprung up.
METHYLENE BLUE IN MALARIAL FEVER.
In the Bulletin of the Johns Hopkins Hospital for May there
is a report by Dr. W. S. Thayer of seven cases of malarial fever
treated with methylene blue. He concludes that it has a defi-
nite action in the disease, accomplishing the destruction of the
specific organism, though less efficacious than quinine and fail-
ing in many cases in which the latter drug is efficacious. Methy-
lene blue acts rapidly, the chills disappearing, and the tempera-
ture falling to normal in the first four or five days, though if a
sufficient number of organisms resist the drug they develop
again rapidly during its administration, and the malarial symp-
toms return. The drug seems to have no advantage over
quinine that would warrant its further employment in malarial
fever.
608
MINOR PARAGRAPHS.— ITEMS.
[N. Y. Med. Jock.,
THE UNIVERSITY OF VIRGINIA.
The annual circular of this institution shows the organiza-
tion of a summer faculty, for the private instruction of intend-
ing medical students and practitioners who desire to refresh
their knowledge during the months of July and August. The
courses of study are also arranged to suit the needs of those
who are about to undergo an examination for the army or navy
medical staff. The summer instruction is carried on both by
lecture and by laboratory work.
THE SUDDEN DEATH OF A BICYCLIST.
A young Englishman is reported to have died recently of
cardiac angina, after overstrain in riding his " wheel." He had
shortly before covered forty miles in very quick time, and was
in training for a competitive or record-breaking contest; so that
the competition rather than the bicycle must be held accounta-
ble for his death.
ITEMS, ETC.
The Massachusetts Medical Society will hold its one hundred and
eleventh annual meeting in Boston on Tuesday and Wednesday, June
7th and 8th, under the presidency of Dr. Amos H. Johnson, of Salem.
The programme gives the following titles :
The Relations of Bacteria to Influenza, by Dr. Henry Jackson, of
Boston ; Pneumonia in the Recent Epidemics, by Dr. W. E. Fay, of
Boston ; The Nervous and Mental Sequel* of Influenza, by Dr. P. C.
Knapp, of Boston ; A Revision of the Medical Nomenclature employed
in the Vital Statistics of Massachusetts, by Dr. S. W. Abbott, of Wake-
field ; Bacteriological and Clinical Investigations into the New Antiseptic
Dermatol, by Dr. A. K. Stone, of Boston ; The Diagnosis and Treatment
of Pott's Fracture of the Ankle, by Dr. L. A. Stimson, of New York ;
Acute Intestinal Obstruction (the Symptoms and Diagnosis, by Dr. F.
C. Shattuck ; the Surgical Aspects, by Dr. John Homans, Dr. J. C. War-
ren, Dr. G. W. Gay, Dr. M. H. Richardson, Dr. J. C. Irish, and Dr. A.
T. Cabot) ; Resume of 100 Cases at the Knowles Maternity, Worcester,
by Dr. G. 0. Ward, of Worcester ; Alexander's Operation, by Dr. W.
M. Conant, of Boston ; Hydatidiform Moles, by Dr. G. A. Craigen, of
Boston; The Treatment of Inflammatory Diseases of the Falloppian
Tubes, with Cases, by Dr. Edward Reynolds, of Boston ; the Shattuck
Lecture, by Dr. J. F. Alleyne Adams, of Pittsfield ; The General Practi-
tioner as a Gynaecologist, by Dr. W. H. Pierce, of Bernardston ; An
Outbreak of Trichinosis in Colerain, by Dr. F. H. Drew, of Shelburne
Falls ; The Treatment of Compound Fractures by Modern Methods,
with a Demonstration of " putting up " adapted to Private Practice, by
Dr. H. L. Burrell and Dr. E. W. Dwight, of Boston ; and The Annual
Discourse, by Dr. Frank W. Draper, of Boston.
The Medical Society of the County of New York. — The programme
for the meeting of Monday evening, May 23d, included a paper on
Plaster Models of Skin Diseases and of Pathological Objects, by Dr. W.
S. Gottheil ; a Note on the Treatment of Cholera, by Dr. C. L. Dana ;
and a paper on Infant Feeding, with Special Reference to Hot Weather,
by Dr. H. D. Chapin.
The New York Dermatological Society. — At the annual meeting,
on Tuesday evening of this week, officers for the ensuing year were
elected as follows : President, Dr. George T. Elliot ; secretary and
treasurer, Dr. Hermann G. Klotz ; members of the executive committee,
Dr. George H. Fox, Dr. Robert W. Taylor, and Dr. Daniel Lewis.
A Monument to Dr. Coste, according to the Union medicate, was
recently inaugurated in a little village of the department of the Ain.
Our contemporary does not mention which Coste it is whose memory is
thus honored, but it speaks of him as the friend of Voltaire, of Choiseul,
of Washington, and of Goujon. From this we infer that it is Jean
Francois, who figured in the American Revolution, and not the great
embryologist.
The Death of Dr. John K. Ambrose, formerly of Staten Island and
Brooklyn, took place at his home on Madison Avenue on May 17th.
He was a native of Ireland, and about fifty-six years old. He was a
graduate of the Long Island Medical College. He served as coroner in
Richmond County for six years. Until quite recently he was a medical
sanitary inspector of the board of health.
The Death of Professor Wilhelm Braune, of Leipsic, is announced in
the Lancet as having taken place on the 29th of April. He was in his
sixty-first year.
The Death of Dr. Pliny Earle, of Northampton, Mass., on the 17th
inst., removes one of the foremost of American alienists. He was bora
at Leicester in 1809. In 1837 he was graduated from the University
of Pennsylvania. He entered into practice in Philadelphia, but soon
afterward accepted the post of resident physician to the Friends' Asy-
lum for the Insane at Frankford. In 1844 he was called to the Bloom-
ingdale Asylum, and a few years later became visiting physician to the
county buildings on Blackwell's Island. In 1848 he published his well-
known history and statistics of Bloomingdale Asylum. In 1864 he re-
ceived his appointment as superintendent of the State Asylum at North-
ampton, where he made a name for himself in psychopathic medicine
wider than his State and country. His contributions to medical litera-
ture have been numerous, chiefly but not solely in the field of the treat-
ment of the insane. Many of his papers were published in the Ameri-
can Journal of Insanity and the American Journal of the Medical Sci-
ences. Some of these papers have been republished in book and pam-
phlet forms. He was a member of many scientific societies at home
and abroad, also president of the New England Psychological Society.
He was one of the early members of the American Medical Associa-
tion.
Change of Address. — Dr. Horatio F. Wood, to the Masonic Temple,
corner of State and Randolph Streets, Chicago.
Army Intelligence. — Official List of Changes in the Stations and
Duties of Officers serving in the Medical Department, United Slates
Army, from May 15 to May 21, 1892:
Lippitt, William F., Jr., First Lieutenant and Assistant Surgeon, upon
being relieved from duty at Fort McPherson, Georgia, will report in
person to the commanding officer, Camp Eagle Pass, Texas, for duty
at that post, relieving Rafferty, Ogden, First Lieutenant and As-
sistant Surgeon. First Lieutenant Ogden Rafferty, on being relieved
by First Lieutenant Lippitt, Jr., will report in person to the com-
manding officer, Alcatraz Island, Cal., for duty at that post.
Bailt, Joseph C, Colonel and Surgeon, is granted leave of absence for
six months, on surgeon's certificate of disability, with permission to
leave the Department of Texas.
Purviance, William E., First Lieutenant and Assistant Surgeon, is re-
lieved from duty at Fort Riley, Kansas, and will report in person to
the commanding officer, Jefferson Barracks, Missouri, for duty at
that post.
Winter, Francis A., First Lieutenant and Assistant Surgeon, is relieved
from duty at Jefferson Barracks, Missouri, and will report in person
to the commanding officer, Fort Riley, Kansas, for duty at that
post.
Huntington, David L., Major and Surgeon, is relieved from duty in
New York city, to take effect on the final adjournment of the
Army Medical Board, and will then proceed to Los Angeles, Cal.,
and report in person to the commanding general, Department of
Arizona, for duty as Medical Director of that department, relieving
Smith, Joseph R., Colonel and Surgeon. Colonel Smith, on being re-
lieved by Major Huntington, will proceed to San Francisco, Cal.,
and report in person to the commanding general, Department of
California, for duty as medical director of that department.
A board of medical officers, to consist of Forwood, William H., Lieu-
tenant-Colonel and Surgeon ; Gibson, Joseph R., Major and Surgeon ;
and Turrill, Henry S., Captain and Assistant Surgeon, is appointed
to meet at West Point, N. Y., June 1, 1892, or as soon thereafter as
practicable, for the physical examination of the cadets of the gradu-
ating class at the U. S. Military Academy, and such other cadets of
May 28, 1892.]
ITEMS.— PROCEEDINGS OF SOCIETIES.
609
the Academy and candidates for admission thereto as may be or-
dered before it.
Kimball, James P., Major and Surgeon. The leave of absence granted
is extended one month.
Shaw, Henry A., First Lieutenant and Assistant Surgeon, is granted
leave of absence for two months, to take effect June 25, 1892, or as
soon thereafter as his services can be spared.
Suter, William N., Assistant Surgeon, to be Assistant Surgeon with
the rank of Captain, May 16, 1892, after five years' service, in
accordance with the act of June 23, 1874.
De Witt, Theodore F., First Lieutenant and Assistant Surgeon, re-
signed May 16, 1892.
Naval Intelligence. — Official List of Changes jn the Medical Corps
of the United States Navy for the two weeks ending May 21, 1892 :
Babin, H. J., Surgeon, and Drennan, M. C, Passed Assistant Surgeon,
ordered to Naval Academy to examine the physical condition of
candidates for admission to Naval Academy.
Biddle, Clement, Passed Assistant Surgeon. Ordered to Marine Ren-
dezvous, Philadelphia, Pa.
Eckstein, H. C, Surgeon. Detached from Marine Rendezvous, Phila-
delphia, Pa., and to wait orders.
Wells, Howard, Surgeon. Ordered to the training-ship Portsmouth.
Stoughton, James, Assistant Surgeon. Detached from the Portsmouth
and ordered to the Constellation.
Marsteller, E. H., Passed Assistant Surgeon. Detached from the Naval
Academy and ordered to the Constellation.
Field, James G., Assistant Surgeon. Granted one year's sick leave.
Horwitz, P. J., Medical Director (retired). Granted six months' leave
to go abroad.
Lovering, P. A., Surgeon. Detached from the IT. S. Steamer Philadel-
phia and granted two months' leave of absence.
Crandall, R. P., Passed Assistant Surgeon. Detached from the Naval
Laboratory, Brooklyn, N. Y., and ordered to the U. S. Steamer
Philadelphia.
Bogert, E. S., Jr., Assistant Surgeon. Detached from the Coast Survey
Steamer Blake and ordered to the Naval Laboratory, Brooklyn, N. Y.
Guthrie, J. A., Assistant Surgeon. Detached from Port Royal Station,
S. G, and ordered to the Coast Survey Steamer Blake.
Eckstein, H. C, Surgeon. Granted leave of absence for six months.
Marine-Hospital Service. — Official List of the Changes of Stations
and Ditties of Medical Officers of the United States Marine-Hospital
Service for the two weeks ending May 21, 1892 :
Murray, R. D., Surgeon. Granted leave of absence for fifteen days.
May 14, 1892.
Hamilton, J. B., Surgeon. Granted leave of absence for eleven days.
May 20, 1892.
Gassaway, J. M., Surgeon. Granted leave of absence for ten days.
May 10, 1892.
Godfrey, John, Surgeon. When relieved as Medical Inspector of Im-
migrants, to resume command of station at New York. May 11,
1892.
Irwin, Fairfax, Surgeon. To proceed to New Bedford, Mass., on spe-
cial duty. May 11, 1892.
Carter, II. R., Surgeon. To proceed to Gallipolis, Ohio, on special
duty. May 18, 1892.
Wheeler, W. A., Surgeon. Detailed as Medical Inspector of Immi-
grants, port of New York. May 11, 1892.
Banks, C. E., Passed Assistant Surgeon. To assume command of serv-
ice at Portland, Maine. May 11, 1892.
Devan, S. C, Passed Assistant Surgeon. To assume command of serv-
ice at Norfolk, Va. May 11, 1892.
Perry, T. B., Passed Assistant Surgeon. To assume charge of Cape
Charles Quarantine Station. May 14, 18!>2.
Woodward, R. M., Passed Assistant Surgeon. Granted leave of ab-
sence for five days. May 16, 1892.
Vaughan, G. T., Passed Assistant Surgeon. Detailed as recorder of
Board for the physical examination of candidates, Revenue-Marine
Service. May 9, 1892.
Wertenbaker, C. P., Assistant Surgeon. Granted leave of absence for
seven days. May 10, 1892.
Houghton, E. R., Assistant Surgeon. To assume command of service
at Vineyard Haven, Mass. May 11, 1892.
Society Meetings for the Coming Week :
Tuesday, May 31st : American Surgical Association (first day — Boston) ;
Medical Association of Central New York (Syracuse) ; Medical Soci-
eties of the Counties of Queens (annual — Mineola) and Rockland (an-
nual), N. Y. ; Boston Society of Medical Sciences (private).
Wednesday, June 1st : American Surgical Association (second day) ;
Society of the Alumni of Bellevue Hospital ; Harlem Medical Asso-
ciation of the City of New York ; Medical Microscopical Society of
Brooklyn ; Medical Societies of the Counties of Cattaraugus (annual)
and Richmond (Stapleton), N. Y. ; Penobscot, Me., County Medical
Society (Bangor) ; Orleans, Vt., County Medical Society (annual) ;
Bridgeport, Conn., Medical Association ; Philadelphia County Medi-
cal Society.
Thursday, June 2d: State Medical Society of Arkansas (first day — Lit-
tle Rock) ; Oregon State Medical Society (first day — Portland) ;
Rhode Island Medical Society (first day — Providence) ; American
Surgical Association (third day) ; New York Academy of Medicine ;
Brooklyn Surgical Society ; Society of Physicians of the Village of
Canandaigua ; Boston Medico-psychological Association ; Obstetri-
cal Society of Philadelphia ; United States Naval Medical Society
(Washington).
Friday, June 3d: State Medical Society of Arkansas (second da)-) ; Ore-
gon State Medical Society (second day) ; Rhode Island Medical Soci-
ety (second day) ; Baltimore Clinical Society.
Saturday", June Ifth : American Academy of Medicine (Detroit) ; State
Medical Society of Arkansas (third day) ; Oregon State Medical So-
ciety (third day) ; Clinical Society of the New York Post-graduate
Medical School and Hospital ; Miller's River, Mass., Medical Society ;
Manhattan Medical and Surgical Society (private).
Answers to Correspondents :
No.. 382. — See an article by Dr. Vaughan, in the Transactions of the
Ninth International Medical Congress.
Iprocccbings of Societies.
NEW YORK ACADEMY OF MEDICINE.
SECTION IN ORTHOPEDIC SURGERY.
Meeting of April 15, 1892.
Dr. Henry Ling Taylor, Chairman.
Hip-joint Disease. — Dr. Lewis A. Sayre said that in his
paper read at the last meeting (see page 477) he had referred to
a case of hip disease that he had seeu in consultation with Sir
James Paget and Mr. Adams, of London, in which it had gen-
erally been considered that recovery could not take place with-
out ankylosis and deformity. He was fortunate in having the
opportunity of presenting the patient at this meeting. The
man could place the feet on a table, could squat down, and, in
fact, could perform every motion so well that it was difficult to
tell which had been the diseased hip.
The Effect of Persistent Motion.— Dr. John Ridlon ex-
hibited a girl, nine years old, who had come to him at the Van-
derbilt Clinic on April 23d. Eight months previously she had
received an injury to the right elbow, which was diagnosticated
as a " fract ure of the coronoid process of the ulna, and a dislo-
cation backward of the radius and ulna." She was attended
by a well -qualified practitioner. The arm was immobilized for
♦;io
PROCEEDINGS OF SOCIETIES.
[N. Y. Med. Joan.,
about four weeks, and then passive motion was begun. Twice
daily the forearm was flexed and extended on the arm to the
limits of tolerance, and twice weekly, under an anaesthetic, the
forearm was flexed and extended to the normal limits of motion-
This treatment was faithfully continued for seven months, dur-
ing which time the range of motion gradually became more re-
stricted, the joint more and more swollen and more painful un-
der the attempts at motion. Examination showed the forearm
flexed on the arm to a right angle, much swelling about the joint,
enlargement of superficial veins, and atrophy of the muscles of
the arm and forearm. The swelling had a pulpy feel, but no
point of fluctuation could be detected. The bony points were
so obscured that the exact nature of the injury could not be de-
termined. There was no motion at the joint, and attempts at
motion caused pain and intense muscular spasm. In the treat-
ment adopted the head was bent down, and the wrist put into
a "halter" made of a roller bandage knotted around the wrist
and neck. The slack of this was taken up as the rigidity yield-
ed, and at the end of two weeks the joint could be flexed com-
pletely. In this position the joint was held without motion be-
ing once permitted or tested for eleven months. The pain dis-
appeared, the swelling gradually subsided, and when the halter
was removed there was found to be free, painless motion from
a right angle to normal flexion. Since then there had been no
treatment, and the range of motion in the direction of extension
was gradually increasing.
Dr. W. R. Townsend said that this girl had been brought to
the Hospital for the Ruptured and Crippled about two years
ago by her attending physician, who said that passive motion
had been made under ether anaesthesia about three times a week
since the fracture to prevent ankylosis. Dr. W. T. Bull, who
had seen the case in consultation, had agreed with the speaker
ju advising rest. The attending physician dissented from this
view, but finally said he was willing to give the joint rest for
a limited time if [he was relieved from all responsibility as
to the result. The case was accordingly treated in the hospital
with a plaster-of-Paris splint for about four weeks, when the
mother objected to a continuance of this treatment. Dr. Bull
again saw the case in consultation, and the opinion was then
expressed that there was a beginning osteitis, and that if motion
was kept up, the child would undoubtedly have a stiff elbow.
The patient and doctor dissented again, and wished passive mo-
tion made; so she was then discharged from the hospital out-
patient department.
Dr. S. Ketch said that if the arm was moved beyond a
certain point, especially in rotation, there was reflex spasm,
and he thought there was still some active disease in the elbow
joint. He asked if the halter allowed of pronation and supina-
tion.
Dr. Ridlon replied that the halter did not prevent these
motions, but, so far as his experience with it had gone, when
properly applied under the clothes, the children, as a matter of
fact, did not attempt to make these motions.
A Case for Diagnosis was presented by Dr. Ridlon. A
man, thirty-four years old, had come to him at the Vanderbilt
Clinic on February 15th. For two weeks he had been stooping
and stiff in the lumbar spine, with pain in the back and lower
abdomen, and, at times, down the front of the thighs. Seven
years before, he had had a similar attack, at which time, after
suffering for four weeks, he went to the dispensary of an ortho-
psedic institution in New York, where the diagnosis was made
of Pott's disease and a Taylor spinal brace applied. He re-
mained in bed for two months, wearing the brace, but without
any relief. He was then admitted into the St. Francis Hospital,
where a blister was applied, and the pain was immediately re-
lieved. At the end of two weeks he was quite well again, and
had remained so up to the present attack. Examination revealed
the whole lumbar spine curved backward and rigid ; there was
psoas contraction on the left side, but none on the right ; and
there was a doubtful fullness in the left iliac fossa. He was
treated with antirrheumatic remedies, and soon showed im-
provement, and in the course of a few weeks felt entirely well.
There was now no spinal curvature, no rigidity, no psoas con-
traction, and the patient was quite well, except that at times
after long sitting over a bench at his work he felt some stiffness
of the back.
An Inexpensive Head Support.— Dr. Royal Whitman
showed a support that he had devised for a child with mid-
dorsal disease, in whom there was a tendency for the shoulders
and the whole body to droop forward. The support consisted
of a curved piece of steel attached to th6 back of the brace
used iu connection with lateral pads for holding the shoulders
back, a form of apparatus which he had already exhibited and
described.
Dr. V. P. Gibney then exhibited a series of operative cases,
including one of ankylosis of the hip after typhoid fever, one of
excision of one hip in a case of double hip disease where sacro-
iliac disease was first diagnosticated, one of excision of the hip,
a case for diagnosis (probably one of subacute rheumatism), and
one of atonic knock-knee.
Some of the Indications for Operative Interference in
Orthopaedic Surgery.— A paper with this title was read by
Dr. Gibney. The paper dealt first with the range of ortho-
paedic surgery as held by the majority of surgeons practicing
this specialty throughout the world. The author commented
on the brilliant results obtained by general surgeons in many
cases that were strictly orthopaedic, and emphasized the im-
portance of supplementing operative procedures with mechani-
cal appliances. It was suggested that orthopaedic surgery might
be advanced if as much time was devoted to the clinical history
and the pathology of the disease which produced deformity
as to the devising of splints and modifications of splints. The
importance of devising splints to suit individual cases and to
meet certain conditions was regarded as an important part of
orthopaedic surgery. It was stated that the orthopaedic surgeon
seldom had an opportunity of putting a splint on a patient in
the very first stage of the disease; that many of the cases of
what was called early hip disease were not early cases, but
that deformity had already arisen when they came to mechani-
cal treatment. The same was true of Pott's disease of the
spine. Some of the indications for operative interference were
mentioned, such as the correction of deformity in these early
hip cases by manual force under ether anaesthesia, by division
of tendons and muscles, if the correction were difficult; and in
the advanced cases, where the disease was fully arrested,
osteotomy below the trochanter minor was suggested as a
valuable addition to therapeutics. With regard to abscesses,
incision was urged if four or five aspirations failed to relieve.
It was further suggested that old sinuses and pockets of pus
should be treated by operative interference. Operative inter-
ference in spinal disease was not recommended except where a
severe trauma had fractured the lamina and where pressure had
resulted. In these cases laminectomy was advised, but it was
suggested that in many instances of this kind the ordinary me-
chanical treatment proved of valuable service. In disease of
the knee partial arthrectomy was advised in preference to com-
plete arthrectomy or to excision, especially in children. In the
internal derangements of the knee operative interference was
advised rather than the prolonged use of apparatus and fixation
splints. In synovial disease, pure and simple, an occasional as-
piration of the joint, with strapping, was regarded as good
practice.
May 28, 1892.]
PROCEEDINGS
OE SOCIETIES.
Dr. L. A. S^yre said that the paper covered too hroad a
field to admit of discussing it in detail, but in general the author
had expressed his own views most accurately.
Dr. Ridlon did not consider that the element of time was
very important, except in those uncommon cases where it was
the difference between a few weeks and several years. On
the principle of leverage, he had been able to reduce the de-
formity in some of the very worst cases of hip-joint disease in
a few hours or a few days as safely by mechanical means as by
operation. It was only the question between a few days fol-
lowing an operation and a few days more with mechanical treat-
ment, and under these circumstances we should not think of
doing a cutting operation. In all cases of disease of the hip or
of the knee leverage reduction would accomplish the result as
well as an operation.
Dr. Ketch said that, while theoretically tbe"orthopaedic sur-
geon should be a good general operating surgeon, in practice he
was not frequently called upon to perform operations, and hence
could not be expected to be as skillful manually as surgeons who
were constantly operating, and on this a natural division of labor
was founded. He inferred from the paper that the author must
have met with a class of cases in which it was unusually diffi-
cult to reduce the flexion, for, as a rule, there was no special
difficulty about reducing this deformity, provided sufficient time
was allowed. Forcible leverage or stretching added an unneces-
sary risk, as there was no way of accurately gauging the amount
of force employed, and hence there was danger of inflicting trau-
matism which would result in lengthening the course of the dis-
ease and causing a speedy return of the deformity.
Dr. Townsend thought there was one class of cases in which
mistakes were likely to follow mechanical treatment, but which
yielded brilliant results after operation — viz., the so-called peri-
articular abscesses. Such an abscess situated outside of the hip
joint often gave rise to symptoms simulating hip disease, and if
it was not treated by operation there was great danger of its
opening into the joint.
Dr. L. W. Hubbard indorsed what Dr. Ketch had said about
the treatment of deformity in the early stages ; he bad found
that the reduction was usually quite rapid. He had never seen
a case of hip disease in any stage, where there was motion, in
which the deformity could not be reduced by position and trac-
tion in a short time, usually not over six or eight weeks. He
could not see the force of the remarks just made about periar-
ticular abscesses, for they were just as likely to open externally
as internally, and, as a rule, they healed quickly without opera-
tion.
Dr. H. W. Berg said that had it not been for careful atten-
tion to mechanical details such important orthopaedic appliances
as the plaster jacket, the long splint, and the Taylor brace would
not have been known ; yet orthopaedic surgery should be broad
enough to include within its scope both mechanical and opera-
tive treatment.
Dr. N. M. Shaffer thought that many of the conditions de-
scribed should necessarily come under the care of the general,
and not the orthopaedic, surgeon. We were all agreed, how-
ever, that the orthopaedic surgeon should be competent to per-
form all the operations of general surgery, just as he should be
able to diagnosticate typhoid fever, the exanthemata, etc. But
it did not follow, because the orthopaedist was prepared to per-
form these operations, or to diagnosticate the diseases coming
under the care of the physician, that he should do either the one
or the other, unless circumstances made it absolutely necessary.
The speaker would have orthopaedic surgeons devote themselves
to the science and art of the mechanical treatment of deformi-
ties, using operative surgery as an adjunct to the mechanical
work, rather than, as many were prone to do, make the me-
chanical part a sort of kite-tail to operative surgery. There was
so much to be learned and so much to be developed in the con-
tinually broadening field of mechanical treatment that there
seemed to be no excuse for the present tendency of orthopaedic
surgery to invade the well-recognized boundaries of general sur-
gery. The tendency ought to be the other way, if orthopaedic
surgery was to succeed as a specialty.
Dr. R. H. Sayre said that orthopaedic surgeons should be
competent to take charge of a case from the beginning to the
end, whether it required mechanical or operative treatment.
Limiting orthopaedic surgery to the use of apparatus was like
limiting the oculist to the application of glasses for the correc-
tion of refractive errors.
Dr. Whitman was unable to see the force or the application
of Dr. Shaffer's remarks on the paper of the evening. A special-
ist was one by reason of the class of cases he treated, not be-
cause of the means he employed. The broadening field for this
specialty was the study of the aetiology, development, and cure
of deformities ; the study of the course, complications, and ulti-
mate results of joint diseases. Treatment must vary with the
social environment of the patient and the severity and duration
of the disease or deformity, and the most successful surgeon was
the one who could best adapt the means to the end to be ac-
complished. Early diagnosis and efficient treatment would to
a great extent obviate the necessity for operations, and it was
proper for one who could select his cases to devote himself ex-
clusively to mechanical treatment. On the other hand, many
chronic and desperate cases of disease and deformity were
brought to the institution with which he was connected. These
patients would be neglected at home and rejected at general
hospitals. Mechanical treatment alone in this class was inef-
fective, unless supplemented by an operation, which was often
a necessary and a life-saving procedure. This exaltation of
mechanics was opposed to the best interests of the patients,
since, in the minds of many, mechanical and operative treat-
ment, which were mutually dependent, were contrasted and
opposed to one another ; thus, on the one hand, patients were
subjected to early and unnecessary operation and afterward
neglected, and, on the other, the benefits of legitimate surgical
interference were not appreciated. Why a broader and, as it
seemed to him, more rational view of the subject need prevent
the study and appreciation of mechanical supports was not ap-
parent. Believing that disease was to be treated in its en-
tirety, and not in phases, he was unable to accept the limita-
tions that Dr. Shaffer would impose on the future development
of orthopaedic surgery.
The Chairman said that, if the orthopaedic surgeon must be
familiar with operative methods, as undoubtedly he must, he
should also be a competent neurologist, for just as serious mis-
takes would follow ignorance of this subject as ignorance of
operative surgery. Certain limitations were naturally placed
upon one's practice, depending upon whether it was private or
dispensary or hospital practice, for in the latter it was often
not the best ultimate result, but the best that could be obtained
within a limited time or with limited means, that must decide
the plan of treatment to be adopted. The author's directions in
regard to the reduction of the deformity in joint disease, and
especially in certain stages of hip disease, while perhaps suc-
cessful with him, wrould be exceedingly dangerous if followed
by the general practitioner.
Dr. Gibney said that the great drawback to letting the gen-
eral surgeon operate in orthopaedic cases was that one frequently
lost sight of the patients, and they were accordingly allowed to
go without the use of protective apparatus and that careful
treatment after operation which was necessary to insure a good
result.
612
PROCEEDINGS
OF SOCIETIES.
[N. Y. Med. Joan.,
NEW YORK SURGICAL SOCIETY.
Meeting of December 23, 1801.
The President, Dr. Arpad G. Gerster, in the Chair.
Excision of the Hip for Disease.— Dr. V. P. Gibney pre-
sented two cases. The first was that of a boy, four years and a
half old, admitted into the hospital on June 30, 1888, with
disease of a year's standing. At that time he was unable to
walk, and stood with his weight on the left limb, with the right
leg flexed at the hip and knee and adducted. There were two
deep cicatrices on the posterior aspect of the hip, with two open
sinuses having everted edges, and there was marked induration
about the hip. The angle of greatest extension was 135°, that
of greatest flexion 120°, and there was adduction over an arc of
about 24°. The distance from the anterior superior spinous pro-
cess of the ilium to the lower border of the inner malleolus was
sixteen inches on the right side, seventeen inches and a quarter
on the left side; the distance from the umbilicus to the lower
border of the inner malleolus was sixteen inches on the right
side and nineteen inches and three quarters on the left side. He
had been operated on six months before in Worcester, Mass.
His general health was poor. Excision was performed on July
17th, the femur being divided below the trochanter major. An
effort was made to remove all the diseased bone within reach,
and the acetabulum was thoroughly curetted. The limb was
put up in plaster of Paris after a full antiseptic dressing. The
highest temperature was 102-4° F. This was on the second day.
It fell a point on the third day and after that did not rise above
101 •2°. The splint was kept on for three months. On the 25th
of August there remained a small sinus. On November 25th,
the sinus persisting, the patient was etherized and the tract of
the sinus was curetted and injected with an ethereal solution of
iodoform. By the 4th of January, 1889, the sinuses had closed.
They opened again on the 8th and remained open until the 29th
of May. On the 26th of January his limb could be extended to
180° and flexed to 140" without using force. Shortly after this
he was attacked with measles and was sent to the Riverside
Hospital, where he remained until the 22d of February, wearing
his splint during the whole time. On the 13th of July the
power of flexion was not quite so good, and that of extension
was not equal to what it had been at the last measurement. The
limb was parallel with its fellow and the cure seemed about
complete. He spent the summer in the country, and in Sep-
tember the splint was removed. At the date of his discharge,
October 10th, the angle of greatest extension was 180° and that
of greatest flexion 130° ; adduction, abduction, and rotation
were about half normal. The distance from the anterior supe-
rior spine of the ilium to the lower border of the inner malleo-
lus was seventeen inches and a half on the right side and
eighteen inches and three quarters on the left side; the dis-
tance from the umbilicus to the lower border of the inner mal-
leolus was twenty inches and a half on the right side and
twenty-one inches and a half on the left side. In other words,
he had an inch and a quarter of real shortening and one inch of
practical shortening. The thigh was three quarters of an inch
shorter than its fellow, the knee half an inch, and the calf
half an inch. The speaker had examined him again on Decem-
ber 19, 1891, and found his general condition excellent; he
walked with a limp, but freely. The distance from the anterior
spine of the ilium to the lower border of the inner malleolus
was twenty inches and a halt on the right side and twenty-two
inches and a half on the left side; the distance from the um-
bilicus to the lower border of the inner malleolus was twenty-
four inches and a half on the right side and twenty-five inches
and a quarter on the left .-ide ; that is, there were two inches of
real shortening and three quarters of an inch of practical short-
ening. His thigh was an inch and a half smaller than its fellow,
the knee three quarters of an inch, and the calf an inch. The
angle of greatest extension was 160° and that of greatest flexion
110°. He had had no relapse since leaving the hospital.
The second case was that of a boy, four years and a half old,
admitted into the hospital on February 13, 1890. His disease
dated from June, 1888. In August, 1888, a splint had been ap-
plied in the out-patient department and had been worn since
that date. A blow upon the hip in January, 1890, had done
much injury, to all appearances, and he came into the hospital
with the hip flexed at an angle of 100°, with great pain, and
allowing of no motion. [A photograph was exhibited, showing
his attitude at the time of admission.] The distance from the
anterior superior spine of the ilium to the lower border of the
inner malleolus was sixteen inches and a quarter on the right
side and the same on the left side; the distance from the um-
bilicus to the lower border of the inner malleolus was seven-
teen inches and a quarter on the right side and seventeen inches
on the left side ; the right thigh was nine inches in circumfer-
ence, the left thigh eight inches and a half; the right knee
eight inches and three quarters, the left knee seven inches; the
right calf six inches and three quarters, the left calf six inches.
He wa9 put to bed and a weight-and-pulley apparatus was ap-
plied with an inclined plane, but at the end of the month his
condition was worse. The inflammation was very active, and
on the 16th of May excision was done. Half an inch of the
upper end of the femur was removed, along with what remained
of its head, and the acetabulum was thoroughly curetted. Care
was taken to remove with the scissors the soft tissues wherever
they seemed to be affected. A counter-opening was made, a
drainage-tube was inserted, and the hip was put up in full dress-
ing with a plaster- of-Paris spica. On July 2d, less than two
moDths after the operation, the operation wound had healed and
a hip splint was applied. It was found that the knee was in
marked recurvation, and a piece was attached to the splint
whereby this could be corrected. The distance from the ante-
rior superior spine of the ilium to the lower border of the inner
malleolus was seventeen inches and a quarter on the right side
and seventeen inches on the left side ; the distance from the
umbilicus to the lower border of the inner malleolus was nine-
teen inches and three quarters on each side ; that is, there was
three quarters of an inch of real shortening, but no practical
shortening. The thigh, knee, and calf were each half an inch
smaller than on the opposite side. He went to Saratoga for the
summer and returned in the autumn, when the measurements
were unaltered. On October 1st the angle of greatest extension
was 135°, that of greatest flexion 100°. On November 5th a
convalescence hip splint was applied. On February 25, 1891,
the splint was removed and a shoe was employed with the sole
a quarter of an inch thicker than that of the other shoe. On
the 23d of March the boy had a fall, striking on his hip, and
this caused some pain after a few days. On the 25th he was
attacked with whooping-cough. In May, 1891, he had a sub-
maxillary abscess, which was opened and soon healed. While
he had the whooping-cough his splint was reapplied, and it was
removed again in June. He seemed so weak in his hip that the
convalescence splint was retained and he was discharged on the
9th of September. At that time the angle of greatest extension
was 150° ; very little motion was presented ; there was a little
reflex spasm, also some tenderness. The distance from the an-
terior superior spine of the ilium to the lower border of the in-
ner malleolus was eighteen inches and a quarter on the right
side and seventeen inches and a half on the left side ; the dis-
tance from the umbilicus to the lower border of the inner mal-
leolus was twenty inches and a quarter on the right side and
May 28, 1892.]
PROCEEDINGS OF SOCIETIES.
613
nineteen inches and three quarters on the left side; that is,
there was half an inch of both real and practical shortening.
The thigh was three quarters of an inch smaller than its fellow,
and the knee and calf each half an inch. He had been very
active since leaving the hospital, and was examined again on
the 19th of December. At that time the distance from the an-
terior superior spine of the ilium to the lower border of the
inner malleolus was eighteen inches and a half on the right side
and eighteen inches on the left side; the distance from the um-
bilicus to the lower border of the inner malleolus was twenty-
one inches on the right side and twenty inches on the left side;
the right thigh measured eleven inches and the left thigh eight
inches and a quarter ; that is, the left thigh had lost two inches
and three quarters in circumference and the knee and calf each
half an inch. The angle of greatest extension was 155° and that
of greatest flexion 140°. There was some genu recurvatum.
External Urethrotomy as a Preliminary to an Opera-
tion for Inguinal Hernia. — The President presented a child
on whom he had operated for the cure of double inguinal hernia
after doing a preliminary external urethrotomy, which pre-
vented contamination of the dressing by the urine. The urethral
opening had proved a distinct advantage and the case was very
, satisfactory, as there was no sign on either side of a return of
the hernia. Silver-wire sutures had been used to approximate
the pillars of the ring. These had been removed from one side
on account of suppuration due to an attack of scarlet fever; on
the other side they had not produced any irritation.
Dr. F. Lange recommended silkworm gut as a substitute
for silver or copper wire for the closure of the ring. It was
stronger, softer, and more elastic, consequently not so apt to
cause mechanical irritation.
Faecal Fistula following Perityphlitis.— Dr. Charles
MoBurnev showed a patient on whom he had operated for the
cure of a faecal fistula resulting from a perityphlitic abscess.
The operation had resulted in a complete cure.
Perityphlitis. — The President emphasized the necessity of
early diagnoses and operations in perityphlitis. He observed
faecal fistula resulting from this affection only where the abscess
was allowed to persist for a comparatively long time. The in-
testine forming part of the abscess wall was apt to slough if
subjected to great tension by the abscess contents. Only re-
cently he had observed a fatal and very extensive necrosis of
the ascending colon, where a very large abscess was allowed to
extend upward until the pus bathed the lower surface of the
liver. Though the abscess was incised and drained on the
tenth day after the inception of the trouble, the patient died
with intensely septic symptoms, as the cause of which post-
mortem examination revealed a slough of the colon three square
inches in extent.
Dr. Lange thought that the case narrated by the President
had been one of those in which, on account of the anatomical
position of the appendix, the abscess had developed behind the
colon and had perforated into the retroperitoneal tissue. It
was possible to approach these abscesses, even before their
perforation, by a lumbar incision parallel to -the crest of the
ilium, which he had done in several cases. He had also oper-
ated in two cases in which, after infection of the retroperitoneal
tissue, extensive sloughing had taken place. In one of these,
for some time after the operation, faecal extravasation of moder-
ate amount had occurred, but the patient had eventually recov-
ered. The other patient had been operated upon about four
weeks ago and was now doing well and out of danger. In this
case suppuration had extended as far up as the diaphragm.
The speaker emphasized the advantage of proceeding against
perityphlitic abscess, if possible, without opening into the free
peritoneal cavity. He also mentioned one very severe case, still
under his care, which he had seen on the 25th of November, in
consultation with Dr. Nicolai, thirty hours after the onset of
the symptoms. This patient had septic peritonitis advancing so
rapidly that in the course of an hour the physician had been able
to observe a decided increase in the exudation. The pulse was 160,
the temperature more than 104°, and the patient weak. Such
patients were most apt to go into collapse after laparotomy and
a radical operation. In this case he had perforated the recto-
vesical recess of the peritonaeum through the anterior wall of
the rectum, and had given vent to several ounces of stinking
pus. The symptoms abated promptly and sufficiently to admit
of laparotomy two days later, with removal of the appendix,
which showed perforation near the point of its insertion into
the colon. Fourteen days later a third operation was done for
an encysted abscess below the lower border of the liver, and
since then the patient had been without fever and was doing
well. He had had faacal discharges from the first abdominal
wound for about a week, owing, probably, to the cutting through
of the ligature of the appendix, which had had to be applied
almost within the wall of the colon, on account of the perfo-
ration being so close to the latter. To the speaker this case had
been very instructive in his effort to gain time, by a quick pro-
cess which was not fraught with danger, for a radical interfer-
ence, which the patient most probably would not have borne
when suffering under the depressing effect of the acute process.
Statistics of Operations upon Tuberculous Hip Joints.—
Dr. Charles T. Poore read a paper with this title (see page
449).
Dr. Lange asked whether the author or any other member
of the society had found symptoms which pointed to the locali-
zation of the osteitic process before perforation into the joint,
so that one could say whether the femoral or the iliac constitu-
ent of the joint was affected. Dr. Poore had trephined the neck
through the trochanter in a number of cases. What had led
him to suppose that he would find the focus there? The speak-
er's own experience had convinced him that acetabular coxitis
was observed almost as frequently as femoral, and he had tried
to approach such foci in three cases without opening into the
joint. In these cases tenderness on deep pressure and a slight
tumefaction over the rim of the socket had been present, but
the movements of the joint were comparatively free in spite of
the fact that the disease was of considerable duration. In one
case an intrapelvic abscess existed, which could be felt as a hard
swelling through the rectum. This patient got well without re-
moval of the head of the femur, though the joint was opened
into during the operation and several years of mechanical treat-
ment had to follow. The second patient had passed from bis
observation after having done well for a number of months.
Later on he had seen the patient with all the symptoms of de-
structive joint disease and spontaneous dislocation of the head
of the femur upon the ilium. He had not treated him since.
The third patient he had operated upon at the German Hospital
five or six years ago. In this instance the joint had to be opened
to get at the focus, which was at the top of the socket. The
femur was then replaced. He was unable to say what the final
results in this case had been, but up to the date of the patient's
discharge from the hospital he had done well. Theoretically,
this method of procedure was rational, and it was a great func-
tional advantage to the patient if the head of the femur could
be preserved. His experience had been too limited to permit
him to form a decided opinion.
Dr. Poohe, in reply, stated that in his experience primary
disease of the acetabulum was exceedingly rare, that he did not
see how it could be detected, because the joint itself must be-
come involved very early in the course of the disease, and the
symptoms would be those of trouble within the articulation.
614
MISCELLANY.
[N. Y. Med. Jouk.,
The vast majority of cases of tubercular disease of the hip be-
gan in the femoral portion of that articulation. The symptoms
of articular osteitis were so well marked that he did not think
the diagnosis was attended with any difficulty. He was satis-
fied that, if one intended to trephine, it should be done early,
not after spasm had existed for a long time, for in the latter
case the joint itself was probably involved.
HT t s c c 1 1 a n g .
The Nature of Hysteria. — The May number of the Edinburgh
Medical Journal gives the substance of a communication to the Royal
Medical Society by Lim Boon Keng, Queen's Scholar of the Straits'
Government ; Curator of the Library of the Royal Medical Society ;
Student of Medicine, Edinburgh University.
The subject, says Mr. Keng, is probably as old as medical literature
itself. Yet the account given of it in our ordinary text-books is far
from being satisfactory, in spite of the fact that most medical writers,
from Hippocrates downward, have attempted to solve the problem.
Indeed, a reference to the literature of this " neurosis " is not likely to
give one much encouragement in the study of its nature. Instead of
finding our difficulties solved, we are at a loss to know how to effect an
escape from the tangled web of ancient, mediaeval, and modern theories,
whose number is legion ! The doctrines of Hippocrates and his follow-
ers, founded on those of Pythagoras and Plato, are interesting enough ;
while the teaching of Galen, embodying as it does the essence of the
humoral pathology of the older school, shows a decided advance, inas-
much as Galen and Aetius deny that the uterus moves from its place.
According to Hirsch, in the Brahminical hymns hysteria is referred to
as a disease of the nervous system. But in the Middle Ages science
was in such a condition that demonology, which the Coan sage success-
fully discarded from medicine, again occupied the attention not only of
the ignorant, but also of the learned. The credit belongs to the much-
maligned Paracelsus for boldly asserting, amid much opposition, that
the epidemic dancing manias were not due to the influence of evil spirits
or such like. When the anatomy and physiology of the nervous sys-
tem became better understood from the works of Willis, Sylvius, Des-
cartes, Haller, and others, numerous authors began to regard the nerv-
ous system as the seat of hysteria. But from the time when the uterus
was regarded as a roving animal, down to the eighteenth century, hys-
teria had been regarded as a malady peculiar to women. Sydenham
was among the earliest observers to show that this neurosis was also
seen in men, although he did not seem to make a distinction between
hysteria and hypochondriasis. Without attempting to consider the
views of Piso, Lepois, Stahl, Hoffmann, Cullen, Pinel, and a host of
well-known writers, we pass to the most widely accepted theory in the
present generation. Some thirty or forty years back, Romberg, Bright,
Copland, and others associated the uterus with the nervous system in
explaining the nature of hysteria ; but no authority now maintains that
uterine irritation or congestion is an essential element.
The favorite theory accepted nowadays is, of course, more scien-
tific and rational than that of Piso or any of his contemporaries. It
explains, however, as little as did " the animal spirits " of Sydenham
and his school. The result is, therefore, no progress is made in the
study of hysteria. In hospitals, cases of this affection are well re-
corded, but nothing is done in the way of research that is calculated to
increase our knowledge of the pathology of hysteria. So long as no at-
tempt is made to investigate this complex disease beyond staring, as it
were, at our patients, no advancement need be expected. What line of
research, then, is open to us ? The answer will appear quite obvious
when we have discussed the nature of hysteria in the light of modern
physiology.
Hysteria is often described as a neurosis resulting from defective
inhibitory power, or caused by a perverted will. The emotion and
imagination have, as it were, rebelled against common sense and judg-
ment. But does this theory of " faulty inhibition " really inform us
much as to the nature of the malady ; does it not rather tend to cover
our ignorance t How often one hears "a general neurosis" or "func-
tional disease " mentioned in reference to hysteria ! These words mean
nothing more than this — the disease exists, but we are ignorant of
its nature. Unfortunately for some of us, these terms are sometimes
employed as if they imply pathological entities. The perverted will, the
exalted emotion, the erotic condition, the loss of controlling power, or
the diminution of mental activity, can not, properly speaking, be the
cause of hysteria any more than can we say that apoplexy is due to the
loss of nerve power on one side of the body. The undue activity of the
ideational centers and the diminution or perversion of volitional power
are surely only the manifestations of the hysterical constitution. They
presuppose a morbid condition which produces them rather than are in
themselves causal factors in the production of hysteria.
The symptoms of mild cases of hysteria point to a morbid condition
of the functions of the higher parts of the brain. They are capable of
being explained by some f unctional disturbance, truly so called, of the
cells concerned in ideation. The habit, education, and mode of life of
the individual may be sufficient to produce this neurotic condition. It is
more common in women than in men, simply because females are more
easily excitable and more emotional than men. The perversion and ex-
altation of imagination may come on gradually or suddenly, according
to the nature of the exciting cause. But the activity or sluggishness of
the mental functions depends upon the same laws as those that regulate
the functions of other tissues. The whole question, therefore, of the
action of nerve cells — sensory, psychical, motor, or organic — is at bottom
a chemical problem. The amount and character of the work done by the
cells of the cerebral cortex determine, no doubt, the extent of waste prod-
ucts discharged into the circulating medium, and also the properties of
these effete or transitional compounds. These cells must, like other cells,
possess a maximum and minimum limit to their activity. Within this
range their metabolism may be increased or diminished, and likewise
the waste products of this intracellular change will vary, but they are
not likely to produce obvious evil effects. They, no doubt, are largely
concerned in causing the multitude of subjective phenomena complained
of by hysterical patients. But it must be remembered that the perverted
psychical functions are quite sufficient to give rise to nearly all the symp-
toms. Bad moral training, undesirable environment, sentimental read-
ing, undue emotional or sexual excitement, especially if often repeated,
aided by idleness or late hours, or both, may so disturb the psychical
processes that the nervous system becomes exhausted. In this condition,
those parts of it which have been little or not at all influenced by the
will may be the first to indicate the irritability of the nervous system.
But if the will, as is so often the case, has never been put to much use,
then the weakness tells principally on the cells concerned in volition.
In other words, this breakdown shows itself through the weak points.
The inherited neuropathic diathesis is therefore an important element
in the causation of hysteria. But even in one without a neurotic heredi-
tary history constant undue attention to trifling sensations will and must,
according to the law of summation of stimuli, produce in the end mis-
chievous results by altering the modality of the normal processes in the
nervous system. As surely as each additional link in a chain adds to
its length, so does each response to central or peripheral stimulus aug-
ment the cell-activity occurring between the arrival of the afferent and
the discharge of the efferent impulse. Thus ovarian irritation, fright,
and so on, produce in such persons, neuropathic or otherwise, the char-
acteristic features of hysteria. The constant association of this condi-
tion with movable kidney lends some countenance to our view. As an
example of how a diminution of action in the nerve cells will explain
certain cases of hysteria, it will suffice to point out the effects of the use
or non-exercise of the will. Every one is aware of the difficulty of get-
ting up early in the morning, especially if unaccustomed to do so. A
person may lie wide awake — may feel he has something to do — but can
not, rather will not, muster up enough courage to rise. The perversion
of the will in certain cases of hysteria is an example of this condition in
an exaggerated form. Under an unusual stimulus the greatest sluggard
will be too glad to get out of his bed hours before the usual time. In
like manner, by an unusually active stimulus we may bring these pa-
tients suffering from mild forms of hysteria to their common sense. No
May 28, 1892.]
MISCELLANY.
4—
615
doubt, as Dr. C. H. Jones remarked, a good whipping will sometimes do
more good in these cases than all the antispasmodics, and will prove as
efficacious as the much-vaunted hypnotic influence. In short, a moral
treatment is what is required. This is much emphasized by Dr. Rev
nolds. In Dr. Wyllie's female wards in the Royal Infirmary a stomach
siphon-tube hanging by the bedside sometimes acts as a charm in pre-
venting vomiting which, perhaps, can not be easily controlled by seda-
tive medicine.
But hysteria may show itself in much graver forms than we have
hitherto considered. Besides subjective phenomena, it may produce
symptoms that closely simulate those of organic disease. Sir J. Paget's
chapter on Nervous Mimicry brings out this point very well. In these
cases, which we must regard as the graver manifestations of hysteria,
the histokinesis may be supposed to have passed beyond the usual range,
or may have been otherwise perverted. In consequence, abnormal transi-
tional products are thrown into the blood, and affect those parts most,
or first, or solely, according to their affinities for them. In this way,
probably, are produced the convulsions, paralysis, hallucinations, delu-
sions, erotomania, visual aberrations, coma, and other phenomena, which
are more or less permanent, until the patient has received proper treat-
ment. In these cases, too, the purely nervous action is not ignored, but
it is maintained that, apart from the perversion of nervous function,
waste products, the result of this state of the nervous system, aggravate
the condition. What the nature of these poisonous bodies may be is a
subject for investigation. It is in the blood and body fluids that they
must be looked for. Possibly they may be of the nature of albumoses
or proteids of some kind. At any rate, the researches of Gautier justify
our supposition, which is made only as a basis for purposes of investi-
gation. In short, this assumption opens up anew line of research which,
even if it does prove our supposition to be entirely fallacious, must tend
to throw more light on the subject.
In conclusion, the nature of hysteria may be briefly said to be a
psychico-chemical disturbance of the nervous system. The constant
presence of nervous symptoms in chronic metallic poisoning, in malaria,
litiuemia (Murchison and Fagge), some forms of diabetes mellitus, and
other diseases of allied nature, point to the importance of suspecting the
presence of chemical bodies in the blood. Dr. Weir Mitchell's method
of treatment is so valuable and efficacious because it insures the re-
moval from the body of waste products whilst it tones up the nervous
system. If this paper seems too wildly speculative to those who decry
hypotheses based even on established facts, then the writer may ask
what we know of the nature of diseases like diabetes, gout, rheumatism,
and other forms of blood poisoning. Dr. Ferrier, on a recent occasion,
referred to the value of speculations, and defined their proper sphere.
In his great work he adopts a passage from Lewis as his motto — " In-
deed every discovery is a verified hypothesis." The writer only hopes
that this imperfect paper may lead some who have the opportunities to
make a rational research into the nature of hysteria ; so that in the
treatment of this common malady it may not be said of us : " Medicus
nihil aliud est quam animi consolatio."
The Song of the Bacilli of la Grippe. — Dr. S. K. Davis, of Liberty-
ville, Iowa, has sent us the following verses :
We're a band of jolly rovers ;
We have come, but not to stay.
Though you think our visit lengthy,
We will leave you by next May.
Like the icy winds of winter,
You may feel us down your back ;
Or the raging heat of summer,
When you think your head will crack.
But to see us, please remember,
You had just as well be blind,
For we're not on exhibition,
We're not of the showy kind.
You may scan our field of labor,
Bring the microscope to bear,
But you'll only find the foot-prints
That we left behind us there.
Scientists of every nation,
Skilled in hunting down the germs,
Have been thwarted in the efforts
Made to bring us to their terms.
Doctors, too, of skill and knowledge,
Have been seeking us to kill,
But as yet they're undecided
Just what thing will fill the bill.
Charlatans with vague conceptions
How toward victims we behave,
Have attributed our departure
To the mixtures vile they gave.
But, intrenched in mucous membranes,
At their efforts we grin in glee,
Feast and fatten on quinine powders,
And warm our feet in ginger tea.
Antifebrin, though so deadly
To our friends the fever germs,
Has no terrors for us fellows,
For we're on the best of terms.
Phenacetin, though much lauded
By the firms where it is made,
Has been by progressive doctors
Tried, and then laid in the shade.
In fact, we've waged bitter warfare
With all drugs to science known,
But have never yet retreated
Till we made our victim groan.
Though to kill we've no ambition,
Yet, to hear the stories told,
You would think that all the graveyards
Would not half our victims hold.
That many die is not denied ;
But here suspicion takes a breath
And hints that drugs in heroic doses
May, and do sometimes, cause death.
Antipyrine, though so potent
To deplete the doctor's purse,
Has outrivaled us in favor
With the man that runs the hearse.
Old moss-backs of ancient laurels,
Advocates of leech and lance,
With " ten and ten " and antimony
Seize the prize ere we've a chance.
If our victim treats us kindly,
Stays indoors and keeps us warm,
We will make our visit shorter,
And will do him little harm.
But in cold and stormy weather,
Should he take us out to freeze,
He will soon regret the treatment,
For we'll surely make him sneeze.
We will make his back and head ache,
And his muscles pain him sore,
And the tears run down his cheeks
As they never did before.
We may shake him like an ague
Till he's cold enough to freeze ;
Then we'll penetrate his lungs
Till we make him cough and wheeze.
Or perchance attack the pleura
Which all lungs arc with supplied,
And will penetrate this membrane
To the cavity inside.
616
MISCELLANY.
IN. Y. Mkd. Jour.
Sometimes we invade the sanctum
Of the thinking part of man,
And inflame the dura mater,
Though not usually our plan.
Instances, too, are recorded
Where our army did invade
The renal regions, and a siege
To Malpighi's tufts was laid.
In fact, there is no tissue
Of man's body, that we know,
But which we can, if needs be,
Take refuge in and grow.
But the membrane rich in mucus
Is the place that takes our eye :
There we grow and flourish best,
And our numbers multiply.
Mortality in Cities in the United States. — The following table
represents the mortality in the cities named, as reported to Dr. Walter
Wyman, Surgeon-General of the Marine-Hospital Service, and pub-
lished in the Abstract of Sanitary Reports for May 20th :
Chicago, 111
Chicago, 111
Philadelphia, Pa
Brooklyn, N. Y
St. Louis, Mo
Boston, Mass
Baltimore, Md
San Francisco, Cal . . .
Cincinnati, Ohio
Cleveland, Ohio
New Orleans, La
New Orleans, La
New Orleans, La
New Orleans, La
Washington, D. C
Detroit, Mich
Milwaukee, Wis
Minneapolis, Minn. . .
Rochester, N.Y
Kansas City, Mo
Kansas City, Mo
Kansas City, Mo
Kansas City, Mo
Providence, R. I
Toledo, Ohio
Richmond, Va
Richmond, Va
Nashville, Tenn
Pall River, Mass
Manchester, N. II
Erie, Pa
Portland, Me
Binghaniton, N. Y. . .
Mobile, Ala
Altoona, Pa
Altoona, Pa
Altoona, Pa
Altoona, Pa
Altoona, Pa
Galveston, Texas
Auburn, N. Y
Newton, Mass...
San Diego, Cal
Pensacola, Fla
May
May
May
May
May
May
May
May
May
May
Apr.
Apr.
Apr.
May
May
May
May
May
May
Apr.
Apr.
Apr.
Apr.
May
May
May
May
M ay
May
May
May
May
May
May
Apr.
Apr.
Apr.
Apr.
Apr.
May
May
May
May
May
p 2
2 3
sj a
1,099,
1,01)0
1,046
80(i,
461,
448,
434.
298,
386,
261.
242,
242,
242,
242,
230,
205
204.
164.
144.
132,
132.
132.
132,
132,
81.
81,
81,
76,
74,
44,
40,
36,
35,
31,
30,
30.
30,
30,
30,
29,
25,
24.
16,
U,
484
458
454
375
178
210,
166
"98
90
154
159
189
nil
85
91
97
44
49
31
35
30
28
51
84
39
23
DEATHS FROM—
10
16
^Results of the Application of Lannelongue's Sclerogenic Treatment
in Tuberculous Affections. — The Lancet's Paris correspondent says: At
the French Surgical Congress M. Coudray furnished a highly interesting
report on the results of the application of the new method of treating
surgical tuberculous diseases devised by Professor Lannelongue. His
report is founded upon sixty cases, including thirty-one of affections of
the larger joints, nine of the lymphatic glands, six of the foot and fingers,
and four of the spine. The results are stated to be excellent, recovery
from the local lesion being the rule, and the propagation of the bacillus
to distant parts being prevented through the formation of the sclero-
genic hairier due to the chloride of zinc. What is the fate of the ba-
cilli in their conflict with the new elements generated around the terri-
tory occupied by them ? M. Coudray opines that they perish, or that,
at any rate, their activity is paralyzed. This opinion is based upon three
microscopical examinations he has conducted on extirpated masses, and
on the negative results of inocidations. M. Lannelongue explains the
apparition of certain abscesses some time after the injection of the ehlo-
ride-of-zinc solution by supposing that the bacillus colony is encapsuled
temporarily. It is also possible that certain lesions may accidentally
escape the action of the remedy. In a previous letter I wrote of the
treatment of congenital dislocation of the hip joint by Lannelongue's
method. M. Coudray tells us that a little girl of three years, thus treated
five months ago, has now begun to walk, her lameness having diminished
considerably. The femoral head now reaches during adductory and in-
ternal rotatory movements only to a point one centimetr e above the line
of Nelaton-Roser, instead of three centimetres, the point reached before
treatment. M. Coudray has also essayed the method in the combating
of such hopeless diseases as malignant tumors. Applied in three in-
stances (two generalized malignant lymphadenomata and one cancer of
the breast), the size of the growths seemed to be materially diminished
and their development arrested. The difficulty is to circumscribe the
infected lymphatic glands. MM. Ivesco, of Paris, and Dubois, of Cam-
brai, cited cases of surgical tuberculosis cured by them by means of the
sclerogenic method, the practice of which will, doubtless, in time diffuse
itself all over the civilized world.
To Contributors and Correspondents. — The attention 0/ all who purpose
favoring us with communications is respectfully called to the follow-
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THE NEW YORK MEDICAL JOURNAL, June 4, 1892.
#rigrmil Communinttioits.
OBSERVATIONS ON
THE EXCRETION OF URIC ACID
IN HEALTH AND DISEASE*
By C. A. HERTER, M. D., and E. E. SMITH, Pn. D.,t
NEW YORK.
The study of the end-products of nitrogenous metabo-
lism, urea and uric acid, through which nitrogen is excreted
from the body, has for a long time occupied the attention
of investigators and to a less extent that of practicing phy-
sicians. The practitioner has concerned himself especially
with the question of uric-acid excretion in its relation to
■disease, but the usefulness of his observations has usually
!been impaired, even for clinical purposes, by a very serious
deficiency. This is that he has not had at his command
:any method of estimating, with even reasonable accuracy, the
amount of uric acid in a specimen of urine. The presence
of a considerable number of uric-acid crystals in the sedi-
ment of a urine has commonly been regarded as evidence of
exeessive uric-acid excretion. The important fact has been
overlooked that the separation of uric-acid crystals or of
urates depends more on the degree of concentration of the
urine amd its acidity than on the presence of uric acid in
exeess. In other words, such separation does not necessa-
rily depend on an excess of uric acid. Nor, on the other
hand, does the non-deposition of uric acid constitute evi-
dence that a urine does not contain uric acid in excess. We
do not wish to be understood that the separation of crystals
of uric acid from the urine has no significance. Such a
separation is more likely to occur when uric acid is in ex-
cess than when it is not, and when it occurs in the course
of a few hours in a urine of which the specific gravity is less
than T025 may perhaps be regarded as creating a presump-
tion that there is an excess. The use, however, of such a
criterion as this is responsible for many erroneous state-
ments.
But supposing that the methods at the command of the
physician could give him a reasonably accurate knowledge
of the amount of uric acid present in a given urine, he would
still be somewhat in the dark as to the significance of the
result unless he was conversant with the variations in uric-
acid excretion that occur in health. We propose in this
paper to show what these variations are and upon what they
depend, with a view to establishing a criterion for the use
of those who wish to know the state of uric-acid excretion
in special cases. We shall endeavor to point out especially
the following facts :
First. That the absolute quantity of uric acid excreted
varies chiefly with the character of the diet, being high on
a highly nitrogenous diet and low on a diet of carbohy-
drates principally. In health the quantity of urea excreted
depends on the quantity of nitrogenous food ingested.
* Read before the New York Neurological Society, May 3, 1892.
f The determination of uric acid, and the chemical work generally,
have been done by Mr. Smith at my request. — C. A. H.
Hence in health both urea and uric acid totals vary widely
with the quality and quantity of the food.
Second. That the chief clinical criterion as to whether
uric-acid excretion is normal, is not the absolute amount of
uric acid excreted, but the ratio of the uric acid to the urea
excreted.
Third. That the ratio of uric acid to urea in the twenty --
four hours' urine from the same individual in health is fairly
constant.
Fourth. That this ratio is not so constant for different
individuals at different periods of life, but varies between
1 to 45 and 1 to 75.
We shall give the facts from which these conclusions
have been reached. They are derived largely from original
observation. In many respects our results merely confirm
and extend those of other workers. We shall, however, call
attention to certain facts regarding deviations from normal
uric-acid excretion which, so far as we are aware, have been
hitherto unnoted.
It is not easy to present the facts we wish to touch upon'
in simple and logical order. It is convenient to consider
them under the following heads :
1. The Methods used in determining Uric Acid and'
Urea.
2.. The Variations in Total Uric-acid Excretion under
the Influence of Diet, Exercise, etc.
3. The Variations in Total Urea Excretion under the
Influence of Diet, Exercise, etc.
4. The Quantitative Relation of Uric Acid and Urea in
Health.
5. The Excretion of Uric Acid as influenced by Drugs..
6. The Excretion of Uric Acid in Disease.
1. The Methods used in determining Uric Acid and.
Urea.
It is exceedingly important that we should mention
briefly the methods employed in our work, since the char-
acter of the results and the reliance to be placed on them
depends largely on correct methods. The error in much of
the work that has been done on uric-acid excretion is due
to the use of inaccurate methods of determining uric acid..
Of the numerous methods used in determining uric acid,
that known as the Ludwig-Salkowski * method is undoubt-
* A good description of this method can be found in the last edition
of Neubauer's and Vogel's work on the urine. The following modifica-
tion of the method is employed by us : 200 c. c. of urine are treated with
20 c. c. each of the standard magnesian mixture and silver-nitrate solu-
tion, after the usual manner. With concentrated urine, of from 1-022
sp. gr. and upward, especially where highly colored, it is more satisfac-
tory to take only 100 c. c, using 20 c. e. each of the standard solutions
as before. After filtering and washing with ammoniacal water, the pre-
cipitate of phosphates and silver urate is removed from the filter paper
into the beaker by the aid of a stream from the wash bottle, the paper
being retained for subsequent filtration. Instead of using sodium sul-
phide for decomposing the silver urate, we employ a solution of potassi-
um iodide, as suggested by Graves (Jour, of Phys., 12, 1801). Occa-
sionally, however, silver iodide appears in the nitrate, in which case it
is necessary to redissolve the separated uric acid in weak sodium hy-
droxide and filter hot, when the urate is obtained in solution quite free
from weighable traces of silver. For weighing, filter papers of 7 ctm.
618
HERTER AND SMITH: THE EXCRETION OF URIC ACID.
[N. Y. Mku. Jocb.,
edly deserving of the greatest confidence and is the one em-
ployed hy ns. It is a gravimetric method of great accu-
racy.* The drawbacks to it are the number of manipula-
tions involved and the fact that it usually takes several days
to get a result. It is not adapted for clinical work, and, un-
fortunately, there is as yet no method which is.
It is customary to calculate the urea of the urine from
its total nitrogen content. This is accomplished either di-
rectly by the Kjeldahl process or the well-known hypobro-
mide method, or, indirectly, by Liebig's urea method. The
method used by us is Pfluger's modification of Liebig's
method,f a volumetric process that has been well indorsed
for clinical and research work. Among its advantages
are its ready applicability and the relatively simple appa-
ratus required. The method, however, only approximates
a urea method, since other nitrogenous substances which
are contained in the urine are estimated as urea. The
chief of these are uric acid, creatin, creatinin, xanthin,
and other extractives. These substances are contained in
the urine in amounts that are small as compared with urea,
but they make the results on urea determinations higher
than they should be. We shall return to this point.
But while the Liebig method approximates a total ni-
trogen method, it differs from it in one important respect —
namely, this : that it does not include the nitrogen of the
ammonium salts. These are present normally in only small
amount, but when administered for therapeutic purposes
they appear in the urine in increased quantity, and hence
increase the nitrogen as estimated from the total nitrogen
present. On the other hand, the use of salicylates in large
amounts leads to an overestimation of the urea as deter-
mined by the Liebig method, since the salicyluric acid that
appears in the urine is precipitated as urea.
2. The Variations in Total LTric-acid Excretion
under the influence of dlet, exercise, etc.
Uric acid is the medium by which in man the largest
amount of nitrogen, next that eliminated as urea, is ex-
creted from the body. Recent investigations have made it
probable that uric acid is formed chiefly in the liver and
spleen ; there appears to be no satisfactory evidence that it is
formed in the kidney. The most interesting work that has
been done on the source of uric-acid production is that
of Schroder \ and Minkowski.* Schroder found that after
the removal of the kidneys in birds uric acid continues to
be formed and accumulates both in the blood and liver.
He found, further, that the quantity of uric acid in the
liver could be greatly increased after the removal of that
organ from the body by passing blood through it.
diameter are employed, which are dried and weighed in small weighing
bottles. The crystals are washed with about 30 c. c. of water and the
usual correction for dissolved uric acid added to the weight actually
found. — E. E. S.
* Ludwig recovered about ninety-eight per cent, of uric acid from
pure solutions. Two parallels on the same urine gave us 0-390 gramme
and 0-382 gramme for the twenty-four hours.
•(• The chlorides are removed with a standard solution of silver ni-
trate.
% Ludwig's Fextxchrift, 1887, p. 89.
* Archiv f. cjpcriiiicntcllc I'liiininikohnjie und Patholot/i,; xxi.
Minkowski's results confirmed those of Schroder. This
observer removed the liver from geese and studied the
effect of this removal upon the urine. He found that the
urine, instead of containing sixty or seventy per cent, of
uric acid, as it normally does, contained only two or three
per cent. Coincident with this fall in uric acid there was
a great increase in the amount of ammonia. Furthermore,
the urine contained lactic acid. Minkowski thinks it prob-
able from these facts that the liver is the chief agent in the
formation of uric acid, and suggests that uric acid may be
derived in the liver by the synthesis of lactic acid and
ammonia.
The quantity of uric acid excreted daily by a normal
adult varies considerably, and this variation depends more
upon the character of the diet than upon any other factor.
A highly nitrogenous diet increases the excretion of uric
acid. A diet poor in nitrogen greatly diminishes it. A
healthy man weighing one hundred and fifty pounds usually
excretes between seven and ten grains (0"5 and 0-75 gramme)
of uric acid daily. But it is a very important fact, and one
which we wish to emphasize particularly, that the mere
total quantity of uric acid in the twenty-four hours' urine
gives no knowledge as to whether this quantity is or is not
excessive. In order to obtain this knowledge it is essential
that we should know what is the total quantity of urea
(or the total nitrogen) excreted during the twenty-four
hours in which the uric acid is estimated. We shall refer
to this point again.
Exercise increases somewhat the quantity of uric acid
excreted, but the influence even of vigorous and prolonged
exercise is inconsiderable. The differences in uric-acid ex-
cretion at different ages are not exactly proportioned to
the body weight of the individual. Thus, from the second
year of life to the time of puberty the quantity of uric acid
contained in the urine is distinctly greater in proportion to
the body weight than in adults. This is due apparently
to the greater relative assimilation of nitrogenous food at
this period of life. It is said that during the first year of
life the uric-acid excretion is more nearly proportioned to
the body weight.
3. The Variations in the Total Urea Excretion as
influenced by plet, exercise, etc.
Urea is thechief end product of nitrogenous metabo-
lism. Probably nearly ninety per cent.* of the nitrogen
that leaves the body is in the form of urea. Of course, the
urea in the urine is not derived directly from the food taken
into the body ; it is necessary that the food should be first
assimilated and its nitrogen become part of the tissues of
the body before the ingested nitrogen enters into the for-
mation of urea. Nevertheless, the quantity of urea excreted
is, in a general way, proportioned to the amount of nitro-
genous food assimilated. This is a most important fact,
for it thus happens that the quantity of urea excreted is an
index of the activity of the nitrogenous metabolism of the
body. If an adult (of 150 pounds weight) is regularly ex-
* Camerer gives this figure. See Zeitschri/t f. Biologic, xxiv, p.
306. Other observers give somewhat lower figures.
June 4, 1892.J
HERTER AND SMITH: THE EXCRETION OF URIC ACID.
619
creting a large amount of urea daily,* say 50 grammes or
thereabouts, this is good evidence that there is extensive
tissue waste, and if the individual is not losing weight we
know that he must be assimilating a large amount of nitro-
genous food. If, on the other hand, he is excreting a
small amount of urea daily, say 12 or 15 grammes, it is
safe to infer that a small amount of nitrogenous food is
being assimilated, provided the weight is reasonably con-
stant.
The influence of food on urea is well illustrated by the
following observation: A man weighing 170 pounds, in
good general health, and who was somewhat cautious
about the use of nitrogenous food, passed in five consecu-
tive days the following amounts of urea daily: 21*490,
22-591, 19-514, 19-649, and 19-989 grammes. He was
then put upon a highly nitrogenous diet and the urea ex-
cretion jumped at once to the following figures: 28-701,
29-076, 19-799, 29-350, 37*268, 39-731, 41-203, 39*161,
38*126, 41*392, and 36*602 grammes. The subject re-
turning to a less liberal nitrogenous diet, the urea fell at
once to the following figures: 27*795, 29*191, 24*143,
23*034, 24*292, 26*549, 25*085, 23*150, 24*901, 22*362
grammes.
It is thus plain that the quantity of proteids ingested is
the great factor in determining the amount of urea ex-
creted. Other influences are of relatively little importance.
Exercise, which was once thought to exert an important
influence in increasing the urea elimination, has been
shown to have little effect. The observations of Voit f on
a dog made to turn a tread-mill, and those of Fick and
Wislicenus J in the ascent of the Faulhorn, are well known.
More recently Parkes,* experimenting on soldiers, and
North,|| experimenting on himself, have shown that the
increase of urea from exercise is exceedingly small as
compared with the loss of body weight or the work
done.
What has been said of the disproportionately large ex-
cretion of uric acid in childhood is true also of the excre-
tion of urea. Thus reference to Table I will show that a
child eighteen months old, and weighing twenty- eight
pounds, excreted about 12 grammes of urea per day, while
a child ten years old, and weighing one hundred pounds,
excreted regularly between 25 and 30 grammes. This rela-
tively greater excretion of urea in childhood than in adult
life depends probably on the more active metabolism of
child life.
We have already spoken of the importance of using the
urea excretion as a standard in deciding whether the excre-
tion of uric acid is normal or abnormal. We may now pass
to a more minute examination of the quantitative relation
* A normal man weighing 150 pounds and varying only slightly in
weight excretes from 25 to 40 grammes of urea per day if he is on a
mixed diet — i. <?., his urea averages somewhere in the neighborhood of
one ounce.
f Untermch. iiber der Einftuss des Kochsalzes, dex Kaffccs wnd der
Muskelbewegimgenauf der Stoffwechsel. Munich, 1860.
\ Vierteljahrcsschrift d. naturf. Oesellsch. in Zurich, 1865.
* Proceedings! of the Royal Society, xi, 339.
| Journal of Physiology, i, 171.
of uric acid and urea in health, and subsequently to their
relation under the influence of drugs and in disease.
4. The Quantitative Relation of Uric Acid and
Urea in Health.
We have stated that the quantity of uric acid excreted
by a normal individual depends chiefly on the character of
the diet, and we have stated that the quantity of urea ex-
creted depends chiefly on the same factor. If we increase
the assimilation of nitrogenous food beyond the average re-
quired, there is an increase both of uric acid and urea in the
urine, and this increase in the two end-products is in a gen-
eral way proportional. According to some observers, the
uric-acid excretion increases a little more rapidly than the
urea excretion. Other observers have found the urea out-
put to increase a little faster, proportionally, than that of
the uric acid, when nitrogenous food is increased. Our ex-
perience, so far as it goes, confirms the latter view, but it is
possible that more extended observation would show that
no general statement can be made as to this point.
The quantity of nitrogenous food assimilated by an in-
dividual in health who lives on a mixed diet and leads a
reasonably regular life, of course varies a little from day to
day, but not enough to cause a wide variation in the quan-
titative relation of uric acid and urea in the urine.* We
have analyzed the twenty-four-hour urines of a considerable
number of persons, and have found the relation between
uric acid and urea to be fairly constant from day to day,
even though no effort was made to keep the quantity of
nitrogenous food daily ingested even approximately the
same. Reference to Table I will illustrate the truth of this
statement.
But, while the relationship between uric acid and urea
is thus fairly constant in the same individual, there is a
much more considerable variation among different indi-
viduals of the same and different ages. It is difficult to
give figures stating what is the average relation in health.
We may say that in our experience the relation varies be-
tween 1 to 45 and 1 to 65 in adults. A relation higher
than 1 to 45 we look upon with suspicion, unless it is
known that it is a habitual relation, and that the individual
is in good health. A relation lower than 1 to 70 is proba-
bly not met with in normal adults on a mixed diet. On a
bread or milk diet, however, the relation may easily run as ■
low as 1 to 80, or even lower, in health. Thus, Bunge f
mentions the case of a young man whose urine showed a
relation of 1 to 48 while he was on a meat diet, and a rela-
tion of 1 to 82 while he was on a diet of bread. In one
case of petit mal the relation of uric acid and urea ran as
follows on a mixed diet : 1 to 32*5, 1 to 36*8, 1 to 39*2, 1
to 43-2, 1 to 39-2. On an exclusively milk diet the rela-
tions ran as follows : 1 to 61-4, 1 to 66-1, 1 to 76-5, and 1
to 85-8. The absolute reduction in the excretion of uric
acid was in this case even more striking than the relative
reduction, for the total excretion of urea was distinctly re-
duced by the milk diet.
* Of course, twenty-four-hour samples of urine must be used for
comparison. It is also desirable that the patient should take little or
no alcohol during the period of observation.
f Lehrbuch </. physiolog. Chemie, 1889.
620
IIERTER AND SMITH: THE EXCRETION OF URIC ACID.
[N. Y. Med. Jouk.,
Tablk I.
Showing the Ratio of Uric Acid and Urea in Health.
Weight. Sp. gr. Vo1'
I ame.
1
12 mos.
" 1
19 '
19 '
2
2Jyrs.
3
3
tt
4
((
5
4-1
u
6
V
((
7
6
it
8
6*
tl
9
7
tt
(t
7
a
10
8
u
11
10
a
it
10
it
12
12
u
13
12
a
14
15
tt
15
19
a
16
21
n
ll
21
tt
17
21
a
a
21
tt
it
21
a
a
21
a
18* 21
21
tl
c<
21
«
tt
21
a
((
21
a
ti
21
a
((
21
t(
<i
21
tl
it
21
it
19
24
«
u
24
tl
it
24
ti
At
24
It
it
24
ll
C(
24
tt
ti
24
20
24
21
25
tt
25
22
26
it
U
26
tl
23
27
tt
it
27
24
28
a
28
a
25
30
u
27
53
a
28
i 67
29
I 74
tt
<(
1 74
a
Pou mis.
22
28
a
33
36
40
39
43
45
50
55
it
60
74
ti
76
150 (?)
150
190
HI
1-010
1-017
1-014
1-028
1-022
1-013
1021
1-019
1-024
1-027
1-024
1-021
1016
1-015
1-010
1-024
C. c.
244
470
685
375
580
615
510
715
450
765
530
540
lor,:,
1,385
1,300
695
Grammes.
•69
160
90
145
160
((
130
a
103
165
170
104
1-028
1-021
1*122
1-020
1-027
1-025
1-018
1-020
1-016
1-.)17
1-014
1-018
1-017
1-015
1-023
ImI:;
1016
1-031
1-029
1-030
1031
1-030
1-029
1-028
1-019
1-024
1-028
1-026
NaCl.
3-268
5- 754
4247
6- K.-.1
■lot:,
1166
1-099
Urea.
Uric
acid.
Ratio.
•6815
1-736
1- 591
2- 681
1-028
1-026
1-271
5-674; 1-888
1-017
1-022
1-020
1-023
1-026
1-020
825
600
1,195
1,780
965
1,370
1,640
1,485
1,280
1,200
1,340
1,030
1,150
1,250
880
1,590
1,250
1,035
1,000
895
710
635
800
755
660
1,585
840
955
5 838
1,970
2,880
1,045
1,130
420
500
12 398
1-906
2-osc,
1- 211
2- 330
2-317
20-456
9-980
1 1 ■:,•>:,
18-27
4-785
lie
3-312
2-239
2-774
1-741
2436
1- 211
2- 070
1 956
Grammes.
3701
12-095
11- 508
4 437
12- 702
12-979
12-495
16016
1755
25 245
13 606
15-040
21-244
31294
25-410
24116
19-904
25-905
12-230
30 233
38445
31555
37401
34768
32 224
33-380
30486
33- 947
33 058
31- 502
32- 619
33440
34- 370
33- 334
25- 890
27- 805
23 244
30-569
26- 218
28- 538
22 692
11-748
42671
2859
38- 82
39- 88
27- 30
32-95
27-97
35- 74
1277
27-06
25-38
11- 55
12- 010
Grm.
OIl'.IU
206
■207
141
166
1752
■200
•208
•259
•328
•251
•282
•396
•418
•351
•398
•329
•465
•226
•424
•587
•595
•682
•657
•643
•749
•708
•739
•753
•779
•723
•741
•694
•777
•446
•490
•462
•514
•482
•540
■448
•258
•789
•549
•738
•715
•620
•740
•329
•764
•246
•509
•489
•215
•253
53- 9
55-7
55-5
81-1
76-5
74
624
77
67-7
76-9
542
531
541
746
72-4
60-6
605
55-7
54
71-3
655
526
54- 9
52-9
501
4430
4729
45-82
45-21
44- 28
4513
45- 11
49-52
42-98
58
: 56
; 50 3
: 59-4
: 54 3
: 52-8
: 50-5
: 45 5
: 54
: 52
: 54
: 55 7
: 441
: 44 5
: 52 8
: 46-8
: 51-9
: 53-1
: 519
: 53-7
: 47-4
It will be noted on examining the table that there is ap-
parently little difference in the quantitative relation of the
two end products at different times of life. Upon the
whole it would appear that in children the average ratio is
a little lower normally than in adults, but our observations
are not sufficiently numerous to enable a definite conclusion
to be drawn as to this point.
Newly born children are an exception to the general
equality that holds for different periods of life.f It has
been shown that during the first few days of life the rela-
tion of uric acid to total nitrogen excretion is much higher
* The figures from this case are taken from Chittenden and Taylor.
fitudie* from tin Laboratory of Pfiyxio/ooicul Chemistry (Yale), 1889.
f See Martin, Huge, and Biedermann, Ctrlbl.f. d. m. Wissenschafien,
1875, p. 387. See, also, Hoftneier (Virch. Arch., 89, p. 493).
than at any other period ; but this exception is of no prac-
tical interest to us.
We have, then, in the quantitative relation between uric
acid and urea a standard of practical utility by which it is
possible to determine with confidence the state of uric-acid
excretion. It is of course essential that twenty-four-hour
samples be used, for the ratio between the two substances
varies at different times of day, and a partial sample may
not be a reliable index to the condition of the twenty-four
hours' uric-acid excretion.* Thus, a partial sample taken
two or three hours after a meal rich in nitrogen might show
a suspiciously high relation — say, 1 to 40 — whereas the
twenty-four hours' urine from the same individual might
show a relation of 1 to 50, which would be, presumably,
normal.
The variations that occur in health in the relation of
uric acid and urea at different periods of the day have not
been studied so carefully as could be wished. Camerer f
has shown that, after a meal rich in nitrogen, the uric-acid
excretion is at its highest during the hours immediately
after the meal, while the excretion of urea is at its highest
eight or nine hours after the meal. But Camerer's obser-
vations were made in cases where only one nitrogenous meal
was taken in the twenty-four hours, and these cases did not
conform in this and other respects with ordinary condi-
tions.
It is necessary that we should say a word about the
figures given in our table. As already stated, the Liebig
method of determining urea is not, strictly speaking, a urea
method ; it is more nearly a total nitrogen method. Hence
the ratios given in the table are lower than they would have
been if obtained by the use of an ideal urea method. Ac-
cording to Camerer,J about ninety per cent, of all the nitro-
gen the urine contains is present as urea ; according to
Bohland,* the amount is smaller, being about eighty-five
per cent, of the total nitrogen. We might therefore have
corrected our figures by the subtraction of ten or fifteen
per cent, from the figures which we give for urea, but have
preferred to give our first figures for what they are, and al-
low others to make a correction of this kind if they wish.
Haig'H follows Garrod in giving 1 to 33 as the relation
of uric acid to urea in health. There is thus a wide dis-
crepancy between this ratio and the limits in health as given
by us — namely, 1 to 45 to 1 to 65. This difference is not to
be accounted for by the facts mentioned in regard to the
urea method we have employed, since, even with the cor-
rection above suggested, there is still a wide difference be-
tween the figures. Moreover, the urea method used by
Haig is open to precisely the same objection as that used
by us. There can be little doubt that the reason for Haig's
high figure is that the method used by him for determin-
ing uric acid (Haycraft's method) is faulty and regularly
gives high results. This is conclusively shown by Herring -
* Zeitschrift f. Biologie, 1889, 26 (p. 109).
■f Ibid.
| Loc. cit.
* Pfliiger's Archiv, xliii.
|{ Bruin, 1891. This view seems to be based chiefly on one case.
See also Journal of Physiology, vol. viii, 1887.
Juno 4, 1892.]
HERTER AND SMITH: TEE EXCRETION OF URIC ACID.
621
ham and Groves* in a recent paper. We have no hesita-
tion in stating that a relation of 1 to 38 in a twenty-four-
hour sample of urine is pathological. The ratios given
by us for health correspond closely with the figures of
Bunge, Vogel, Salkowski, and Pfeiffer.
5. The Excretion of Uric Acid as influenced by
Drugs.
From a practical point of view, no observations on the
excretion of uric acid are of more interest than those which
relate to the effect of drugs. Observations have been made
upon the action of a variety of drugs, and in some instances
conclusions have been reached that may be regarded as de-
finitive ; but much that has been written is of little or no
value, owing to the inaccuracy of methods used in deter-
mining uric acid, or to more or less glaring defects in the
conditions under which the experimental work has been
done. In the case of some drugs there are conflicting
opinions as to their influence upon the elimination of uric
acid. We shall touch briefly upon the results of the work
which, in our estimation, is most to be trusted. We may
conveniently consider, first, the drugs that are supposed to
increase the excretion of uric acid, and, secondly, those that
are supposed to diminish it.
Alcohol. — As to the effect of moderate doses of alcohol
upon uric-acid excretion the evidence is conflicting. Ac-
cording to von Jaksch, alcohol, in other forms than beer
and wine, diminishes the excretion both of uric acid and
urea. We have made some observations which bear on this
question. A healthy young man, weighing one hundred
and ninety pounds, was given whisky in increasing doses
for three days. The first day the quantity taken was two
ounces ; the second day, three ounces and a half ; the third
day, six ounces. The urine was examined before and after
the trial. The results are shown in the table :
Table II.
Showing Influence of Whisky upon Uric-acid Excretion.
Relation of uric
acid 1 3 urea.
First day before experiment, no j Urea, 31 555 grm. )
alcohol ] Uric acid, -599 " f
Second day before experiment, ( Urea, 37*401 grm. }_
no alcohol ) Uric acid, ,682 " f
1 : 52-6
1 : 54 9
Third day before experiment, ) T- „„ -._„ ,
j f e i i f Urea, 29-052 grm. /
moderate use of beer and V TT . ' ., ° .. y
l Uric acid, -601 " )
36 425 grm.
champagne
First day on whisky, 2 oz. . . .
Second day on whisky, 3£ oz. .
Third day on whisky, 6 oz. . . .
\ Urea,
) Uric acid
1 : 48 3
52- 2
54
53- 1
52-9
50-1
•697 " f
j Urea, 33-534 grm. )
j Uric acid, -620 " J
S Urea, 33-460 grm. )
j Uric acid, -630 " \
First day after experiment, no j Urea, 34-768 grm. )
alcohol j Uric acid, -657 " ^
Second day after experiment, \ Urea, 32-768 grm. )
no alcohol ( Uric acid, -643 " f
Inspection of this table makes it evident that in this
case the whisky taken exerted no appreciable effect
upon the excretion of uric acid. The relations between
uric acid and urea on the days when whisky was taken co-
* Herringham and Groves. Journal of Physiology, 12, 1891. These
observers used the Ludwig-Salkowski method, but their normals give
much wider variations than do ours.
incides with those of the days before and after, when no
alcohol was taken. The slight change in ratio on the
day before the use of whisky was begun may have been due
to the use of beer and champagne on that day. With a
view to seeing whether the influence of champagne (in
quantities containing alcohol in amount approximately
equivalent to that contained in the whisky) differed from
that of whisky, another observation was made. The sub-
ject was given champagne in increasing amounts for three
days. On the first day the quantity taken was eight ounces ;
on the second, sixteen ounces ; on the third, twenty-four
ounces. The results are shown in the table :
Table III.
Showing Influence of Champagne on Uric-acid Excretion.
Ratio of uric
acid to urea.
699 grm. )
First dav, 8 oz. champagne \ J"T'Ta' . . °*
• ' y & / Unc acid,
Second day, 16 oz. champagne.
Third day, 24 oz. champagne . .
j Urea, 29
( Uric acid,
j Urea, 32
( Uric acid.
754 " )
758 grm. )
655 " j
172 grm. )
686 " I
947 grm. |
643 " f
1 : 42
1 : 45-1
1 : 46 8
Fourth day, no alcohol -j acid
It is evident from these figures that while whisky had
no effect upon the ratio of uric acid and urea, champagne
in quantities containing an equivalent of alcohol caused a
decided deviation from the habitual ratio owing to an in-
crease in uric acid. It is interesting to note that the ratio
returned at once to the habitual on the discontinuance of
the wine. A single observation like this proves nothing,
but is not without suggestiveness.
There is good reason to believe that doses of alcoho'
which in health cause no effect upon the excretion of uric
acid, increase this considerably and disturb the normal rela-
tion to urea in persons with the uric-acid diathesis — i.e.,
in persons who tend habitually to excrete uric acid in
excess.
The best work that has been done upon the influence of
large doses of alcohol is that of Chittenden and Smith,*
whose observations were on dogs in a state of nitrogenous
equilibrium. There is no doubt as to the effect, at least in
dogs, of the doses employed by these observers. While the
total excretion of nitrogen was somewhat diminished, the
elimination of uric acid was greatly increased, the increase
amounting to about one hundred per cent.
Sodium Salicylate. — There has been some difference of
opinion as to the effect of this drug, but recent observers
Table IV.
Showing Influence of Sodium Salicylate upon Uric Add.
Day before salicylate j Jj£c\cid) ^ \
First day on salicylate, 3 grm. j Urea, 26-684 grm. |_
taken { Uric acid, -555 " \
Second day on salicylate, 3 gnu. $ Urea, 31-420 grm. /
taken / Uric acid, -615 " )
Third day on salicylate, 3 grm. \ Urea, 27'784 grm. )
taken } Uric acid, -730 " )
! Urea, 27"805 grm. (
Day after salicylate - ^ ^ „ j
Ratio of uric
acid to urea.
1 : 55 3
1 : 481
1 : 511
1 : 38
1 : 56
* The Influence of Alcohol on Proteid Metabolism. Journal of
Physiology, vol. xii, No. 3, 1891.
622
HERTER AND SMITH: THE EXCRETION OF URIC ACID. [N. Y. Med. Jocb.
agree that salicylate of sodium causes a decided increase in
uric-acid excretion as compared with urea. We have made
the following observations on this drug : A young man in
good health was given three grammes of sodium salicylate
three times daily for three days. The urine was studied on
these days, and on the day before and the day after. The
results are given in Table IV.
In this case the effect of the salicylate of sodium was
decided. The increase in uric acid was greatest on the third
day of the trial, when the ratio to urea was 1 to 38. On
the day after this the relation went back to 1 to 56 — that
is, to about where it was on the day before the salicylate of
sodium was first taken.
Two similar observations were made upon persons who
are subject to migraine. In the first case five grains of
salicylate of sodium, t. i. d., were taken for three days.
After this, ten grains, t. i. d., were taken for three days.
The results were quite inconclusive. In the second case
the quantity taken was three grammes daily for three days.
The results in this case were also inconclusive. It is in-
teresting that in both cases the use of the drug was accom-
panied by headache, which in the first case lasted several
days and was general in distribution ; and in the second
case was a typical migraine paroxysm coming on at the end
of the experiment.
Alkalies. — Alkaline waters are said by some to increase
and by others to decrease the excretion of uric acid. Which
of these views is correct we are unable to say. The ques-
tion appears to call for reinvestigation.
Quinine. — In recent times the influence of quinine upon
metabolism has been studied by Kerner,* Prior, f and Sas-
setzky. \ Kerner found that doses of 9-3 grains of quinine
hydrochloride, continued for three days, reduced very con-
siderably the excretion both of urea and uric acid. But
while urea was decreased twelve per cent., uric acid was
decreased fifty-four per cent. These small doses of quinine,
therefore, greatly diminished uric-acid excretion, both ab-
solutely and relatively. The experiments of Prior gave
equally striking results as regards the diminution of uric-
acid elimination, and Sassetzky, experimenting with fever
patients, was able to confirm Kerner's observations.
Kerner's results have been criticised by Oppenheim,*
who found that a dose of 30-8 grains of quinine increased
the elimination of urea by four grammes a day. Oppenheim
believes that the results obtained by Kerner were due sim-
ply to interference with the proteolytic action of the gastric
and pancreatic juices, which the use of quinine certainly
causes. Prior has shown, however, that such interference
does not satisfactorily account for the unquestionable re-
tarding influence of quinine on proteid metabolism.
Chittenden and Whitehouse,|| working with cinchoni-
* Pfliiger's Archiv, vol. iii, p. 104.
f Ueber den Einfluss des Chinin auf den Stoffvvechsel des gesunden
Organismus. Pfliiger's Archiv, vol. xxiv, p. 237.
% Ueber den Einfluss fieberhafte Zustiinde, etc. Vircbow's Archiv,
vol. xciv, p. 485.
* Pfliiger's Archiv, vol. xxiii, pp. 476-47*7.
| Influence of Cinchonidine Sulphate on Metabolism. Studies from
the Laboratory of Phys. Chemistry, Sheffield Scientific School of Yale
College, 1884-'85.
dine sulphate, found that small doses of the drug dimin-
ished the excretion of urea and that large doses (fifty
grains) diminished both urea and uric-acid, the latter out
of proportion to the former.
It is probably safe to conclude that the various salts of
quinine in moderate doses diminish uric-acid excretion out
of proportion to the urea excretion, but it is greatly to be
desired that more extended observations on quinine should
be made.
Antipyrine. — Only a few of the observations that have
been made on the influence of antipyrine on nitrogenous
metabolism include the study of uric acid, and these ob-
servations give contradictory results. Thus Umbach,* ex-
perimenting both on himself and on a dog, found that four
grammes of antipyrine in two days diminished slightly the ex-
cretion of total nitrogen, but had no perceptible effect on uric
acid. Chittenden and Adams, \ working on a healthy man,
found that antipyrine in doses of thirty to sixty grains had
a marked effect in checking the excretion of uric acid and
urea, which were diminished nearly proportionately. More
recent experiments by Kumajawa \ are directly opposed in
their results to those of Chittenden and Adams. This ob-
server found that in a dog large doses of antipyrine (fifty-
one grammes in sixteen days) produced no effect upon the
excretion of urea, but increased the excretion of uric acid
on the average to sixty-five per cent, above the normal. Ob-
viously more work needs to be done before we can reach
definitive conclusions regarding the effect of antipyrine
upon uric-acid excretion.
Antifebrine. — The best work that has been done on the
action of antifebrine on uric-acid excretion is that of Chit-
tenden and Taylor.* It was found by these obsevers that,
in a healthy man, doses of antifebrine, varying from six to
forty grains a day, slightly increased the excretion of urea,
but decidedly diminished that of uric acid. The condi-
tions of the experiments were such in this case that there
is good reason to think that doses of more than fifteen
grains daily of antifebrine have a specific effect in lessen-
ing the excretion of uric acid. This effect of the drug
is of considerable interest in connection with the fact
that in chorea and migraine, both of which conditions
are associated with an excessive elimination of uric acid,
antifebrine has been used successfully as a therapeutic
agent.
Thallin,|| iron, lead, and mineral acids A are said to de-
crease uric-acid elimination ; but the observations on which
this opinion is based are not of a character sufficiently seri-
ous to require consideration here.
* Ueber den Einfluss der Antipyrine auf die Stickstoffausscheidung.
Abstract in Jahresbericht f. Thierchemie, 1886, p. 418.
\ The Influence of Urethane, Paraldehyde, Antipyrine, and Anti-
febrine on Proteid Metabolism. Studies from the Laboratory of Phys.
Chemistry, 1887-'88.
X Virchow's Archiv, Bd. cxiii, p. 192.
* The Influence of Urethane, Paraldehyde, Antipyrine, and Anti f eb-
rine on Proteid Metabolism. Loc. tit.
| See Robin. Berliner klin. Wochenschrift, March, 1889.
A Variations in the Excretion of Uric Acid and Urea produced by the
Administration of Acids and Alkalies. A. Haig. Journal of Physiology,
vol. viii, 1887.
June 4, 1892.]
HERTER AND SMITH: TEE EXCRETION OF URIC ACID.
623
6. The Excretion of Uric Acid in Disease.
We have seen that there is some lack of agreement on
the part of writers regarding the influence of drugs upon
uric-acid excretion. When we pass to the consideration of
the relation of disease and uric-acid excretion we find an
uncertainty about fundamental matters that opens our eyes
anew to the imperfections of our knowledge.
Before referring to our own somewhat fragmentary
work, which deals especially with nervous disease, we may
advantageously review some of the more general aspects of
the uric-acid question.
Not long since an English writer, Dr. Haig,* attempted
to show that uric acid is in some way the cause of a long
and almost suspiciously varied list of diseases, including
gout, rheumatism, migraine, epilepsy, mental depression,
etc.
The idea of Dr. Haig is that these conditions are due,
not to an increased formation of uric acid, but to its reten-
tion in the organism. Certain kinds of food, according to
this view, render the blood less alkaline than normally, with
the result that the uric acid formed is less perfectly dis-
solved than it should be, and is hence stored up in the tis-
sues, instead of being removed from them.
This process of storing up continues until, as the result
of an error or peculiarity in diet, the blood becomes more
alkaline than before, and, in consequence of this increased
alkalinity, the uric acid stored in the tissues is dissolved
out into the blood. The blood (and consequently the urine)
now contains a great excess of uric acid (uric acidamiia),
and the patient suffers from uric-acid poisoning. This uric-
acid poisoning is shown, in a general way, by a contraction
of the peripheral arterioles, with increased blood-pressure
and hard and slow pulse. The effects of the poison may,
however, be shown in even a more striking way, as by an
epileptic paroxysm, a migraine headache, or great mental
depression, according to the particular predisposition of the
patient. After a time the kidneys eliminate the excess of
uric acid in the blood, and the blood ceases to acquire uric
acid from the tissues, either because the tissues have no
more uric acid to give up, or because the blood has grown
less alkaline. When this elimination has occurred, the pa-
tient is once more relieved of his acute symptoms.
We believe this to be a fair general statement of the
attitude of Dr. Haig regarding the relation of uric acid and
disease. It will, however, repay us to examine his position
somewhat critically.
Dr. Haig's views are based upon theoretical considera-
tions and upon observation. Of the theoretical considera-
tions on which these views rest, there are two which it is
especially important to bear in mind. The first is that
there is a varying condition of the uric-acid constituent of
the blood, due to the varying alkalinity of the blood. The
second is that the varying uric-acid excretion depends on
corresponding variations in the storage of uric acid in the
tissues, and not on changes in the formation of uric acid.
As to the first proposition, it may be said that, while it
may safely be considered probable that the uric-acid con-
* Uric Acid as a Factor in the Causation of Disease, 1 892, Blakiston.
tent varies with the alkalinity of the blood, it must be ad-
mitted that there is no proof whatever that this is so. We
know that uric acid is more soluble in highly than in weak-
ly alkaline fluids, and there is nothing unreasonable in the
supposition that a more alkaline blood would dissolve
more uric acid, if it were accessible, than a less alkaline
blood. But, if there is really a definite relation between
the uric-acid content and the alkalinity of the blood, it
is a fact susceptible of direct demonstration such as we
might very properly demand. Yet, so far as we are aware,
we have not even satisfactory evidence that the uric-acid
content of the blood does actually vary in the same indi-
vidual. Neither have we satisfactory information about
the varying alkalinity of the blood in the same individual
in health and disease. The point we wish to make is
that the proposition of which we are speaking may be
and probably is true, but that it is, after all, a mere suppo-
sition at present. We may use it, if we choose, as a work-
ing hypothesis, but we must not forget, as Dr. Haig appears
to do, that it has not been shown to be a fact.
The second proposition — namely, that the variations in
uric-acid excretion depend on the varying storage of uric
acid in the tissues and not upon changes in uric-acid pro-
duction— appears to be without any foundation and seems
improbable. It is difficult, in the first place, to suppose
that uric acid is produced in any definite quantitative rela-
tion to urea, as held by Dr. Haig. Both urea and uric acid
result from cell activities, which must be undergoing such
continual changes in intensity as to make it in the highest
degree improbable that they are produced under all circum-
stances of health and disease in even approximately the
same relation.
There is likewise no evidence whatever that uric acid is
stored in the tissues and redissolved when the blood grows
more alkaline. The formation of urate-of-sodium tophi
in gout has been regarded as positive evidence that in gout,
at least, there is such a storage. But the fact of the for-
mation of tophi is susceptible of explanation in another
and perhaps more satisfactory way. According to this
view, the local mechanical deposition of sodium urate de-
pends on local necrotic changes, which, in turn, depend on
an excess of uric acid in the blood and not in the tissues.
We may now consider for a moment the character of
Dr. Haig's observations on uric-acid excretion in disease.
At the outset we are struck with the scantiness of the
actual observations. On the urine of migraine a good
many observations were made, but they were chiefly on one
person and were made with an inaccurate method of esti-
mating uric acid.* The urine in epilepsy was examined,,
so far as we can find, in only two or three cases.f Yet I >r.
Haig has no hesitation in elaborating a uric-acid theory of
epilepsy on the strength of his facts. And so it is with
mental depression, suicide, gout, uraemia, Raynaud's dis-
ease, and a long list of conditions which Dr. Haig refers to
uric-acid poisoning. In each of these cases there is a huge
superstructure of hypothesis upon a scarcely discernible
basis of fact. We do not, however, wish to be understood
* Ilaycraft's method.
f Uric Acid as a Factor in the Causation of Disease, etc., 1892.
HERTER AND SMITH: THE EXCRETION OF URIC ACID.
[N. Y. Med. Jouh.,
as contemning Dr. Haig's work absolutely. It is only just
to say that his writings contain many interesting sugges-
tions, and that his observations, though obtained by an un-
trustworthy method, are probably not without value. In-
deed, we may say that Dr. Haig's work upon the fluctua-
tions of uric-acid excretion in migraine is of much interest,
notwithstanding its deficiencies, and contains the best ob-
servations that have been made on this aspect of the disease.
What we especially condemn in Dr. Haig's writings are
the sweeping conclusions that are drawn from so small
a store of facts ; we do not object to his ideas as sug-
gestions, but we take exception to them as conclusions in
fact.
It is instructive to examine briefly the state of knowl-
edge regarding two conditions which are of wide general
interest in connection with the uric-acid question — namely,
uric -acid excretion in fever and in gout.
As regards uric acid in febrile conditions, it is generally
assumed by authors that uric acid is excreted in excessive
amount in fever from any cause, but especially in the case
of fevers that are the result of conditions which produce
embarrassed respiration (such as pneumonia, bronchitis,
pleurisy with effusion, or pericarditis). There appears to be
considerable doubt whether the uric-acid excretion is merely
absolute or whether it is both absolute and relative as re-
gards urea. Probably many of the statements that there is
an increase of any kind in fever are based on the well-known
separation of urates from fever urines. Scheube * states
that in the case of pneumonia he found both an absolute
and relative increase in uric acid. On the other hand,
Bartels f has shown that in many cases of acute febrile dis-
ease the uric acid excreted was present in normal propor-
tion to the urea. It is thus plain that our knowledge re-
garding the influence of fever is in a most unsatisfactory
state. It has been thought that the supposed increase of
uric acid in fever urines was due to the defective oxidation
of nitrogenous substances, but there is no support for this
view. Thus Senator \ and Nunyn and Riess* produced
experimental dyspnoea in animals with a view to studying
the effects of imperfect oxidation, but were unable to
satisfy themselves that there was any alteration in uric-acid
excretion. It has been often held that respiratory diseases
in man cause increased uric-acid excretion, but there is no
satisfactory evidence that this is so. The results that many
writers have obtained are rendered worthless by the imper-
fections of their methods and their ignoring of the influence
of diet. Bunge || makes a very positive statement that in
diseases of the respiratory organs the uric-acid excretion
varies, in its relation to the excreted urea, within limits
that are to be unhesitatingly considered normal. It is an
interesting fact in this connection that in birds, whose res-
piration is the most active of any class of animals, nearly
all the nitrogen excreted is in the form of uric acid. In-
deed, nitrogen may be introduced into the body of a bird
* Archiv <1. Hdlk., 1876, xvii, p. 185.
f Yon Ziemesen'a Homdbuch, ix.
\ Vircbow's Archiv, 42, p. 1.
* Dubois-Reyniond's Arc/)., 1869, p. 381.
I Lchrbnch, p. 301.
in almost any form — as urea,* as leucine, as glycocoll, as
ammonium carbonate,f or as hypoxanthin \ — and the nitro-
gen reappears in the urine as uric acid and not as urea. It
must be owned, however, that we should not allow these
facts, whose significance is not clear, to weigh too much
with us in the consideration of the relation between defect-
ive oxidation of nitrogenous tissues and excessive uric-acid
excretion. We may, nevertheless, conclude that there is
no good reason for referring excessive uric-acid excretion,
in febrile or other conditions, to defective oxidation.
One might reasonably expect that in the case of gout
there should be some well-established facts regarding the
uric-acid excretion, since it is in this connection that most
has been said and written about uric acid as a cause of dis-
ease. But when we come to examine the actual observa-
tions on the occurrence of uric acid in the urine in gout we
find that most of them are of an unsatisfactory nature. Ac-
cording to Garrod, whose views have been widely accepted,
there is an increase of uric acid in, the blood during the
paroxysmal period, due either to its over-production or de-
fective elimination. For a long time this opinion was
based entirely on the results of the well-known thread ex-
periment, which is said by recent writers to be unreliable.
Von Jaksch,* however, has recently shown, by actual analy-
sis, that there is an excessive accumulation of uric acid in
the blood in gout. Coincident with this increase in the
blood there occurs, according to Garrod, a decided diminu-
tion in the excretion of uric acid by the urine. Recently
Ebstein || has attacked this view of Garrod and stated that it
is in the highest degree improbable that there is any dimi-
nution in the uric acid excreted. He refers the results of
Garrod to the use of imperfect methods. It certainly is
difficult to believe that an excess of uric acid in the blood
can be associated with a diminution of it in the urine. It
is much more probable that whenever the blood contains an
excess of uric acid there is a prompt increase in the elimina-
tion of uric acid by the kidney.
Probably the most satisfactory work that has been done
in late years on uric acid in gout is that of Pfeiffer.A Ac-
cording to this observer, there is a decided diminution in
the excretion of uric acid in all cases of gout, except during
a paroxysm. This diminution he considers characteristic
of gout, even in its earliest stages. When the cachexia of
gout develops there is also a great diminution in the excre-
tion of urea, and we are not clear whether or not, according
to Pfeiffer, there is then merely an absolute diminution of
uric acid or a relative diminution also.
During a paroxysm of gout there is regularly, according
to Pfeiffer's view, an increase in uric-acid excretion, at least
as compared with the excretion before and after the
paroxysm. In some cases the diminution which regularly
* Meyer and Jaffe. Ber. d. deutsch. chem. Gen., Bd. 10, S. 1930,
1877.
t Schroder. Zeit. f. physiol. Chcmie, 1878.
\ W. von Maeh. Arch. f. cxpcr. Path. u. Pharmuk., Bd. 24, S.
389, 1888.
* Deutsch. med. Woch., 1891.
|| Verh. d. Conc/r.f. innere Med., 1889, viii, p. 133.
A Ibid.
June 4, 1892.]
HERTER AND SMITH: THE EXCRETION OF URIC ACID.
625
precedes the attack may persist during the first and second
day of the atta«k, but in every case there is, contrary to
Garrod's view, an increase during the paroxysm. Pfeiffer
believes that in gout there is not necessarily any increased
formation of uric acid, but rather a retention of it in the tis-
sues and body fluids, owing to its being present in an insolu-
ble form. We shall not, however, concern ourselves further
with this question, which is largely one of theory. The ob-
servations of Pfeiffer appear to be well made, and his con-
clusions are consistent with what we know about uric-acid
excretion. The one criticism it is necessary to offer on his
work is that he employed a notoriously poor method of de-
termining uric acid. We can not say to what extent this
deficiency may have impaired the value of his results.
We have referred to the state of our knowledge as to
uric-acid excretion in gout and in fever partly to illustrate
the uncertainty that still exists regarding such common
conditions. How little we actually have known until re-
cently about uric-acid excretion in disease is shown by the
remark of Bunge, in his recent work,* that up to the
present time (1889) there is only one disease in which it
has been positively shown that there is an excessive ex-
cretion of uric acid — namely, leucaemia. But at the
present time this statement would scarcely hold, for we
have proof that there are several functional forms of nerv-
ous disease in which uric-acid excretion is abnormally large.
We may pass to the consideration of these conditions.
Our own work refers especially to chorea, epilepsy,
neurasthenia, and migraine, and we shall confine our atten-
tion especially to these forms of disease.
So far as we are aware, no observations have hitherto
been made on uric acid in chorea, and our own work is not
so extensive as could be desired. In four cases of chorea
in which we have studied the urine there was a continuously
excessive excretion of uric acid. This excess appeared to
be proportional to the severity of the choreic movements,
and grew less under the influence of treatment and in pro-
portion as this was effective. We shall elsewhere give our
data in full.
Not long since Haig advanced the proposition that epi-
lepsy and certain kinds of headache, especially migraine,
depend on temporary uric acidemia. Haig's claim is that
the epileptic paroxysm is preceded by a diminished excre-
tion of uric acid, that the paroxysm itself coincides with an
excessive excretion of uric acid, and that after the paroxysm
the excretion falls quietly back to the normal.
This view appears to rest chiefly on the fact that in one
case of epilepsy, recorded in the Neurologisches Centralblatt
for 1888, Haig observed a diminution of the ratio to 1 to 50
(which he considers abnormal, 1 to 33 being his normal)
before paroxysms, and of 1 to 20 immediately after them.
Haig states that he has investigated other cases, but does
not give figures that are satisfactory. He appears to recog-
nize in some degree the insufficiency of the facts on which
he bases his hypothesis, for he says that he would have
liked to examine a large number of cases, but found the dif-
ficulties too great. Being, as he admits, unable to extend
* Zehrbueh, 1889, p. 301.
his observations to his satisfaction, he abandons his investi-
gations and retreats from fact to speculation. " I now look
upon many other signs and symptoms," says he, " as more
or less satisfactory evidence of uric-acid causation."
A similar indication of the insecurity of Dr. Haig's
position is that he constantly attempts to support it by
leaning on purely clinical considerations. He thinks, for
example, that the uric-acid theory of epilepsy must be cor-
rect because there is a close clinical relationship between
epilepsy and migraine, and he believes that he has shown
migraine to be a " uric-acid headache."
We have made an extended series of observations on
the state of uric-acid excretion in epilepsy. The detailed
presentation of these observations and the conclusions that
follow from them we propose to defer to another occasion.
We may, however, say here that we have as yet obtained no
grounds for the view that the grand-mal paroxysm of idio-
pathic epilepsy is regularly or even usually preceded by a
diminished uric-acid excretion. On the other hand, our re-
sults support the view of Haig to the extent that we find
the paroxysm to be usually succeeded by an increase in the
uric acid of the urine. In many cases the increase is great-
est on the second day after the seizure.
This latter fact suggests that the increase in uric acid is
the result of conditions that are associated with, and per-
haps determine, the paroxysm, and that this increase is not
itself a cause.
WTe have made some observations which suggest that
the uric-acid factor is of more significance in cases of petit
mal than in cases of grand mal of idiopathic tvpe. Thus,
while the grand-mal cases in general have shown merely an
increased excretion of uric acid after the paroxysm, the
petit-rnal cases have shown' a large and persistent excess in
the uric acid of the urine. That this excess has been in
some degree related to the petit-mal seizures in three cases
which we have examined repeatedly, was shown by the
cessation or reduction in frequency of the seizures by the
use of a diet which has lessened uric-acid elimination. This
suggestion is further based on the repeated examination of
the urine in seventeen cases of grand mal, many of which
were placed at our disposal by the courtesy of Dr. Fisher.
Up to the present time we have made one hundred and
fifty -six determinations of uric acid in these cases of epi-
lepsy.
Analysis of the urine from nine cases of pronounced
neurasthenia showed in each instance but one an excess of
uric acid. In this case the ratio was on the border line. In
four of the cases the neurasthenic symptoms were referable
directly to sexual excess. As a group these cases show
nothing distinctive. A marked feature in some of the neur-
asthenic cases was a tendency to rather sudden variations
in the ratio of uric acid and urea.
In all the cases that are tabulated below, organic disease
of every kind was so far as possible excluded. The influ-
ence of alcohol was also barred out.
Our observations on migraine are few in Dumber. In
one case two paroxysms were studied; in another ease only
one paroxysm was studied. In each paroxysm a consider-
able excess in the excretion of uric acid was observed im-
626
EERTER AND SMITE: TEE EXCRETION OF URIC ACID.
[N. Y. Med. Jocb ,
mediately after the period of headache. No diminution of
uric acid was found in the samples of urine passed immedi-
ately before the period of headache.
Table shouting Uricacid Excretion in Neurasthenia.
No.
of
case.
Symptoms.
Headache,
general debili-
ty, loss of
memory.
Pressure sen-
sation on ver-
tex, mental
depression.
Quan-
tity.
8p. gr.
Chlo-
rine.
Headache,
mental de-
pression.
Headache,
debility.
Hypochon-
driasis.
Headache,
hypochondri-
asis, debility.
Irritability,
debility.
Irritability,
depression.
1,585 1-024J
1,810 1022
1,235 1026
l,67o l ol7
1,305 1-oltU
i-( am
2,654 1-020
1,818; 1021J
1,90? 1022|
2,010! 1-023.}
2,277| 1-020"
1,950| 1-01H
1,950! 1-Ollj
2,070 1-09J
840 1 018
12-398
N-9-4 5
9-813
5-610
1,150
1,005
1,000
650
1,640
1026
1024
1024
1030
1 027^
3-631
3- 510
4627
5319
4-7118
6 239
6-338
4- 578
121
3 312
2-177
2-678
2103
1-170
4-099
4 238
4-880
3819
2-619
2 6775
2142
•727
2-586
2150
2030
2-069
Urea.
42 671
29-977
35-742
29-893
25-839
832
400
905
340
838
435
999
637
689
873
Uric
acid.
Gnu.
■7K9 1
■651 1
•844 1
Ratio of
uric
acid to
urea.
54
45-8
42 3
■731 1 :40-9
•698 1 : 37 1
35-162
30148
25-768
24393
3 431 48-543
•326 1
11167 1
■773|1
1-100 ]
1-257 1
1100 1
•637 1
•193 1
■568 1
■4074 1
: 4 •">".">
: 38-8
: 50-3
: 421
: 38
:43
: 37 6
: 46
: 39-7
: 291
•9953 1 : 35-3
•66911 : 45
•558 1 : 46 7
•648 1 : 37-5
1-417 1 : 34-2
In two cases of paroxysmal vomiting in children we
have made observations which we believe to be unique.
Both the cases were under the care of Dr. L. E. Holt, from
whom the histories were obtained. The first case is that of
a boy, aged seven, who, since his third year, has had occa-
sional periods of persistent vomiting, usually with headache
and some rise in temperature. The paroxysms could not be
referred to any intelligible cause. In the intervals the boy en-
joys what is apparently perfect health. A twenty-four-hour
sample of urine obtained in an interval of health showed a
ratio of uric acid to urea of 1 to 56 — i. e., a normal relation.
A twenty-four-hour sample from the first day of a period
of uncontrollable and repeated vomiting showed a ratio of
uric acid to urea of 1 to 159. During the second day of
the attack the relation was 1 to 134. On the third day the
vomiting ceased and all the symptoms cleared up. The
ratio on this day was 1 to 50, but it is certain that this rela-
tion is too low, as only the uric acid in the sediment was
included in the analysis.
Fourteen weeks after this attack the patient had an-
other. On the first day of the seizure the ratio was 1 to
164-8; on the second day it was 1 to 157. On the follow-
ing day, as the symptoms wore away, the ratio was 1 to
24'9. We have in this case an example of an acute parox-
ysmal disorder, characterized especially by persistent vomit-
ing, in which the attacks coincide in time with a very great
diminution in the excretion of uric acid and are followed
by a period in which its excretion is increased.
The second case which we have to relate belongs appar-
ently to the same clinical type. In this case the patient, a
healthy girl, aged four years and a half, developed symp-
toms which during two days justified a suspicion of tuber-
cular meningitis. There were present the following con-
ditions in the course of four days: persistent vomiting,
obstinate constipation, marked retraction of the abdomen,
irregular breathing and pulse, and, on the first and third
days, slight fever. The urine of the first and fifth days was
studied.
On the first day the ratio of uric acid to urea was 1 to
83-5 — that is, distinctly low. On the fifth day it was 1 to
21 — that is, very high. A normal specimen obtained some
time later gave a ratio of 1 to 42-1. It is to be regretted
that the examination did not extend over the entire time of
the attack in this case, but the results, such as they are, are
suggestive. A detailed presentation of these cases is given
below :
Table illustrating the State of Uric-acid Excretion in Two Cases of
Persistent Vomiting.
Urine before paroxysm (normal).
First day of paroxysm
Case I.
j Urea, 13 606 grm. I
( Uric acid, -2515 " )
( Urea, 17-249 grm. I
) Uric acid, 11 " I
Ratio of uric
acid to urea.
1 : 54 2
Second day of paroxysm.. . \ \lr^ . . 12 "£? 6™- '
r - ( I nc acid, -0912 " )
Directly following paroxysm \^ .. 11 grin. I
J \ Lnc acid, -2345 " (
] Urea, 15-040 grm. )
Urine after paroxysm (normal). .
First day of paroxysm
Second day of paroxysm.. .
Directly following paroxysm
( Uric acid, -2827 " J
\ Urea, 12 576 grm. )
j Uric acid, 0763 " j
\ Urea, 13 824 grm. }
'( Uric acid, 088 " j
j Urea, 21-07 grm.
( Uric acid, -839
Case II.
First day of paroxysm . . .
Fifth day of paroxysm.. . .
After paroxysm (normal)..
S Urea, 12 285 grm. }
j Uric acid, -147 " \
\ Urea, 10-428 grm. )
"( Uric acid, -495 " j
j Urea, )
/ Uric acid, J
1 : 156-9
1 : 131-8
1 : 50
1 : 531
1 : 164-8
1 : 157
1 : 24-9
1 : 83-5
1 : 21
1 : 42-1
We have touched upon some of the aspects of the uric-
acid question which relate to clinical medicine. We have
shown that in the investigation of a particular case it is
necessary to study especially the quantitative relation that
exists between urea and uric acid, for we can place little
reliance on the totals themselves, which vary with condi-
tions which we can not hope to control in clinical work.
Since, as we have further shown, the variations in this rela-
tion are slight in the same individual in health, it follows
that any considerable derangement of the normal relation
is readily appreciable. The degree and persistency of any
derangement in the relation may afford us a valuable index
of the severity of condition with which we have to deal
— a better index, perhaps, in some cases than the symp-
toms themselves, which may, as in the case of neurasthe-
nia, be chiefly subjective. In many cases the variations in
the quantitative relation, as the morbid condition progresses,
may be advantageously noted with a view to watching the
effects of treatment and of obtaining in this way facts for
the establishment of a rational prognosis. We have our-
selves been able to use some of our observations to advan-
tage for this purpose.
June 4, 1892.] GOULD: A SIMPLE METHOD OF TREATING LACRYMAL OBSTRUCTION.
627
But while we have thus dwelt upon some of the more
practical relations of uric acid in health and disease, we
have ignored the question which, of all the interrogatives of
the uric-acid problem, is of the greatest interest. That
question is, What is the significance of the excessive excre-
tion of uric acid which is a concomitant of disease ? Or,
in other words, What is the relation of this uric acid
excess to the cause of the morbid process ? We doubt
whether it is possible, at the present time, to give a satis-
factory reply to this query, but shall endeavor to show,
though it be but imperfectly, what are the considerations
that should weigh most with us in trying to approach it.
The first fact to bear in mind in this connection is that
excessive uric-acid excretion is a condition that is observed
in a considerable number of clinical conditions. As we
have already seen, it occurs in neurasthenic states, in
migraine, in epilepsy, in chorea, in fever, in leukaemia, and
as the result of the use of considerable quantities of alco-
hol. There can be no doubt that this excessive excretion
is a common condition, and there is reason to think that a
more extended study of the subject than has yet been
made would show it to occur with greater frequency than
has ever been suspected, especially as a consequence of dis-
orders of digestion. Another fact of importance is that the
conditions which have been enumerated as being associated
with uric-acid excess differ widely in their clinical charac-
ters. It needs no argument to emphasize the clinical con-
trast between chorea and leukaemia, or that between an
acute febrile and a neurasthenic state. But the fact that
these conditions (so widely different that their comparison
is amusing) have in common the excessive excretion of uric
acid, leads us at once to the conclusion that this excess can
not reasonably be regarded as the specific cause of any one
of the numerous morbid states of which such excess is
characteristic. It is certainly true that the conditions we
have named differ as widely in their setiology, so far as we
understand it, as do the clinical types themselves. How,
then, shall we interpret the important condition which
these different types have in common ? Our view of the
matter is as follows :
Uric acid, like urea, is an end-product of nitrogenous
metabolism. There seems to be no evidence to show that
the formation of uric acid is a necessary precursor to the
formation of urea. Such evidence as there is points to the
idea that both these substances are the consequences of a
more or less lengthy and varied series of metabolic changes,
and that the formation of uric acid is expressive of merely
a slight divergence from the process that ends with the
production of urea.
An increase in the formation of uric acid, such as to
make the quantity in the urine bear a higher ratio to the
urea of the urine, is to be regarded as the result of a de-
rangement in the development of the chain of nitrogen-
holding substances that make their successive appearance
for a short period of time between the commencement of
digestion and the completion of destructive metabolism.
What these substances are and how they are related to one
another is still largely unknown to us, but there seems
nothing unreasonable in the view that in conditions of dis-
ease the early links in the chain may differ from those that
belong to health, and may possibly present a considerable
divergence among themselves in different morbid processes-
But whatever may be the character of the original dis-
turbance or of the morbid substances concerned in it, as
destructive metabolism progresses there are only a few sub-
stances, so far as we know, through which these concomi-
tants of deranged nitrogenous metabolism may be elimi-
nated from the body. Of these, one of the most impor-
tant appears to be uric acid.
According to this view, then, the increased excretion of
uric acid that is met with in disease might be an effect of
numerous different derangements in nitrogenous metabolism.
We believe that this suggestion harmonizes with the fact
that uric-acid increase may be brought about by so many
different nutritional disorders. In this excessive excretion
we should be dealing with the result and probably not with
the cause of disease. Excessive uric-acid formation, in
other words, is a terminal process that may result from
different and perhaps numerous different initial morbid
nutritive conditions. The fact that we can not now point
out what these derangements consist in or with what
poisonous substances they are identified, does not make less
reasonable the view we have ventured to suggest.
A SIMPLE METHOD OF TREATING MANY CASES OF
LACRYMAL OBSTRUCTION.
By GEORGE M. GOULD, A.M., M. D.,
OPHTHALMOLOGIST TO THE PHILADELPHIA HOSPITAL.
I always suspect that system of therapeutics, whether
political, social, or medical, to be wrong that proceeds on
the assumption that its author could have given God some
very good advice had the reformer been present at the crea-
tion of the worlds In social science it is well recognized
that any method of enduring progress must be based on
helping Nature instead of disregarding or opposing her.
In medicine and surgery the history of all failures is that
" the fools rush in " with their little wisdom, supposed supe-
rior to the great wisdom of Nature, and, without study of
the subtle ways and indications of the physiological pro-
cesses, ruthlessly disturb or overturn the delicate measures
of cure silently at work.
There seems to me a little illustration of this great truth
in one small department of ophthalmic surgery — that re-
lating to the condition of the lacrymal excretory appa-
ratus giving evidence of itself by lacrymal retention, or
even epiphora, lacrymal conjunctivitis, dacryocystitis, etc.
There are, of course, a few cases in which the patency of
the system is interrupted by closure of the intranasal ori-
fice of the duct, the result of rhinitis, chronic or acute, mal-
formation of the adjacent parts, indiscriminate use of the
cautery, of the lacrymal probe, etc. There are others in
which a genuine anatomical stricture may exist, the result
of inflammation, morbid growth, traumatism with probes,
etc. Without attempting an enumeration of such cases of
lacrymal stenosis or occlusion, and admitting them out of
this count, I wish to urge that the vast majority of cases
628
GOULD: A SIMPLE METHOD OF TREA
TING LACRYMAL OBSTRUCTION: [N. Y. Mkd. Jon*.,
with symptoms of retention of tears are due to temporary
and functional causes. There is a large number due to ex-
cess of secretion (instead of defective excretion) arising
from eye-strain (overuse of a physiologically normal or an
ametropically abnormal eye), from local irritations or con-
gestions of many kinds, etc. There is another and still
larger class of cases in which the abnormal conditions of
the nares or nasopharynx by contiguity of tissue, or by
duct-transfer of morbific material, living or chemical, to
the upper part of the duct or sac, there set up congestion
of the lining mucous membrane, and hence stenosis and re-
tained secretions. It needs only the very slightest swelling
of the membrane to narrow overmuch or to entirely close
the patency of the tiny lumen of the canaliculus or duct.
Dr. S. D. Risley tells me that in examination of a num-
ber of dry skulls he found none the lacrymal ducts of
which admitted the passage of the larger probes advised for
" probing " the living, membrane-lined, and therefore nar-
rowed, canal. This careful and excellent observer has long
taught that the function of the duct is not that of a large
drain, which it is not, but of a tiny capillary tube, which it
is. The frequency of unhealthy nares, the abundance of
dust and other pathogenic material, living or neutral, in our
modern city life, that is sucked through the nares with
every breath, or deposited in the conjunctiva between every
wink of the eyes, furnish evident reasons for the over-
stimulation of the lacrymal or secretory apparatus, or for
the functional interference of all grades with the act of ex-
cretion. A little narrowing, the irritation of a little re-
tained morbid material, the extension up from the nose or
down from the conjunctiva of a frequently-present local
congestion or inflammation — and we have the eye bathed
in tears, lacrymal conjunctivitis, or dacryocystitis.
Under such circumstances, what anatomic ignorance,
what physiological stupidity, what therapeutic sin, to " slit
up the canaliculus " — that wonderful little structure, with
its sphincters about the puncta, and fashioned so patiently
by Nature for a purpose and use — forever destroying its
function, and, by brute force, jamming a rod of metal down
among the congested membrane, wounding it in every part
of its length by crushing it between the rigid probe and the
bone, against which it lies in such close union ! And yet
this is the routine practice advised and carried out almost
everywhere.
No wonder such cases are " obstinate." The cure cre-
ates the disease, and even worse ; where before was only
functional stenosis, there is doubtless often, by traumatism,
organic stricture following inflammation set up by the probe
injury.
Let us go at Nature less mechanically and brutally. Is
there not a better way ?
About a year ago I found blue pyoctanin (1 to 1,000) an
excellent means of overcoming lacrymal conjunctivitis and
disorders of the sac and duct, and I believe my colleague,
Dr. De Schweinitz, substantially agrees with me in conclu-
sions from the experience. The effect is doubtless due to
the powerful jjenetrating quality of the methyl violet, coupled
with some antiseptic property. But it is almost impossible
to use tliis drug without its highly objectionable staining
qualities becoming obtrusively manifest. I have therefore
discontinued its use and have adopted another plan that
seems to me based upon natural methods and to be an ex-
tension of Nature's indications.
Little children, in whom the fount of tears easily over-
flows, and in whom the excretory function is therefore put
to most active use, are constantly " gouging " the " corners
of their eyes," the inner canthi, with their little fists in a
way that sometimes appears almost dangerous. Here, then,
is the latest discovery in therapeutics — massage made use
of by infantile wisdom. Even therapeutically, " babes and
sucklings " may teach us if we are modest enough to learn.
In dacryocystic troubles every ophthalmic surgeon emp-
ties the sac by slow pressure upward and inward toward the
inner canthus. How frequently in doing this we force a
gush, seemingly absurdly great in quantity, of watery, mu-
coid, or purulent material, through the puncta — especially
the upper one ! But not following up the hint given by the
babies, or by this latter procedure, the surgeon stops here
and reaches for the knife and probes.
It would seem that the suggestion of massage, of con-
tinued and repeated emptying of the clogged sac by press-
ure, were worth trying. Perhaps massage alone would cure
many cases. If now, without injury to the parts, we could
refill these empty but congested canals with an antiseptic
and astringent fluid, would we not at once and certainly
cleanse, heal, and bring all back to physiological order ?
This is very easy.
First empty the sac and canaliculi by dexterous pressure,
and cleanse the eye and palpebral pockets of this unhealthy
material. Then cant the patient's head back and to one
side, or have him lie so that a teaspoonful of liquid will be
held in the depression formed by the nose, orbital border,
and superior maxilla. Fill this space with a solution of
boric acid,* and with the little finger again slowly empty
the sac and canaliculi by pressure, and then, as slowly less-
ening the pressure, allow these spaces to refill, by suction
and capillary attraction, with the solution under which the
puncta are submerged. Again, in half a minute empty the
canaliculi and sac by pressure, but this time beginning the
pressure from the canthus toward the nose and downward,
so as to force the antiseptic solution downward into the
duct. These alternate emptyings and refillings of the sac
may be repeated several times and as often as desirable to
meet the indications of the case. It will usually be found
that the sac will soon become healthy and that pressure upon
it will not cause regurgitation of morbid material through
the puncta.
This treatment may not be " surgical," but it is " com-
mon sense."
A certain number of cases, however, will not yield to
this treatment. There is too great stenosis or spasmodic
contraction of the muscular sphincter of the punctum, etc.,
so that the cleansing solution can not be forced into the
sac and duct. In such cases I am accustomed to insert one
* The solution I use is composed, to the ounce of distilled water, of
boric acid, ten grains ; common salt, three grains ; chloride of zinc, one
grain — all deeply tinted with pyoctanin-blue, and doubly filtered after
long standing.
June 4, 1892.]
WYETH: ETHER NARCOSIS BY TEE ORMSBY INHALER.
629
sharp point of the iris scissors into the punctum and snip
it open about one eighth of an inch, perpendicularly down-
ward toward the conjunctival fold. This gives a larger
opening for the indrawal of the solution.
I have been astonished to see how rapidly cases recover
under this simple treatment that formerly would have seemed
to demand slitting of the canaliculus and probing. I have
been led to wonder if under the old treatment the good was
not really done by the antiseptic or cleansing solutions com-
monly used with the surgical treatment — and, indeed, if the
collyrium did not effect the cure in spite of the probing.
I am thoroughly convinced that the very free use of anti-
septic eye lotions, by the constant passage of the same
through the duct, act therapeutically on nasal inflammations,
that are themselves the primary causes or sources of con-
junctival affections. Of course, a more effective treatment
would be that of the nares direct.
One of the chief advantages of this simple procedure I
would urge as consisting in the ability of the patient or of
the patient's friends to carry on the treatment at home after
a brief explanation and illustration by the physician. I am
aware that some would consider this a disadvantage. An-
other and more important point in its favor is that general
and family physicians can carry it out with the greatest ease.
These, generally speaking, have not the necessary skill, or
the special instruments for probing, etc., or they shrink from
" interfering with the eye " ; hence many patients, failing
to seek the specialist's services, remain untreated and go
on from bad to worse. A large proportion of such cases
would find speedy relief by an application of the foregoing
method.
ETHER NARCOSIS
AS INDUCED BY THE ORMSBY INHALER*
By J. A. WYETH, M. D.
In the Medical Record for August 31, 1889, I saw the
report of an address in surgery before the British Medical
Association by Mr. T. Pridgin Teale. In this address he
spoke in such terms of commendation of ether narcosis as
induced by the method of Ormsby that I determined to
satisfy myself of its value. For the last sixteen months I have
employed it in private and public practice, and am convinced
of its superiority to other methods of ether anaesthesia.
The apparatus consists of a rubber mouth and nose cover,
a wire wicker sponge-holder, and over this a rubber balloon.
It is intended to furnish to the respiratory tract ether
vapor mixed with and warmed by the expired air. It is
claimed, and I hold justly so, that by warming this vapor
some of the dangers of bringing a cold ether vapor in con-
tact with the larynx, trachea, bronchi, and air-cells are less-
ened if not avoided. When it is remembered that the ex-
pired air has a temperature varying from 93° to 95*4° F., it
will be readily understood how such heat will affect the va-
por of ether with the Ormsby apparatus. The expired air
is again inspired and breathed over and over again until
there is added to the narcosis of ether a variable carbonic-
* Read before the New York Surgical Society.
acid narcosis or asphyxia. In ordinary respiration only one
fifth of the oxygen carried in by a single respiratory effort
is absorbed by the blood. If there were no leakage to the
apparatus, it is evident that it would take but a few respira-
tory efforts to consume all the oxygen caught in the mask
and lungs, and that asphyxia must rapidly supervene. Such,
however, is not the case in the practical working of the in-
haler. I think that the partial asphyxia aids a rapid anaes-
thesia, dulling as it does sensibility and lessening the resist-
ance to the absorption of the vapor. The degree of as-
phyxiation can be controlled and perfectly regulated by the
trained etherizer.
In the list of cases to be given the condition of the
urine before and after operation was carefully studied ; noted
the minute of commencing the administration ; the time to
complete insensibility and relaxation ; time of operation ;
time of administration ; time from removal of mask to
restoration of consciousness ; quantity of ether employed ;
whether or not vomiting occurred ; and any notes of in-
terest.
I wish to acknowledge the valuable aid so cheerfully
given me in this work by the very efficient house staff at
Mount Sinai Hospital — Dr. Leigh, Dr. Lovell, Dr. Stern ber-
ger, Dr. Cohen, Dr. Brodhead, Dr. Brickner, and Dr. Gar-
rigues. I must also thank Messrs. Van Horn and Ellison,,
of Forty-first Street and Park Avenue, for the care they
have taken to have the apparatus properly constructed.
Of forty-one cases, from the time of applying the mask
to the time when the patient was relaxed and unconscious, the
total was two hundred and thirty-eight minutes, or an aver-
age of five minutes and three quarters. From the time of
unconsciousness until the ether was finally discontinued,
eleven hundred and eighty-seven minutes elapsed ; average,
twenty-nine minutes. From discontinuance of the ether un-
til consciousness supervened (reaction), two hundred and
four minutes elapsed ; average, five minutes. From com-
mencement to completion of operation, eight hundred and
eighty-six minutes; average, twenty-one minutes and a half.
Quantity of ether poured out of ether bottle, one hundred
and four ounces and a quarter ; average, two ounces and a
half.
In ten of forty-one cases vomiting ensued. In thirty-
one of forty-one cases there was no vomiting.
The study of the changes in the urine gives the follow-
ing result :
Case I. — Carrie M., aged forty-live. Cancer of breast. Gland
and axillary contents removed. Under anaesthesia fifty-five mia-
utes ; quantity, three ounces. Urine before operation, acid, sp.
gr. 1-020, negative; after operation, acid, sp. gr. 1-030, trace of
albumin ; epithelium.
Case VII. — S. S., aged ten, male. Plastic of leg. Under,,
thirty-five minutes ; two ounces. Before operation, urine clear,
acid, sp. gr. 1-020 ; oxalate of lime and granular matter. After
operation, urine clear, acid, sp. gr. 1-032, trace of albumin, leu-
cocytes, and oxalate of lime.
Case XII. — A. B., aged twenty, female. Haemorrhoids,,
clamp and cautery. Under, thirteen minutes ; one ounce. Be-
fore operation, clear, acid, sp. gr. 1-022, bladder epithelium, leu-
cocytes. After operation, clear, acid, sp. gr. 1-010, trace of al-
bumin, leucocytes, and epithelium.
630
WYETH: ETHER NARCOSIS BY THE ORMSBY INHALE 7.'.
[N. Y. Med. Jouh.,
No.
Name.
Age
Operation.
Date.
1
2
Carrie Miller.
Simon Heimerdinger.
54
60
Amputation of breast,
and removal of ax.
contents.
Hiemorrhoids ; liga-
ture ; clamp and
cautery.
1891.
Nov. 23.
0
4
K
Charlesanna Robinson.
Frederick Frohnan.
IHOIllA Kyi 1 1111.. 11
27
14
Haemorrhoids (cau-
tery).
Fistula in ano, in-
cised; haemorrhoids;
clamp and cautery.
Necrosis of meta-
tarsal bone.
6
7
Moses Kirowitz.
Samuel Steinlauf.
43
10
Haemorrhoids ;
clamp and cautery.
W ound of knee ;
plastic.
Nov. 27.
8
Rabinowitz Baruch.
30
Carbuncle of back.
Nov. 28.
9
Simon Hansom.
48
Ischio rectal abscess.
10
Hannah Mikalofsky.
30
Cellulitis of hand.
«
11
Wolf Moldowsky.
42
Haemorrhoids ;
clamp and cautery.
Nov. 30.
12
Anna Besker.
20
Haemorrhoids ;
clamp and cautery.
18
Meyer Sack.
46
Haemorrhoids ; liga-
ture.
14
Siegmund Mandce.
23
Hydrocele.
Dec. 4.
15
Moritz Gross.
4
Hydrocele.
Dec. 7.
16
Joseph Straush.
30
Haemorrhoids ; liga-
ture.
Dec. 10.
17
Faibush Grisbnren.
43
Hemorrhoids ;
clamp and cautery.
Dec. 14.
18
19
Isaac Foster.
Jennie Schenellinkoff.
40
23
Fistula in ano and
haemorrhoids.
Cellulitis of hand.
20
Buruch Bender.
53
Cellulitis of hand
Dec. 19.
21
22
23
24
Rashmael Dilkin.
Lena Blum.
lUn J310CK.
Lena Kronejold.
23
12
17
17
Hiemorrhoids,
Whitehead's.
Compd. fract. skull ;
trephining.
Tuberculosis of
tarsus.
Tubercle of face.
Dec. 24.
Dec. 21.
25
Louis Rappaport.
27
Peri-urethral
11 1 i » i ^
26
27
28
George Newman.
Jacob Sinnis.
Jacob TJngar.
38
23
27
Osteo-myelitis of
tibia.
Ischio-rectal abscess;
fistula in ano.
Mural abscess.
29
30
31
Davis Schneier.
W illiam Atchinson.
Herman Scharreck.
34
18
28
Haemorrhoids ;
clamp and cautery.
Caries of wrist ;
exsected.
Abscess of prostate.
Dec. 29.
1892.
Jan. 4.
32
Solomon Blum.
Ischio-rectal abscess;
fistula in ano.
33
34
35
ATot* v A 11 ■/i-'T'l nu'i t •/
iiiiii^y c\vis.\ i j r > - h i .
Louif* Ort't'iiwflld.
Juli us iiii ii f rflnk .
14
AQ
oU
1 U111UI (U pcipi 1 LtrUl
space.
Caries of os calcis,
Schede.
Fistula in ano.
Jan. 11.
36
Moses Marcus.
23
Perityphlitic abscess.
Jan. 12.
37
Ben (JliJismiowitz.
Fistula in ano.
38
Anna Gunti.
39
Tumor of the groin.
Jan. 18.
39
40
Baer Mirwisch.
S. Weinstein.
36
21
Hiemorrhoids ;
Allingham operation.
Haemorrhoids.
41
Nora Price.
29
Tubercular glands
of neck.
Jan. 22.
TIME
OF —
Un-
der.
Total
anaes.
Oper-
ation.
Reac-
tion.
8 m.
55 m.
55 m.
20 m.
10 m.
30 m.
14 m.
7 m.
3 m.
10 m.
7 m.
10 m.
5 m.
1G m.
14 III.
8 m
3 m.
30 m.
28 m.
10 m.
5 m.
24 m.
11 m.
4 m.
3 m
35 m
27 m.
2 m.
5 m.
13 m.
8 m.
3 m.
7 m.
19 m.
11 m.
4 m.
6 m.
37 m.
26 m.
6 m.
5 m.
17 m.
11 m.
1 in.
3 m.
13 m.
7 m.
1 m.
5 m.
36 m.
26 m.
2 m.
8 m.
29 m.
21 m.
11 m.
3 m.
16 m.
18 in.
5 m.
6 ill.
27 m.
2 m
8 m.
23 m.
12 m.
2 m.
9 m.
15 m.
7 m.
3 m.
3 m.
17 m.
9 m.
1 m.
i m.
14 m
3 m.
50 m.
51 m.
8 m.
3 m.
24 m.
24 m.
5 m.
5 m.
35 m.
23 m.
2 m.
3 m
21 m
12 m.
6 m.
14 m.
6 m.
3 m.
7 m.
26 m.
24 m.
10 m.
4 m.
22 m.
14 m.
1 m.
7 m.
21 m.
7 m.
2 m.
9 m.
14 m.
9 m.
3 m
8 m.
53 m.
53 m.
5 m.
10 m.
18 m.
7 m.
10 m.
4 m.
13 m.
10 m.
5 m.
1 h
3 m.
Oft in
111.
53 m
«i m.
5 m.
9 m
a ro.
8 m.
15 m.
4 m.
5 m.
6 m
21 ni.
15 m
7 m.
10 m
19 ni
2 m.
8 m.
8 m.
1 h.
30 m.
29 m.
1 h.
15 m.
20 m.
7 m.
0 m.
8 m.
12 m.
3 m.
4 m.
15 m.
2h.
3 m.
1 h.
15 m.
3 m.
Char-
Ether.
Fair.
Good.
Fair.
Fair,
weak
pulse.
Good.
Poor.
Good
Fair.
Good
Fair.
Good.
Fair.
Good.
Poor.
Fair.
l"j-
1 iijss
Hi-
1 ijss.
5 iij-
1U-
lij-
5 ij-
1 ijss.
3 ijss.
in-
ly
1 iijss
liij.
lj-
5 iij.
I ijse.
5 ij
li-
iy
l ijss.
lij-
I iijss
lij-
Urine before
operation.
Acid, 1-020, nega-
tive.
Clear, neut..l040;
no alb. + , large
amt. sugar.
Negative.
Clear, acid, 1022,
negative.
Clear, neutral,
negative.
Clear, acid, 1 034,
negative.
Clear, acid, 1 020,
ox. lime, granu-
lar matter.
Operation on
admission.
Operation on
admission.
Clear, acid, 1 020,
negative.
Acid, 1*026, nega-
tive.
Urine after
operation.
| Vom
iting.
Acid. 1 030 ; trace
alb.; epithelium.
Clear, acid, 1 042 ;
no alb.; large
amt. sugar.
Clear, acid, P032 ;
urates.
Arid, 1 020, epithe-
lium, granular
matter.
Clear, acid, nega-
tive ; uric acid.
Clear, acid, P020,
negative.
Clear, acid, 1 032 ;
trace alb.; leuco-
cytes ; ox. lime.
Cloudy, acid,l-030:
phosphates, ox.
cal., and uric acid.
Clear, neut., gran,
matter, ox. lime.
Clear, acid, nega-
tive.
Acid, 1 020, nega-
tive.
Much
No.
Good
Clear, acid, 1 022;
bladder epitheli-
um, leucocytes.
Cloudy, acid,
1 042, ox. calcium.
Clear, acid, 1 028,
calc. oxalate: uric
acid; epithelium.
Clear, acid, 1 028,!
negative.
Cloudy.acid,1020;
trace alb ; leuco-
cytes ; granular
casts.
Clear, acid, 1 026,
negative.
Negative.
Clear, acid, 1 024;
trace alb. ; leuco-
cytes; blood-cells.
Clear, acid, uric-
acid crystals.
Clear, acid, P030,
negative.
Negative.
Clear, acid, 1 040:
leucocytes.
Clear, acid, 1 025 :
epithelial cells.
lj. Clear, acid, 1 025 ;
trace alb. ; leuco-
cytes.
I iij. Clear, acid, 1030 :
leucocytes, uric ac,
Ijss. Negative.
Clear, acid, 1-010 ;
trace alb.; leuco-
cytes, epithelium.
Cloudy, acid, no
alb.; hyaline
casts, calc. ox.
Clear, acid, 1 028 ;
granular matter.
Cloudy, acid,
1-030: urates.
Cloudy. acid,P028;
trace alb ; leuco-
cytes, blood-cells,
kidney epith.,
granular casts.
Cloudy, acid,
1-028; urates.
Idiocy fcot
affected by
anaesthesia.
Amt. sugar
and amt. of
urine not
affected by
aniesthesia.
Recovery
good.
Yes.
No.
Yes.
No.
Mu-
cus in
throat
No.
Yes.
5 iij-
?iv.
liij-
lij.
liv-
;iij.
5 iij-
lij-
5 ij-
5v.
lij-
lij-
1 vij.
i Cloudy, acid,
1 028, negative.
Acid, 1 030, nega-
tive.
Acid, 1-022, nega-
tive.
Clear, acid, P030 :
leucocytes.
Operation on
admission.
Severe endo-
carditis: no
bad effects ;
died.Dec.13.
Dec.l2,urine
clear, acid,
1-030, neg.
Good re-
covery.
Emphysema
and chronic
bronchitis
not affected.
Cloudy, acid,
1 034, negative.
Clear, acid, 1 030,
negative.
Clear, acid, 1-040,
negative.
Negative.
Clear, acid, 1 020,
negative.
Clear, acid, P040 ;
epithelium cells.
Clear, acid, 1035 ;
trace alb.; hyaline
and gran, cants.
Clear, acid, 1 030 ;
no alb. ; leuco-
cytes.
Acid, 1 032, nega-
tive.
Acid, 1-028, nega-
tive.
Acid, 1-022, nega-
tive.
Acid, 1 032 :
urates.
No.
Yes.
No.
Yes.
No.
Clear, acid, 1-030, Yes.
negative.
Clear, acid, P030, . No.
negative.
Cloudy, 1021,
negative.
Cloudy, 1 -037 ;
urates.
Negative.
Acid, 1 033, nega-
tive.
Clear, acid, 1029,
negative.
Negative.
Clear, acid, P028,
negative.
Negative.
Clear, 1015, acid, 1 030, acid, nega-
negative. tive.
Clear. 1 033, acid, 1 029, no alb.;
negative. urates.
Acid, f-033, nega- Cloudy, 1 039,
Yes.
No.
Yes.
No.
Good re-
covery.
tive.
Acid, 1 031, nega
tive.
acid, negative.
Cloudy, 1035.
acid ; urates.
Doing well.
Operated
day of ad-
mission ;
died; septic
absorption.
Doing well.
Cured.
Doing well.
Cured.
Doing well.
Cured.
June 4, 1892.J SKI ETWEE: THE RELATIVE HUMIDITY OF THE ADIRONDACK REGION.
631
Case XIIP. — M. S., aged forty-two, male. Haemorrhoids,
ligature. Under, thirty minutes. Before, cloudy, acid, sp. gr.
1-042, oxalate of lime. After, cloudy, oxalate of lime, hyaline
•casts.
Case XVI. — J. 8., aged thirty, male. Haemorrhoids, liga-
ture. Under, twenty-five minutes; three ounces. Before, cloudy,
acid, sp. gr. 1-020, trace of albumin, granular casts, leucocytes.
After, cloudy, acid, sp. gr. 1-028, trace of albumin, blood cor-
puscles, granular casts, renal epithelia, leucocytes.
Case XXIV. — L. K., aged seventeen, female. Lupus of face.
Under, twenty-one minutes ; two ounces. Before, clear, acid,
sp. gr. 1-023, epithelial cells. After, clear, sp. gr. 1-035, trace
of albumin, hyaline and granular casts.
In ten cases albumin was present before operation and
was not found afterward.
Case XIX. — J. S., aged twenty-three, female. Cellulitis of
hand. Under, seventeen minutes ; one ounce. Before, clear,
acid, sp. gr. U024, trace of albumin, blood cells, leucocytes.
After, clear, acid, sp. gr. 1-030, negative.
Case XXV. — L. R., aged twenty-seven, male. Peri-urethral
abscess. Under, fourteen minutes; one ounce. Before, clear,
acid, sp. gr. 1-025, trace of albumin, leucocytes. After, clear,
acid, sp. gr. 1-030, no albumin, leucocytes.
In one case sugar was present, but was not aflected by
the anaesthesia.
Case II. — S. II., aged sixty, male. Haemorrhoids, ligature,
clamp, and cautery. Under, thirty minutes ; three ounces and
a half. Before, clear, neutral, sp. gr. 1-040, large amount of
sugar, no albumin. After, clear, acid, sp. gr. 1-042, large amount
of sugar, no albumin.
Of the remaining cases, three were operated upon direct-
ly after admission, and no study of the urine was made be-
fore operation. Nothing- abnormal was found afterward.
In six cases the urine was negative before operation and
urates were found afterward. In one case clear before op-
eration and cloudy after. In one case clear before opera-
tion and epithelium and granular matter after.
Directions for use :
1. Remove the sponge, cleanse in clean tepid water, dis-
infect in l-to-500 bichloride solution; again wash it in
clean tepid water, and squeeze thoroughly. The balloon
and mouth-piece should be dipped in the bichloride solu-
tion, and immediately washed in tepid (not hot) water.
2. Pour into the sponge in position two ounces of ether.
If the patient is nervous or unusually apprehensive of dan-
ger, for a minute or two gradually accustom him to the
smell of the ether. Ask him to take a full inspiration, and,
as the expiration begins, apply the mask tight over the
mouth and nose. The sense of irritation and suffocation
can thus be in the main avoided.
3. For the first minute or two allow no admixture of
fresh air. At the first indication of asphyxia, the com-
mencing purple in the ears or cheeks, tilt the mask a little
to one side and allow fresh air to pass in. As it does not
pass through the sponge, the ether vapor is not materially
chilled. I usually tilt the mask at the commencement of
one inspiration, and shut it down tight for this expiratory
effort, and then hold it down for the next two or three res-
pirations. From half an ounce to two ounces of ether may
be added, as the condition of the patient or the requirements
of the operation may demand.
In conclusion, I am of the opinion that the proper ad-
ministration of the anaesthetic, upon which so much of suc-
cess and comfort depends, does not receive the attention its
importance deserves from most surgeons and teachers. In
our hospitals, as at Mt. Sinai, the internes should assist in
the operating-room for six months before being intrusted
with the administration of ether or chloroform. Every
community of doctors should contain at least one man spe-
cially skilled as an anaesthetizer, as every surgeon of large
practice keeps his trained assistant for this purpose.
Ether narcosis with the Ormsby inhaler, as above de-
scribed, induces more rapid anaesthesia with a smaller quan-
tity of ether, and permits a more rapid return of conscious-
ness, than by the open inhalers which admit a free admixt-
ure of air. The danger of inducing laryngitis, tracheitis,
bronchitis, and pneumonia is much diminished, and is prac-
tically avoided by the elevated temperature and the smaller
volume of the vapor. The danger of disturbance of re-
moter organs, as the kidneys, is also diminished, since there
is not the same saturation of the blood with ether, a smaller
quantity being required.
Although this method is safer than the open-inhaler
methods, we are still a long way from that surgical millen-
nium of an anaesthetic absolutely free from danger to the
patient or annoyance to the operator.
With ether and chloroform we must always be watchful.
Both possess dangerous properties even in expert hands.
Although I consider ether to be in general the safer agent,
there are cases in which it is less safe than chloroform, and
I consider it a scientific misfortune to have the dangers of
chloroform or ether exaggerated intra vel extra micros.
THE KELATIVE HUMIDITY OF THE
ADIRONDACK REGION.
By WINSLOW W. SKINNER, M.D.,
MEMBER OF THE ANATOMICAL SOCIETY OF PARIS ;
FORMERLY RESIDENT PHYSICIAN TO THE ADIRONDACK COTTAGE SANITARIUM.
The climatic conditions obtaining in any popular health
resort are objects of general interest. This is especially
true if the resort be near great centers of population, if it
be easy of access, and if it exercise special curative influ-
ence over a disease which attacks and destroys a large num-
ber of human beings. The " North Woods," or Adiron-
dack region, fulfills these requirements, and among the sev-
eral affections that are generally ameliorated or cured by a
sufficient sojourning in this noted region, pulmonary tuber-
culosis is undoubtedly the most important. The great ad-
vantages derived by phthisical patients from an outdoor life
in the Adirondacks are indeed evident and undisputed, and
any statements made below should not in the least be re-
garded as detracting from the general favor with which
this region is viewed by those who are aware of its healing
virtues.
There prevails, however, in the profession and among
the laity (although to a lesser degree in the former) an
632
HATES: NOTES ON SPASM
OF THE ACCOMMODATION.
[N. Y. Med. Joue..
erroneous idea concerning one essential factor in the climate
of this region — namely, the relative humidity. Many per-
sons well informed on most subjects have entertained the
opinion that the atmosphere is much drier here than it
really is, although this opinion is not based upon any exact
data, but is a conclusion arrived at by analogy and deduc-
tion on naturally likening the Adirondack resort to the ear-
lier known Rocky Mountain resorts, where the relative hu-
midity is comparatively low. It was thought that because
the Western resorts for consumptives were dry, all good
resorts for consumptives must also necessarily be dry.
The Adirondack region, nevertheless, is damp ; the mean
relative humidity of the air there is comparatively high.
This is shown by the carefully obtained figures given be-
low, which result from daily observations taken by the
writer during the past summer at one of the finest points
of this region, the Saranac Inn. It is also shown by the
reports of the observer * of the signal station at the Hotel
Ampersand, on the Lower Saranac Lake, as they were given
to the writer by the chief of the Weather Bureau at Wash-
ington, Mr. Mark W. Harrington, to whom my thanks are
due. Again, certain charts, based upon official statistics,
represent the Adirondack region as situated in the midst of
one of the wettest territories on the continent. This ter-
ritory embraces the northeastern part of New York and the
adjoining parts of Vermont and- of Canada, as well as the
region of the great lakes. There are more cloudy days and
greater rain-fall there than anywhere else in the eastern half
of the country. Very fortunately, however, to offset this,
the soil of the region is sandy and the surface is generally
hilly or mountainous, so that the water precipitated from
the clouds rapidly finds its way to the water-courses, or dis-
appears from sight in the earth.
In regard to the relative humidity, the original data ob-
tained by the writer give the following results : The total
number of observations is eighty-seven. These were made
three times daily during the month of August and a part of
September, 1891, at the usual hours for such observations.
From these eighty-seven observations, ranging from a rela-
tive humidity of 19 per cent, on August 19th to that of 94
per cent, on August 22d, it was found that the mean rela-
tive humidity was 70-5 per cent. The instrument used for
taking these observations was given expressly for the pur-
pose by the well-known firm of Meyrowitz Bros., Fourth
Avenue and Twenty-third Street, New York. This instru-
ment, the Naudet hygrometer, was compared with a stand-
ard wet-and-dry-bulb hygrometer until a proper coefficient
of correction was obtained for every five degrees of its
scale, thus affording approximate accuracy for every obser-
vation. It was further frequently compared with a Daniell's
hygrometer, by means of which the dew point was obtain-
able at will in a few moments. This latter instrument was
offered for this work by another large firm of dealers in
scientific instruments, that of Eimer & Amend, of Third
Avenue and Eighteenth Street.
The mean relative humidity of the Adirondacks is
greater in summer than in winter. According to the report
* Mr. James P. Mills.
of the chief signal officer, the average for the period of four
months, from June to September, inclusive, in 1889, at the
Ampersand was 73 per cent., while that from December to
March, inclusive, was 63 per cent. That of August, 1889,
was 72"1 per cent., nearly two per cent, higher than that
found by the writer during the same month two years later.
The annual mean for 1889 was 68 per cent. It is thus seen
that the figure 70*5, mentioned above, is in harmony with
the observations of others. This mean, however, is lower
than that of some other stations not far from the region in
question. Thus the mean annual relative humidity ob-
served at the station on Mt. Washington, computed from
the commencement of observations to December, 1885, is
86 per cent., that of Oswego 78 per cent., and that of a
New Jersey resort (Atlantic City) 80 per cent. All the
stations in New England report a higher mean than that
found in the Adirondacks.
In conclusion, the following statements may be ad-
vanced :
1. Contrary to the generally received opinion, the Adi-
rondack region is comparatively humid, but less so than is
New England.
2. Notwithstanding this, it is demonstrated to be an un-
usually excellent resort for consumptives when utilized in
time.
3. Its excellency in this respect is due somewhat to its
elevation and to its lower temperature, but chiefly to its
rapid drainage, the purity of its atmosphere, the sparseness
of its population, the presence of immense tracts of forest
consisting largely of conifers (unfortunately, diminishing
rapidly before the lumberman's axe), and to the great sense
of mental repose impressed upon one who sojourns in this
health-giving wilderness.
NOTES ON
SPASM OF THE ACCOMMODATION.
By W. H. BATES, M. D.
Case I. — A business man, aged thirty-six, several years ago
complained that his vision for distant objects had failed. He
could not recognize his friends across the street. Large signs
could not be read until he was very near. He felt that he had
become near-sighted. The cause of his poor vision he ascribed
to continued writing by a poor light. After stopping the work
which strained his eyes, he recovered without other treatment.
Now his vision is perfect without glasses.
Cask II. — A lady, aged thirty-three, has had poor vision
for a number of years. To obtain normal vision she re-
qUires _ i D. S. After treatment of the eyelids for one week
vision improved from f£ to almost normal, §£ — , without
glasses.
Case III.— An oculist, aged thirty, reports that ten years ago
he was wearing —1*6 D. S. to obtain good vision. Under atro-
pine at this time he was still myopic. Several years ago, after
an attack of measles, vision normal, f$, without glasses. With
the return of his general health the spasm came back and he was
compelled to use — 1-5 D. S. to obtain vision of f£. Atropine
was used for several weeks until constitutional symptoms of
atropine poisoning were produded. Vision under atropine f&,
with — 1-5 D. S. vision normal, f§.
June 4, 1892.]
BATES: NOTES ON SPASM
OF THE ACCOMMODATION.
Later, without the use of atropine, he finds that there are
times when his"vision is normal, ff, without glasses.
It is a curious fact that the spasm relaxed during ill
health. The impression is prevalent among many authori-
ties that ill health at least aggravates if it does not act as a
factor in the cause of myopia. The following case also
shows that the spasm may relax during ill health :
Case IV. — A medical student, aged twenty-one, has been
wearing four years a minus fourteen-inch glass with no discom-
fort, most of the time at a German gymnasium. The glasses
were prescribed by a prominent oculist who used atropine for
one week and made several tests. Lately, he being run down,
his eyes have not been entirely comfortable. An examination
without atropine showed a myopia of one half the degree of the
glass he is wearing. Under atropine two days, patieut is not
myopic. I am indebted to Dr. H. Seabrook for the notes of
this case.
Case V. — An artist, aged eighteen,'gave the™history of my-
opia after an attack of measles when seven years old. Under
atropine five days, vision T2<$y, w. — 1*5 D. S. = %%. These
glasses were prescribed forjjconstant use. Several months later
vision the same with and without the glasses as when under
atropine. After remaining five minutes in a dark room with
the eyes closed, rubbing the skin of the forehead a few times
with the hand, and then testing the vision, it was found that
the patient had temporary vision of ff without glasses. The
cause of the spasm in this case seemed to be due to the effect of
light.
In the following case also there seemed to be spasm
from the effect of light :
Case VI. — A physician, aged thirty-five, has a vision of
in the right eye ; the left eye has normal vision. After remain-
ing in a dark room for a few moments, the vision of the right
eye is normal, §£, for a short time only. Under atropine one
week, vision of the right eye with a minus twenty-inch
glass, vision normal, f g. After remaining in a dark room for a
few moments and then testing the vision of, the right eye in the
light, vision is normal, f-g, for a short time only.
When treatment can relieve this sensitiveness of the
eyes to the light, the spasm is sometimes relieved also, as
in the following case :
Case VII. — Mrs. H., aged twenty-three, is wearing — -g1^.
She has chronic conjunctivitis slight, with considerable pain in
the eyes from the effect of light, especially gas-light. Treat-
ment of the lids relieved the intolerance of light, and the vision
became normal at the same time without glasses.
Case VIII. — A stenographer, aged thirty, wore glasses to
see at a distance.
April 29, 1888— Vision of the right ey e f£ , with — ^ vision
normal. Vision of the left eye f£ + , and requires same glass to
obtain normal vision. Cocaine applied to the mucous mem-
brane of the left nostril improved the vision of the left eye.
Cocaine in the right nostril did not improve the vision of the
right eye to an appreciable degree. A number of operations
were performed for the removal of nasal hypertrophies, etc.
May 15, 1888. — Vision of the right eye not improved. Vision
of the left eye normal, f£, without glasses.
June 1, 1801. — Three years later the left eye was still nor-
mal, the right eye still myopic.
Cask IX. — Mr. M., aged twenty, complains of being near-
sighted. He has been tested three, times under atropine.
April 5, 1888. — After using atropine for a week, pupils
widely dilated, throat dry, cheeks flushed. Vision of both eyes
f£, with — 2 D. S. vision normal. Ophthalmoscopic examina-
tion showed myopia. Cocaine was applied to the right inferior
turbinated and sajptum of the nose, when the vision at once be-
came nearly normal. At the end of fifteen minutes the vision
returned to f-£, what it was before the application of the cocaine
in the right nostril. The vision of the left eye was not mate-
rially changed by the application of the cocaine in the right
nostril. A sharp projecting point on the right saeptum was re-
moved with the saw after cocaine was applied. Vision of the
right eye became normal, f-g, and remained normal.
July 15, 1888. — Three months later the vision of the right
eye is still normal, §g. The vision of the left eye is unchanged,
f£. Cocaine in the left nostril improves the vision of the left
eye to the normal for a few minutes only.
Case X. — A sailor, aged thirty-five, complained of recent
failure of his vision. He required a minus twenty-inch glass to
give him normal sight. Treatment for several weeks of the
eyelids and nose with nitrate of silver and yellow oxide-of-mer-
cury ointment improved the vision from T2^ to the normal, §£,
without glasses.
Case XL — A colored girl, aged twelve, an epileptic, had
always been near-sighted (?). Atropine was used in both eyes
for a week. At this time, vision of both eyes — ; with a
minus ten-inch glass the vision was normal. With the ophthal-
moscope the fundus could be seen best with this glass, but there
were moments when the light streak on the vessels could be
seen with a far-sighted glass, convex twenty inches, but seen
only dimly. The atropine was continued and the patient seen
twice a week for five months, when the vision and refraction
were found to be still unchanged. At the end of another
month, altogether making six months' use of the atropine, pa-
tient had normal sight with a convex twenty-inch glass.
Case XII. — A boy aged ten years applied for treatment.
July 12, 1888. — Until two years ago vision all right. He
attends school in the winter months. Does not study at home.
Under atropine two days, with the general symptoms of atro-
pine poisoning, fever, dry throat, etc., vision in both eyes
inrV +! with minus sixteen-inch glass, vision normal. He was
kept under atropine ten weeks, with the result that the vision in
both eyes became slowly normal without glasses. Atropine
stopped. One month later vision still normal without glasses.
Patient went back to school and resumed his studies. After a
time the spasm returned ; the use of atropine was followed by
relief, only to have another relapse soon after returning to
school. Patient was lost sight of for several years.
March 19, 1891. — Under atropine has a myopia of 3-5 D. S.
Accommodation paralyzed completely by atropine. The atro-
pine was stopped and a mild trachoma treated. The vision im-
proved to f§ without glasses after a month's treatment of the
lids, when the patient again disappeared.
It seems reasonable to infer that this patient might
have been permanently benefited after receiving temporary
relief if he could have been kept under observation and re-
ceived proper care.
Conclusions.— 1. Spasm of the accommodation can not
always be relieved by atropine.
2. The vision of symptomatic myopia can often be im-
proved so that glasses are unnecessary.
131 West Fifty-sixth Street.
Dr. Broadbent, of London, is announced to have been appointed
physician in ordinary to the Prince of Wales, to succeed the late Sir
William (hill.
634
MUBPHEY: UNCONTROLLABLE VOMLTINO OF PREGNANCY. [N. Y. Med. Joce.,
UNCONTROLLABLE VOMITING OF PREGNANCY.
By GEORGE N. MURPHEY, M. D.,
BOWI.INO GREEN, KT.
The pathology of this disease I shall not attempt to
give, but only relate its clinical history and treatment. I
have no notes of the case, and report from memory.
The patient, Mrs. O., white, twenty-three years old, married
in October, 1891, had always been healthy, menstruated at thir-
teen, and was regular in her periods. On December 12th she
was taken ill with vomiting due to pregnancy, which grew
gradually worse until December 29th, when Dr. H. P. Cart-
wright was called and kept the case under observation until
January 12th, when he asked me to see the patient with him.
He had administered the following drugs without avail : Oxa-
late of cerium, creasote and hydrocyanic acid, bismuth, inglu-
vin, pepsin, cocaine, morphine and atropine hypodermically,
mustard and fly blisters over the epigastrium, and hot douches
to the cervix uteri. When I saw the patient she was much
emaciated, as she had been able to retain food or drink for only
a short time for four weeks; her temperature was normal :
pulse, 120 a minute. We agreed that a little further trial be
given some other drugs. I returned two days later with Dr.
Cartwright, and found all drugs had failed us and that the pa-
tient was worse. The vomited matter now contained much
blood. The patient was losing strength so fast that we ordered
rectal alimentation to be given every four hours, day and night.
The enemata, for the most part, contained the whites of two eggs,
about twenty grains of table salt, and four ounces of warm wa-
ter, occasionally alternating with milk, whisky, and water, which
was continued for a period of two weeks. Twice during this
time the bowel became intolerant of the enemata. The bowel
was then thoroughly washed and given a rest of an'hour. To
the next enema twenty drops of the tincture of opium was
added to sedate the bowel.
We now etherized the patient and dilated the cervix with
the Wylie dilator ; the os was exceedingly small, and the cervix
of almost cartilaginous firmness. The uterus was found in nor-
mal position. We left and returned the following day, but the
patient was no better.
We now concluded to bring on abortion, and for that pur-
pose introduced a uterine sound to the fundus, placed a hard-
rubber plug in the cervix, and tamponed the vagina with cotton
for the purpose of preventing haemorrhage, which the sound
had caused, and to hold the plug in situ. This and subsequent
operations were done under the strictest antiseptic precautions.
At the end of thirty-six hours the patient had had no pains or
symptoms of abortion, and vomiting was as severe as ever. We
now introduced a large-sized soft-rubber catheter to the fundus
with the intention of letting it remain for forty-eight hours if
spontaneous abortion did not occur in the mean time. Every-
thing went as usual for forty -two hours, when she was suddenly
seized with a chill, and complained of being cold all over. I was
present at the time, and found that she was almost pulseless and
with a look that was death-like ; in fact, the patient was col-
lapsed. I immediately went to work to bring about reaction.
I gave a full hypodermic of whisky, with ten minims of tincture
of digitalis, also a rectal injection of three teaspoonfuls of
whisky and twenty drops of tincture of opium in a teacupful of
water as hot as could be borne. Hot bricks were placed to the
feet, and hot wet cloths were placed over the stomach and ab-
domen.
Under such active stimulation the patient rallied in about
twenty or thirty minutes, with a rise of temperature to 103-5°,
which I thought at the time was the beginning of septicaemia,
but now entertain different notions about it for the following
reasons : First, the temperature that had suddenly risen to
103-5° in eight hours thereafter had fallen to 102°, and in eight-
een hours was again at the normal and remained so. Second,
on removing tampons and the catheter, they were found free
from foul and putrid odor. I sent for Dr. Cartwright as soon
as the chill came on. He arrived an hour later ; I had every-
thing ready, and we proceeded to remove the contents of the
uterus w ithout further delay. The patient was placed across
the bed in the Sims posture, a Sims speculum introduced, the
posterior lip of the cervix seized with a volsella, and the uterus
drawn low into the vajrina. The dilator was again used and the
cervix well dilated. The index finger was introduced, and the
foetus and its membranes were first removed, and then the pla-
centa was carefully separated from its uterine attachment and
removed in its entirety.
This operation was done without an anaesthetic, as we con-
sidered the patient too weak to take one with safety. It did
not seem to cause her much pain, however, and there was but
little subsequent haemorrhage. Although much prostrated, un-
der proper stimulation she reacted well, and had but few after-
pains, the vomiting ceased, and she made a slow but good
recovery.
THE LOSS OF SMELL.
By GI1ISLANI DURANT, M. D.
Of the senses, the least essential in man is that of
smell, and it is for this reason that the many changes which
may occur in this function are often unnoticed by both
physician and patient.
While the loss of smell has not any profound effect
upon the general health, yet it is an extremely disagreeable
infirmity, both on account of the disturbance of taste which
it occasions, and because of the uncertainty felt by the suf-
ferer as to his personal surroundings.
Anosmia, the chasemia of Haly-Abbas and the Arabs —
olfactus amissio of Sennert — may be congenital, and is then
probably owing to absence of the olfactory nerve. Cases
of congenital anosmia are not rare.
This condition may follow destruction or compression
of the olfactory nerves or ganglia, by a tumor of the cere-
bral substance, meninges, or any one of the tissues at the
base of the cranium, or may be symptomatic of a local or
general affection. It accompanies inflammation of the
pituitary membrane — at first from the dryness of the mem-
brane at the beginning of the inflammation, and later from
the quantity and character of the mucus secreted. The loss
of smell may be occasioned by destruction or marked modi-
fication of the end organs, as in ozaena, syphilitic ulcera-
tion, or parasitic affections of the nasal mucous membrane.
The nose in the above conditions is insensible to odors, as
the tongue, when dry and parched or covered by a thick
suburral crust, refuses to take cognizance of savors.
Sympathetic anosmia, more or less complete, is often
seen in adynamic or typhoid fevers.
The only allusion to a relationship between arthritis and
anosmia is made by C. Paul (Bull, et mem. de la Soc. de ther.,
1885). The subject was a lady, fifty-seven years of age —
arthritic, undergoing change of life — with an entire absence
June 4, 1892.]
REEVE: REPORT OF A DEATH FROM CHLOROFORM.
635
of the senses of smell and taste. Careful examination, says
Paul, failed to-show any organic lesion that might account
for the absence of these senses.
It has often been said that gout is rare in women. In
a certain degree this is true if the regular gout involving
articulations is meant ; but the gouty diathesis is as com-
mon in women as it is in men. It is possible, if we give it
the requisite attention, to recognize the gouty nature of
many cases of leucorrhcta and acute and chronic menor-
rhagia ; the attacks coincide or alternate with fugitive pains
in the fingers, heels, or great toes, and gout exists in the
family.
In support of the theory of the possible relationship of
gout and anosmia I relate the following case :
Early in October last I was consulted by Miss B. for a
trouble more common than is generally supposed, but often
neglected. The loss of smell and taste is complete. The
taste is totally wanting, as much for bitters — colocynth — as
for sweets or salts. The smell has also completely disap-
peared, for neither asafoetida, musk, nor ammonia is per-
ceived by the patient. Placed near an open gas jet, she is
not aware of it. As to flowers, they look beautiful, but
have no odor.
The history of the case related by the lady is as
follows :
She is twenty-seven years old ; has had no sickness except
rheumatism or neuralgia for three years. Her father and
brother are both gouty. She has had the best of care at the
hands of our most eminent medical men, but never received any
benefit beyond partial relief from pain by morphine. Last May
she was sent to Vichy, where for two months she underwent
the routine treatment and took the regulation exercise, drank
the waters, bathed, and was douched every day. She returned
home late in August, somewhat improved as to her neuralgic (?)
pains. Then she began to notice that she was gradually losing
her sense of smell. For this she has been treated by nasal
douches, sprays, fumigations, etc., all to no avail. The scraping
of her nose having been suggested, she came to me.
On examining the external olfactory apparatus, no lesions
were found, no trouble in the nervous centers, no chronic
coryza. The mucous membranes, lingual as well as pituitary,
have preserved their tactile sensibility. All other senses are
normal.
As she still complained of pains in the joints, and also of late
of an exaggeration of the sudoral secretion over the whole surface
of the body (especially on the face), even though the weather
was cold, arthritis seemed to me the only probable cause of the
anosmia, and 1 determined to treat her for that alone for a while,
selecting ichthyol as the remedy.
Under the administration of ichthyol in water twice a day,
and the application of an ichthyol ointment, gently rubbed over
all painful parts and covered by oakum and a bandage, I ob-
tained in a few weeks a marked diminution of pain. I may say
here that there never was any discomfort accompanying the in-
ternal administration of the drug ; its only objectionable feature,
that I can see, is the smell.
It is now four months since the patient came to me.
To-day she is perfectly free from all neuralgic, rheumatic,
or gouty manifestations. Put of greater importance is the
fact that the senses of smell and taste, which had been lost,
have gradually returned, and are to-day as acute as they are
in most people.
Bearing in mind that nothing was done to the olfactory
organs, that they underwent no treatment whatsoever at my
hands, are we not to believe that the anosmia was caused
by the gouty diathesis ?
12 West Fortv-sixth Street.
REPORT OF A DEATH FROM CHLOROFORM.
By J. C. REEVE, M. D.,
DAYTON, OHIO.
The following account of a death under anaesthetics,
which took place recently in this city, is made up from the
evidence taken by the coroner at an inquest held upon the
case :
The patient was a male, aged thirty years. About two
hours before the occurrence he was quite well, and at noon ate
a hearty dinner. Dr. Kimmel was called to see him about
three o'clock, found him suffering intense pain in the abdomen,
and discovered that he had a hernia, and " also that his nervous
system was very much shocked." He administered a hypoder-
mic injection of a quarter of a grain of morphine, and left
him to obtain assistance and get anaesthetics, as the man was
suffering so much that a satisfactory examination could not be
made. Dr. Shepherd administered the chloroform, which was
Squibb's. The quantity administered is not accurately stated.
"I had a four-ounce bottle not more than a quarter full, and
we didn't use it all. We used a little ether, but it didn't
amount to anything." Dr. Shepherd testifies that " we ad-
ministered about three quarters of an ounce of chloroform, with
a little ether added to it." It was administered on a cone of
sponge without any covering over it. The patient seems to
have taken it very well, with but little struggling. Dr. Kim-
mel testifies: " When I was examining the tumor I looked at his
face and saw he was not breathing very well. I told the doctor
to pull his head off the bed, and he did so. This seemed to be
better for him and for me, for I reduced it very nicely and
wasn't at it very long. He stopped breathing several times
and revived again, and did that several times until it was all
over." Dr. Shepherd testifies to the patient having stopped
breathing several times and having revived again. Finally, im-
mediately after the reduction, respiration suddenly ceased.
Nothing is said of the pulse. Both physicians state that the
heart was examined before the administration, and that its con-
dition was satisfactory, but that the pulse was weak. Dr.
Shepherd says the pulse was 48 and weak.
The means of resuscitation resorted to were artificial respi-
ration (how long continued and the mode not stated) and "the
injection of some whisky."
The coroner rendered a verdict that " deceased came to his
death by nervous shock."
The Medical School of Columbia College. — We are informed that
Dr. Charles MeBurney lias resigned his professorship of surgery in this
institution (the < 'ollege of Ph\>ician< and Surgeons), and been appointed
professor of eliuical surgery, and that Dr. Robert P. Weir has been ap-
pointed a professor of surgery to succeed Dr. MeBurney.
Surgeon Ainsworth, of the Army. — Dr. Frederick ('. Ainsworth,
Surgeon and Major, has been nominated by the President for promotion
to the rank of colonel and to be Chief of the Record and Pension Bu-
reau at the War Department.
The Natural History Society of Rhode Island. — Dr. Horatio 1!.
Storer has been elected president of the society.
636
LEADING ARTICLES.- MINOR PARAGRAPHS.
[N. Y. Med. Joob.,
THE
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by Edited by
D. Appleton & Co. Frank P. Foster, M. D.
NEW YORK, SATURDAY, JUNE 4, 1892.
THE PHARMACOLOGY OF ASPARAGUS.
Aspakagus is the edible lily. Belonging, as it does, to the
same order of plants as the lily-of-the-valley, it is not wonder-
ful that it has become a fascinating article of diet. Botaiiically,
asparagus is nearly related to the asphodel, dear to tbe ancients,
those two plants differing chiefly as regards their fruit. The
■old fables taught that the manes of the Greeks feed upon the
roots of the asphodel, while the gastronomes of to-day delight
in the tender shoots of this less comely liliaceous form. It is
believed that asparagus was known to the Greeks, although
.probably not in the finely cultivated stage, in which it now
«comes to our tables. Pliny and other Latin worthies noted its
.peculiarities as an aliment, and the Asparagus officinalis is sup-
posed to be the do-rrdpayos of Dioscorides.
The plant is probably indigenous to England, and it was a
favorite article of food there two hundred years before the art
of its cultivation was brought over from Holland. The London
markets dispose of vast quantities of this esculent annually, cul-
tivated to a high point of perfection.
The root and shoots of asparagus are not yet discarded from
the French Codex, as they have been from the British Phar-
macopoeia. The French use a syrup, to which are ascribed
diuretic and soothing properties. At Aix les Bains and some
■ other Continental health resorts this vegetable forms a notable
part in the regimen of rheumatic patients. It does not agree
with all persons alike ; in some it occasions more or less gastric
disturbance. Partly this may be due to the vegetable itself,
since it is not always cut at the period of its tenderest growth,
and partly an inadequate amount of cooking may give rise to
indigestion.
An alkaloid was separated from asparagus as long ago as in
1805. This was named asparagine, and has been supposed to
.act, like convallaria and its preparations, as a cardiac sedative.
In former times the plant had some popular repute as an
antilithic. The strong odor imparted to the urine of all who
partake of the young shoots will account for this notion. Sac-
charinity of the urine has been observed after its use. It has
been reported as the cause of urethritis and as an aggravator of
that disease, but very little is known of the truth of these state-
ments as a result of any systematic observations.
The pharmacology of this vegetable is worthy of a closer
study than it has yet received. The profession has rested satis-
fied with the general feeling that the ingestion of asparagus was
followed by a renal depuration, without entering a demand for
proof thereof. According to the Medical Press and Circular,
however, "there are grounds for believing that the asparagus
tops not infrequently exercise a disturbing influence on the
renal functions, causing in some instances a notable decrease in
the amount of urine excreted. It is very improbable, however,
that any injurious effect is produced on the healthy organism,
or this succulent vegetable would not have become a general
favorite. As it may give rise to undesirable symptoms in cer-
tain special cases, it is well that the medical profession should
be made acquainted with the real nature of its physiological
action, and we shall look to our scientific pharmacologists for
some information on this point." If this suggestion is carried
out we trust that those who give their attention to the question
will confine their researches at first to that part of the plant
which is used so lavishly as an article of food. At the same
time, it would be well to determine what differences, if any,
can be found in the renal excretion, before and after the inges-
tion of asparagus.
MICROBIO MENINGITIS.
In the Johns HopMns Hospital Bulletin for May, Dr. W. T.
Howard, Jr., reports the case of an infant operated upon for
imperforate anus in which the rectal wound suppurated. The
child died in the second month, of purulent ependymitis, men-
ingitis, and encephalitis, and a bacteriological examination of
the pus from the inflammatory area showed the presence of a
micrococcus and of the Bacillus coli communis. The child had
atresia of the pulmonary orifice of the heart and patency of the
foramen ovale and of the ductus arteriosus, and the reporter
thought the feebleness of the circulation had favored the mixed
infection by means of the suppurating rectal wound.
He calls attention to Netter's bacteriological examination of
twenty-five cases of simple meningitis, in which the Diplococ-
cus pneumonia; was found present in fifteen ; the Streptococcus
pyogenes in four; an intracellular diplococcus in two ; a short,
active bacillus, the bacillus of Friedlander, and a slender, small
bacillus, respectively, in the three remaining cases. Monti also
found the Diplococcus pneumonim in the pus of four cases of
meningitis ; and the frequency of the presence of the pneumo-
coccus is explained by the fact that meningitis is so often sec-
ondary to pneumonia and otitis media.
Besides these micro-organisms, Dr. H. M. Biggs reported, at
a recent meeting of the Section in General Medicine of the
New York Academy of Medicine, a case of meningitis in which
he had found the bacillus of anthrax, although there had been
no local focus of that disease on the body. It is interesting to
note the varieties of micro-organisms that may cause menin-
gitis.
MINOR PA RA GRA PUS.
PHYSICIANS' FEES FOR PER DIEM SERVICES.
The necessity that a prominent physician of this city has
just experienced of suing a client for a bill for services entail-
ing absence from the city must have been a very unpleasant
ordeal. His services were requested by a business man of a
Southern city, and his assistant, whom he sent in his place, was
absent from the city for ten days. In the bill $250 a day was
charged for his services, and this the defense maintained was an
June 4, 1892.]
MINOR PARAGRAPHS.— ITEMS.
637
extortionate charge. Various prominent physicians of New
York testified that they would have charged from $300 to $600
a day. Evidence was also presented that a physician could
make a certain number of day and night visits that would re-
munerate him to the same amount as that charged for per diem
services. But there is another feature of this subject that does
not appear. This physician was called for his special knowl-
edge and skill, and in all professions the individual has the
privilege of disposing of his services for such remuneration as
he sees tit. Not only this, but during an absence of one day-
even it would be possible for a physician to lose not only one
but several cases that would remunerate him far more than the
sum above mentioned, and it is for this reason particularly that
it has been everywhere the custom to charge what might seem
to be a high price for services entailing prolonged absence from
one's place of business.
THE PRELIMINARY EDUCATIONAL QUALIFICATIONS OF
ENGLISH MEDICAL STUDENTS.
There are many physicians who are rather fond of taking
a pessimistic view of medical education in this country, espe-
cially in regard to the preliminary educational qualifications of
medical students, and who express a longing for the more thor-
ough general education that is required by the European medi-
cal schools. That the disparity is not so great as has been
imagined is shown in an address by Dr. T. Clifford Allbutt, pub-
lished in the British Medical Journal for May 14th. Dr. All-
butt says: " It is sad to hear it commonly said that the day of
learned physicians is past, that they are gone with periwigs and
bric-d-brac. And I have had already to observe, to my pain,
that the Cambridge medical student of to-day is by no means
'learned'; that too often he thinks loosely, and that he does
not always write even the English of the gentlemen who do the
fires and the murders for the country journals. On his Latinity
I will discreetly keep silence." Regarding the latter objection
we must recall that the greatest English poet knew " small
Latin and less Greek," and those geniuses who have made the
greatest impression on the progress of medical science in this
century have been men whose classical training was meager.
THE GOOD SAMARITAN DISPENSARY.
This institution is the successor of the Eastern Dispensary,
one of the oldest aud largest of the dispensaries of New York.
As will be seen in our advertising columns, the trustees desire
applications from candidates for appointment to the office of
attending physician in the department of general medicine. We
would direct our younger readers' attention to the advertise-
ment, and add the remark that the Good Samaritan Dispensary
seems to us, after careful inquiry into its methods, to have
shown unusual care and wisdom in the selection and remunera-
tion of its medical staff and in its attitude toward its benefi-
ciaries.
COLOR-BLINDNESS IN THE NAVY.
A court of inquiry has made an instructive report regard-
ing the causes of the grounding of the United States steamer
Alliance in the harbor of Yokohama. It was proved that the
color-blindness of a lieutenant who had entered the service as
a cadet midshipman as far back as 1807 was the cause of the
accident. In endeavoring to take the vessel out of the harbor
this officer did not distinguish properly the danger-lights sur-
rounding the breakwater. This mishap resulted in the discov-
ery of the lieutenant's visual defect and will, it is said, lead to
his retirement.
ITEMS, ETC.
The Brooklyn Pathological Society.— At the June meeting of this
society, to be held on the 9th inst., the subject of the pathology of the
respiratory system will be opened for discussion by a paper by Dr. J. M.
Clayland. From the Hoagland Laboratory miscellaneous specimens will
be presented by Dr. J. Van Cott, the president of the society.
The Brooklyn Surgical Society. — The special order for the meeting
of Wednesday evening, the 2d inst., was a paper on The Surgical Treat-
ment of Contractures, by Dr. A. T. Bristow.
The Manhattan Eye and Ear Hospital. — Dr. Thomas J. McCoy, of
Los Angeles, has been appointed assistant house surgeon.
Army Intelligence. — Official List of Changes in the Stations and
Duties of Officers serving in the Medical Department, United States
Army, from Ma;/ 22 to May 28, 1892:
Smith, Allen M., First Lieutenant and Assistant Surgeon, will, upon
the return of Munday, Benjamin, Captain and Assistant Surgeon, to
Fort Sully, South Dakota, proceed without delay to Fort Yellowstone,
Wyoming, and report to the commanding officer for temporary duty
with troops in the National Park during the season. Par. 1, S. 0.
80, Headquarters Department of Dakota, St. Paul, Minn., May 24,
1892.
Tdrrill, Henry S., Captain and Assistant Surgeon, is granted leave of
absence for three months.
De Loffre, Aug. A., Captain and Assistant Surgeon. The leave of ab-
sence on surgeon's certificate of disability granted in S. O. 93,
A. G. O., April 20th, is extended one month on surgeon's certificate
of disability.
Naval Intelligence. — Official Lust of Changes in the Medical Corps
of the United States Navy for the week aiding May 28, 1892:
Turner, T. J., Medical Director (retired). Granted one year's leave of
absence, with permission to leave the United States.
Harris, H. N. T., Assistant Surgeon. Promoted to Passed Assistant
Surgeon.
Wilson, George B., Assistant Surgeon. Promoted to Passed Assistant
Surgeon.
Gates, Manly F., Assistant Surgeon. Ordered to Naval Hospital,
Portsmouth, N. H.
Urie, J. F., Passed Assistant Surgeon. Detached from Naval Hospital,
Portsmouth, N. H., and ordered to the U. S. Steamer Chicago.
Byrnes, J. C, Assistant Surgeon. Detached from the U. S. Steamer
Chicago, and granted three months' leave of absence.
Society Meetings for the Coming Week :
Monday, June 6th : German Medical Society of the City of New York ;
Morrisania, N. Y., Medical Society (private) ; Brooklyn Anatomical
and Surgical Society (private) ; Utica, N. Y., Medical Library Asso-
ciation ; Corning, N. Y., Academy of Medicine ; Boston Society for
Medical Observation; St. Albans, Vt., Medical Association; Provi-
dence, R. I., Medical Association ; Hartford, Conn., Medical Society ;
Chicago Medical Society.
Tuesday, June 7th: American Medical Association (first day — Detroit);
Massachusetts Medical Society (first day — Boston) ; New York Neu-
rological Society ; Elmira, N. Y., Academy of Medicine ; Buffalo
Medical and Surgical Association ; Ogdensburgh, N. Y., Medical As-
sociation; Medical Societies of the Counties of Columbia (semi-an-
nual— Chatham), Franklin (semi-annual), Herkimer (annual — Herki-
mer), Niagara (annual — Lockport), Orange (annual — Goshen), Sara-
toga (annual), Schoharie (annual), Ulster (annual — Kingston), and
Yates (annual), N. Y. ; Hudson (Jersey City) and Warren (annual),
N. J., County Medical Societies; Androscoggin, Me., County .Medical
Association (Lewiston) ; Baltimore Academy of Medicine.
Wednesday, June 8th : Maine Medical Association (first day — Portland) ;
South Dakota State Medical Society (first day — Salem); American
Medical Association (second day) ; Massachusetts Medical Society
(second day) ; New York Pathological Society; Metropolitan Medi-
cal Society (private) ; American Microscopical Society of the City of
638
LETTERS TO THE EDITOR.— PROCEEDINGS OF SOCIETIES.
[N. Y. Med. Jour.,
New York ; Medical Societies of the Counties of Albany, Cortland
(annual), Dutchess (semi-annual — Poughkeepsie), and Montgomery
(annual — Fonda), N. Y. ; Philadelphia County Medical Society.
Thursday, June 9th: Maine Medical Association (second day); South
Dakota State Medical Society (second day); American Medical Asso-
ciation (third day); Massachusetts Medical Society (third day); New
York Academy of Medicine (Section in Paediatrics) ; New York La-
ryngological Society ; Society of Medical Jurisprudence and State
Medicine ; Brooklyn Pathological Society ; Medical Society of the
County of Cayuga (annual), N. Y. ; South Boston, Mass., Medical
Club (private) ; Pathological Society of Philadelphia.
Friday, June 10th : Maine Medical Association (third day) ; South Da-
kota State Medical Society (third day) ; American Medical Associa-
tion (fourth day) ; German Medical Society of Brooklyn ; Medical
Society of the Town of Saugerties.
Saturday, June 11th : Obstetrical Society of Boston (private).
fetters to i\t €bitor.
EUROPHEN IN MINOR SURGERY.
303 West Nineteenth Street, New York, April 17, 1892.
To the Editor of the New York Medical Journal:
Sir: The results obtained by me from the use of europhen
have been most satisfactory and lead me to add my indorsement
of its use as a substitute for iodoform.
In the case of a driver of a beer- wagon, the index and
middle fingers of the right hand had been severely crushed by
being caught between two barrels. There was a fracture of the
middle phalanx of the index finger, with several deep lacerated
wounds of both fingers. Several days before coming to me the
patient had applied a carbolic-acid solution to the fingers, which
had become of a greenish-black color. The fingers and hand
were intensely swollen; there was pain in the elbow, and a
dark, foul-smelling pus exuded from the wounds. The treat-
ment was by thorough washing of the injured parts in bichlo-
ride solution, insufflation of europhen into the wounds, and en-
velopment of the fingers in a one-to-eight ointment of europhen
and lanolin. Five days therefrom the swelling of the fingers
had become reduced and there was less pus secretion from the
wounds. The skin was still black and easily detached from the
fingers in several places. A dark pus covered the denuded sur-
faces. As much of the cuticle as could be separated was re-
moved, and europhen was dusted upon the denuded surfaces, as
also into the wounds. This treatment was continued, and in
about eighteen days the wounds were entirely closed, the cuticle
having been freely and completely separated two days pre-
viously.
A child, four years old, was suffering from a large cervical
abscess. It was opened and a large quantity of pus evacuated.
The abscess cavity was curetted and europhen insufflated. The
child was seen several days thereafter. Recovery was uninter-
rupted.
A child, aged three years, had had its buttocks and left lower
extremity severely scalded by falling into a pot of boiling water.
Carron oil was applied for forty-eight hours, followed by the
dusting of europhen over the buttocks and half of the thigh.
Boric acid and bismuth were used on the rest of the thigh and
on the leg. As no deleterious results followed the application
of europhen, its use was adopted upon the whole of the scalded
surface. Recovery was complete with no untoward symptoms.
In several other minor cases I have used europhen, and in no
case have poisonous results followed its application. Europhen
is undoubtedly as effective as iodoform. It is lighter in weight,
does not cake, and is more readily dusted or insufflated. It is
innocuous and free from disagreeable odor.
P. G. Becker, M. D.
flrocecbings of Societies.
NEW YORK NEUROLOGICAL SOCIETY.
Meeting of April 5, 1892.
The President, Dr. Landon Carter Gray, in the Chair.
On the Present State of Treatment of Chronic Diseases
of the Spinal Cord, especially of Tahes and Neurasthenia.
— Dr. Leonard Weber read a paper with this title. In delib-
erating upon the prognosis in any case of chronic disease of the
cord, the first aim should be to distinguish between functional
and organic disease. The first was dependent upon impalpable,
the latter upon structural, changes. In a series of disorders, in
spinal neurasthenia, in some cases of concussion of the spine, of
hysterical paresis, and of toxic paralysis, palpable tissue-changes
were generally not demonstrable. The molecular alterations
were here presumably quite variable in a given series of cases,
yet they might come to complete restoration, but they not in-
frequently persisted, particularly in neurasthenia gravis. In the
treatment of chronic structural disease of the cord, tabes in par-
ticular, there were three methods of procedure which constituted
our main reliance and which we put to use singly or in combina-
tion, according to the special indications of the case. As to the
relation between syphilis and tabes and the amenability of the
latter to treatment, the author was of the opinion that we were
justified in using antisyphilitic remedies in a case of tabes with
a syphilitic history, and, furthermore, that the results were bet-
ter where the interval had been short between the infection and
the appearance of spinal symptoms and where the case was not
complicated by other disorders. The longer the lapse of time
between syphilitic infection and the outbreak of spinal disease,
the longer the duration and progress of the latter, the less was
to be expected from a course of antisyphilitic treatment. In all
cases of the kind it would be well to combine hydrotherapy and
electrotherapy with the specific remedies. A combination of
mercury and iodide of potassium seemed to offer the best results,
inunctions of half a drachm of gray ointment and fifteen grains
of the iodide two or three times daily. Authorities were not
yet agreed upon the importance of the role which syphilis played
in the aatiology of tabes, and we were not yet able to pass judg-
ment on the therapeutic value of specific treatment of the dis-
ease, but we were also aware that some of the best men had
reported favorable results and even a few cures. Symptomatic
remedies were useful and often necessary to control pain. It
was the author's practice to give antipyrine and acetanilide in
combination. In regard to electrotherapy, no other remedy had
been and was applied as much in chronic disease of the cord.
From the crude way of its former use to the present rational
modes of its application great progress had undoubtedly been
made, but the reports as to the curative powers of electricity
were contradictory, and it appeared to the speaker also that the
number of observers who were losing faith in its value was in-
creasing. Nevertheless, inasmuch as it could, when properly
applied, relieve certain symptoms and by its stimulating and
tonic effect benefit the patient, the author was not prepared to
abandon its use. The constant current directly applied took pre-
cedence over all other methods. The faradaic brush was also
Juno 4, 1892.]
PROCEEDINGS OF SOCIETIES.
to be recommended. The third method of treating chronic spinal
disease was by hydrotherapy. The sulphur bath was especially
useful in spinal disease of syphilitic origin, in conjunction, of
course, with antisyphilitic remedies. The author had no confi-
dence in the heroic measures that had been recommended from
time to time in the treatment of these disorders, such as revul-
sion, the cauterization of painful points, etc., as his efforts in these
directions had not been attended with success. With the con-
sideration of the treatment of spinal neurasthenia (" spinal irri-
tation ") the author closed his remarks. For the lighter forms,
such as were observed in young people in consequence of sexual
aberration to a moderate degree, or in the state of convalescence
from various acute disorders, the removal of the cause, regula-
tion of the mode of life, mild tonics combined with evening doses
of bromides or other sedatives, the use of the steel sound where
there was much urethral or prostatic irritation, a three or four
weeks' course of mild galvanism to the spine, the cold sponge
bath, and other suitable hydrostatic procedures, would generally
be found sufficient to effect a cure. When it was practicable, a
sojourn in the country and the use of cold baths of short dura-
tion was often advisable. Not so positive were the results of
the treatment of neurasthenia gravis, as it might develop par-
ticularly in persons with a neurotic history after influences of an
exhausting character, such as years of mental or physical over-
work, sexual excesses, and prolonged and frequent masturbation
at the age of puberty, when the entire central nervous system
was often disturbed. It was true that the life of the individual
was not put in great jeopardy by the vicious habit, but was often
made very miserable, inasmuch as his capacity both for work and
for reasonable enjoyment was very much diminished. Even in
the neurasthenic the molecular changes in the nervous centers
might be such that, on removing the cause and applying the
proper treatment, functional readjustment might not be accom-
plished. Whatever progress had been made in the treatment of
spinal diseases had not been due so much to the light furnished
by the study of their astiology as by clinical observation and prac-
tical personal experience.
Dr. W. J. Morton said he used mercurials in cases of loco-
motor ataxia, but did not regard the trifling improvement mani-
fested as due to any antisyphilitic effect from the drug, but sim-
ply to its alterative properties, if he might use the ambiguous
term. If syphilitic neoplasms were present, some good result
might be expected from such treatment. He had been making
observations upon patients as to the effect of electricity upon
the excretion of urea and upon the temperature. The results
had been surprising. Changes had always resulted. In some
instances the temperature during an electrical seance had been
from the normal to 100° F., and, when subnormal, had been
raised a degree and a half.
The President had never seen the typical neurasthenic con-
dition as a prodrome of organic spinal disease. He had, how-
ever, seen some forms of so-called sexual neurasthenia simulat-
ing disease of the cord quite closely. In some diseased condi-
tions of the prostate or urethra or from mercurial poisons there
might ensue a train of symptoms indicated by pain down the
small of the back and along the sciatic, capricious and intermit-
tent, and lasting for years, also an enormous increase of the
cremasteric reflexes. There was an ataxia which seemingly re-
sulted from syphilis. There was a cerebro-spinal form of syphi-
lis in which symptoms of locomotor ataxia were present. It
was a question whether true locomotor ataxia was not a neu-
rosis. There were cases in which no lesion of the cord could be
found. Some of these cases remained stationary for years after
a course of treatment; or there might bo some improvement
and then general paresis. Again, the general paresis might im-
prove. He had found that the great pain might often be re- '
lieved by rest. The ataxia was a different thing to treat. Sus-
pension gave [marvelous results sometimes. He agreed that
those who found no"good in electricity as a therapeutic agent
knew nothing about it. Galvanism in locomotor ataxia, espe-
cially in the neurotic forms, was of as distinct benefit as most
drugs. Faradism of the motor-nerve troubles had also been of
great benefit. We saw cases of neurasthenia gravis where there
was a limited atrophy or disease of the ganglionic portions of
the cord. Patients so affected were of feeble molecular power.
Posterior sclerosis could arise which might have no connection
with the condition, but he thought that every one who had ob-
served many cases would find that in after years the elastic-
symptoms of tabes would develop.
Meeting of Maij 3, 1892.
The President, Dr. M. Allen Starr, in the Chair:
Acquired Myotonia. — Dr. George W. Jacoby presented'a
man with the typical phenomena of this disease. He gave a
history of chancre a few years before, but of no further symp-
toms. He had first observed, nine weeks previous to his pres-
entation, cramps in the hand, and found that flexion of the
fingers caused tonic contraction. This condition existed to a
marked extent in both bands, and some time elapsed before the
hands could be voluntarily opened when flexed. The shoulders
were beginning to be involved in the process. There were no
sensory [disturbances. Electrical examination gave myotonic
contraction. Mechanical reaction over the hands, forearms, and
shoulders was plainly demonstrated. The patient was a cigar-
maker, and the speaker put the question as to whether the dis-
ease was a professional neurosis or not. It was not a case of
Thonisen's disease, but the speaker thought that there might be
a link between such cases, because he had seen a similar case of
acquired myotonia develop into Thomsen's disease.
Live Issues in Neurology.— The President had selected
this as the title of his inaugural address. After reviewing the
work of the society for the past few years, he offered a sugges-
tion in the mapping out of future work. It was that there-
should be a more general discussion of neurological subjects.
Collective investigation of disease was certainly of the greatest
value.
For such discussion, the subject presented many divisions,,
especially in cases in which the pathology was still an open
question, also in the theory of disease. It should be sought
to connect symptoms with underlying lesions. One of the in-
teresting studies should be the possible relation of physiological
chemical processes to the various functional nervous affections.
Turning from theory to fact, would not some general discus-
sion that would bring individual experience to a focus aid
greatly in prognosis and therapeutics? It was only by co-
operation that the society could be made of the greatest service.
The histories of three cases of angeioneurotic oedema were
then read.
Observations on the Excretion of Uric Acid.— Dr. C. A.
Herter read a paper on this subject. (See page 617.)
Dr. L. C. Gray said that the one fact of value elicited by
Dr. Herter had been the relation of uric acid to disease, but he
thought that one of the drawbacks to this knowledge being of
practical utility was that we were not by any means positive as
to the normal standard of the ratio. He could not say that he
had observed the same action from a nitrogenous diet as the
writer of the paper had. Dr. Herter had not classified neuras-
thenia, but the speaker thought that the ratio in the uric-acid
excretion would be very different in cases of lithremie neuras-
thenia.
Dr. B. Sachs thought that the paper could be used as a
640
PROCEEDINGS
OF SOCIETIES.
[N. Y. Med. Jour.,
guide by which to work up further facts in regard to this ques-
tion of uric-acid excretion in health and in disease. He was
satisfied that in treating a number of cases the uric acid had
been reduced by a non-nitrogenous diet and plenty of fluids.
NEW YORK SURGICAL SOCIETY.
Meeting of January 27, 1892.
The President, Dr. A. G. Gekster, in the Chair.
Deformity of the Thigh from Faulty "Union of a Fract-
ured Femur. — Dr. Parker Syms showed a patient illustrating
this condition, and asked for suggestions concerning the proper
mode of treatment.
Dr. J. D. Rushmoee suggested Hacewen's operation.
Dr. F. Lange suggested linear osteotomy, with a shoe with
the sole an inch and a half in thickness.
Dr. Syms agreed with Dr. Lange as to the use of the shoe,
and had asked advice as to the feasibility of the operation, con-
sidering the danger from the stretching of nerves and vessels,
■which might be serious.
Excision of the Elbow Joint.— Dr. Lange presented a pa-
tient, fifty-three years of age, on whom he had excised the right
elbow joint for an old ankylosis with relapsing suppuration, the
consequence of an osteomyelitis of the humerus, the primary
attack of which seemed to have occurred at the age of eight
years. At that time the elbow was not involved. Almost twenty-
five years later the process must have recurred, with perfora-
tion, probably, into the joint. From the scar on the posterior
aspect it was apparent that an operation of some extent had
been done by the late Dr. Krackowizer. Healing had taken place
with complete bony ankylosis at an angle of about 135°. About
five months before, abscesses had formed again, after an inter-
val of more than twenty years, and fistula? remained which led
to the bone just above the joint. The patient had suffered for
several years past from a nervous trouble the symptoms of
which pointed to a slowly progressing locomotor ataxia. In
spite of that, the speaker thought excision of the joint and,
through that, the removal of the diseased bone, was indicated.
In the operation and after-treatment the plan was followed which
he had explained in another case that had been presented at a
previous meeting this winter, so-called chiseling exsection, with
preservation of a shell of bone corresponding to the important
ligamentous and tendinous insertions. The after-treatment had
been given by the apparatus previously demonstrated. Healing
took place very rapidly, and, though the arm of the patient, on
account of the ankylotic condition of the joint during more
than twenty years, had become very atrophic, and his age and
general condition excluded extensive new formation of bone,
the joint was now — about two months after the operation — be-
ginning to get somewhat useful. For a number of weeks the
patient had not shown any ability to use the muscles which
flexed or extended the elbow joint. Apparently he had entirely
forgotten to use them co-ordinately. Every muscular effort was
made from the shoulder or wrist joint, though, when the elbow
joint was kept in a fixed position, not inconsiderable force could
be executed by the extremity. The patient was soon able to
elevate the arm, even in a flexed and pronated position of the fore-
arm, but not until very recently had the use of the elbow itself
been acquired. Perhaps, also, his nervous trouble had some-
thing to do with this inability to use his muscles with accuracy.
Pes Valgus on Both Sides, operated upon after Trende-
lenburg's Method on One Side, and by Cuneiform Excision
and Arthrodesis in the First Tarsal Joint on the Other.—
Dr. Large presented a patient, twenty-two years of age, from a
healthy family and otherwise healthy, who had begun to suffer
in his eighteenth year. For about a year he had been treat-
ed with orthopaedic shoes. During the past year his suffering
had become quite intense, so that he was unable to stand for
more than very short periods of time. Both his feet were extreme
pedes valgi. The tendons of the extensors and peronei were
contracted, and both active and passive motions of the feet
were greatly limited and somewhat painful. The head of the
os tali on each side protruded sideways and toward the ground,
so that the inner border of the foot seemed to be elongated and
the forefoot abducted. In the beginning of November Trende-
lenburg's supramalleolar osteotomy was done on the right side;
but the resistance of the contracted tendons was so great that
they, too, had to be cut across on the dorsum of the ankle
joint and above the external malleolus. The remainder of the
operation consisted in forcible correction and a plaster-of-Paris
bandage. Three weeks later the left foot was operated upon.
After a semilunar incision over the head of the astragalus the
latter was partly chiseled away and a wedge of the joint ele-
ments was removed, the sharp edge being in the cuboid bone;
and incision was then made over the outer half of Chopart's
joint, and with a broad chisel the same was sufficiently freed to
allow of an equal approximation of the os naviculare to the
astragalus. The after-treatment was the same on both feet.
Under the permanent antiseptic dressing and plaster of Paris,
union took place without noteworthy suppuration. On the side
where the a-tragalus had been excised the speaker had been
struck by a softened condition of the bone and its greater vol-
ume, as if there had been a chronic inflammation with some
osteoporosis. He had presented the case principally to allow of a
comparison of the results in the two tnethods described. The pa-
tient was wearing flat-foot shoes with lateral splints to the knee
joint, which kept the feet snpinated, and it was intended that
he should wear these protecting apparatuses for several months
to come. The functional result was not yet perfect, owing to
the short time that had elapsed since the last operation. The
foot last operated upon was still weak and its motions were
more limited than those of the other, the tendons of which had
been cut across. With reference to the abnormal protrusion of
the astragalus, the outlines were somewhat nearer the normal,
but both feet might still be called moderate pedes valgi in spite
of the not inconsiderable correction. For the present, on ac-
count of its greater mobility, the foot operated upon after Tren-
delenburg's method with tenotomies seemed to present a more
promising outlook. It would be of interest to see the same
patient about four months later, and it was his intention to pre-
sent him again. He believed the operation indicated only in
extreme cases where other remedies were of no avail. With
reference to the methods to be chosen, a selection must be
made which would be adapted to the requirements of the given
case.
The President inquired whether, in the case of excision of
the elbow, the open treatment and packing had been used.
Dr. Lange replied in the negative. The available tissues
were not abundant. The wound was allowed to fill with blood,
and healed with the clot in situ.
Dr. F. Kammerer observed that the patient seemed to him
to have little power of motion in the flexor muscles, considering
that several months had elapsed since the resection. He asked
if it was advisable in such cases to try to get a movable jointi
and if an ankylosis in a good position was not preferable.
Dr. Lange replied that there was motion in certain direc-
tions. He supposed the muscle-consciousness, as it were, was
still undeveloped.
Dr. Willy Meyer, commenting upon Dr. Lange's second
case, reported seven operations of supramalleolar osteotomy
for ordinary flat-foot which he had performed upon four pa-
Juno 4, 1892. J
BOOK NOTICES.
641
tients. In two of the cases, which were far advanced, walking
was easier than before, but still slightly painful. Perhaps Og-
ston's operation should be added yet. In all of his cases he had
found the bones abnormally soft. Trendelenburg had advised
that the operation should be performed as near the foot joint as
possible. The speaker believed that patients should be ex-
amined in a year or two after the performance of the operation.
Only the permanency of the result obtained would prove the
merits of the different operative methods.
Sarcoma of the Femur, without Recurrence Five
Years after Amputation through the Trochanter Minor.
— Dr. Frank Hartley reported the case of a man, twenty
years of age, who had been admitted into the Roosevelt Hos-
pital, on October 9, 1886. The history showed disease in the
knee joint for eight months. The diagnosis was that of sarcoma
of the lower end of the femur, involving the knee joint. The
patient was markedly anaemic. The thigh was amputated
through the trochanter minor, and the patient was discharged,
cured, November 29, 1886. There had been no recurrence of
the disease. This fact was important because Borck, of Ro-
stock, had collected a hundred and twenty cases of exarticula-
tion at the hip joint for malignant growths, of which he found
that in only eighty-seven had the patients recovered from the
operation. Of the remaining patients, twenty-six had died from
metastases — twenty in the first year, two in the second, one in
the third, one in the fifth, and in two the time had not been
determined. In six cases death had occurred in from twenty
days to fourteen months after the operation, from disease un-
connected with the original trouble. Four cases existed in
which the patients had lived more than ten months, as follows:
One lived twenty-seven months without metastases (Madelung) ;
one lived two years and a half with metastases upon the back
and beneath the arm, connected with the ribs (Ozerny) ; one lived
three years without metastases (Kuster) ; and one lived thirteen
years with a suspicious tumor in the arm. We did not cure
these cases by disarticulation. Twenty-four of the twenty-six
patients had had internal metastases, and two had had local re-
currences.
The case now reported suggested the question of whether
amputation at the trochanter minor, except in cases involving
the bone near it, was not a less severe method of treatment than
exarticulation, and one likely to be followed by equally good
results.
Dr. J. A. Wyeth believed that most of the" patients upon
whom amputation at the hip joint was performed for sarcoma
of the femur perished within a year or less, from recurrence of
the disease locally, or in the internal organs.
Dr. Lange bad operated in two cases of this character. One
patient died from metastatic sarcoma of the brain ; the other
had been operated upon two years ago, and the speaker was not
certain as to the result. Both had recovered from the opera-
tions without untoward symptoms.
The President had operated seven years ago at the tro-
chanter minor, and there had been recurrence before the wound
had healed. The patient left the hospital with an unfavorable
prognosis. A very severe attack of erysipelas intervened, from
which the patient recovered, and when he was seen, three years
subsequently, the sinus of the original wound had healed, and
there had been no recurrence of sarcoma.
Ether Narcosis as induced by the Ormsby Inhaler.—
Dr. J. A. Wyeth read a paper with this title. (See page 629.)
Dr. Rushmore failed to see the advantages of the method
over ordinary methods, judging from the statements that had
been made. He did not feel sure that the expired air in the in-
haler prevented the cooling of the ether vapor. If nausea and
vomiting had occurred in twenty-five per cent, of the author's
cases, he believed the number was too great, and that carbonic-
acid poisoning had had something to do with it.
Dr. F. Gwyer had been impressed by the statement that
ether should not be administered by inexperienced persons, as
was the prevalent custom in hospitals.
Dr. Lange remembered that the late Dr. IT. B. Sands had
recommended the Ormsby inhaler ten years ago. The speaker
had used it six years, and had usually been satisfied with its ac-
tion. The quantity of ether required when using it was small,
and he agreed with the author in thinking that the number of
those who were nauseated after its use was smaller than with
other inhalers, though in his own experience larger than in Dr.
Wyeth's.
Dr. C. K. Briddon thought that any form of apparatus by
which the quantity of ether used was minimized would be de-
sirable.
Dr. Hartley corroborated the statements made by the reader
of the paper.
Dr. Syms suggested a simpler and less expensive inhaler than
the Ormsby, which included the advantages of the latter.
Dr. W. W. Van Arsdale feared carbonic-acid poisoning from
the use of the Ormsby inhaler. A death from such a cause had
recently occurred. Of course a single case was not sufficient to
condemn the method.
The President showed a complicated apparatus for ether
anaesthesia, invented by M. D. Hobbs, of Richmond, Indiana,
which effected the warming of the ether vapor to body heat,
and so diminished its refrigerating and irritating effect upon the
respiratory tract. The apparatus was cumbersome, but in those
cases in which it had been tried it had been demonstrated that
it was not without merit.
Dr. Wyetii disagreed with those who thought there was no
advantage in anaesthetizing a patient rapidly. He believed that
every minute saved to the patient from the influence of the
anaesthetic was a decided gain. With other inhalers he had
found that nausea followed an operation much more commonly
than with the Ormsby. In patients who had been addicted to
the use of alcohol he preferred chloroform as an anaesthetic.
Rules were given for the proper care of the inhaler and for giv-
ing the anaesthetic.
§ooh Boticcs.
The Science and Art of Midwifery. By William Thompson
Lusk, A. M., M. D., Professor of Obstetrics and the Diseases
of Women and Children in the Bellevue Hospital Medical
College, etc. New Edition, revised and enlarged, with
Numerous Illustrations. New York: D. Appleton & Co.,
1892. Pp. xviii-761.
This edition of Dr. Lusk's text-book is so thorough that, as
the author says in the preface, it is "essentially a new book."
However, since on its first appearance the work gave such a
faithful representation of the best obstetrical teachings of the
period, the author's task of revision must have been almost con-
fined to the grateful work of recording the advance of his art'
In other words, but few errors called for correction, and that
fact must have left the author comparatively free to devote him-
self to the much pleasanter part of the work of revision.
Lusk's Midwifery is so widely known and so highly esteemed
that a formal review of this fourth edition is uncalled for. The
mere announcement that a revised edition has appeared ought
to be enough to impress every general practitioner with the
necessity of his possessing a copy of the book.
642
MISCELLANY.
[N. Y. Med. Jodb.t
The Pocket Pharmacy, with Therapeutic Index. A Resume of
the Clinical Applications of Remedies adapted to the Pocket-
case, for the Treatment of Emergencies and Acute Diseases.
By John Auldk, M. D., Member of the American Medical
Association, of the Medical Society of the State of Pennsyl-
vania, etc. New York: D. Appleton & Co., 1892. Pp. 204.
[Price, $2.]
The author's pocket pharmacy consists of a pocket-case con-
taining twenty-four varieties of tablet triturates that have been
selected to meet the usual emergencies of daily practice ; and
any one objecting to one or more of the preparations could sub-
stitute others that he preferred. But with this particular selec-
tion the author describes under the name of each remedy the
various morbid conditions in which it may be employed. There
are mentioned many unfamiliar applications of old remedies,
and we believe that their administration as indicated may prove
valuable.
Small doses of each drug are recommended, and the most
confirmed therapeutic pessimist can only say in the face of the
optimism exhibited by the author that the amount administered
can do no great damage even though all the good expected may
not be accomplished.
The author believes that clinicians should study the effect of
therapeutic agents upon diseased cells, and enriches our vocabu-
lary by calling this " cellular therapy," considering that the
light furnished by this doctrine will explain the therapeutic value
of properly selected remedies.
We believe the work will be found interesting and useful to
many besides the " intellectually rich though often technically
poor " recent graduate.
BOOKS, ETC., RECEIVED.
Atlas of Clinical Medicine. By Byrom Brarnwell, M. D., P. R. C. P.
Edin., F. R. S. Edin., Assistant Physician to the Edinburgh Royal In-
firmary. Vol. I. Part IV. Edinburgh: T. & A. Constable, 1892.
Pp. 141 to 184.
The Diagnosis of Diseases of the Nervous System : A Manual for
Students and Practitioners. By Christian A. Herter, M. D., Physician
to the Class of Nervous Diseases, Presbyterian Hospital Dispensary.
New York and London : G. P. Putnam's Sons, 1892. Pp. viii to 628.
Price, $3.
A Study of Influenza, and the Laws of England concerning Infec-
tious Diseases. A Paper read before the Society of Medical Officers of
Health, January 18, 1892. By Richard Sisley, M. D. Lond., M.R.C.P.
Lond. etc. London: Longmans, Green, & Co., 1892. Pp. 11-13 to 119.
Suggestions as to the Technique of Intestinal Anastomosis. By H.
Horace Grant, M. D., of Louisville. [Reprinted from the Annals of
Surgery.]
Poisoning by Creasote. By W. Freudenthal, M. D., of New York.
[Reprinted from the Medical Record.]
Some Differential Points in the Diagnosis of Syphilis and Tubercu-
losis, with Illustrative Cases. By Prince A. Morrow, M. D. [Reprinted
from the Journal of Cutaneous and Gtnito-urinary Disease?.]
Sur Taction toxique et antiseptique de chloroforme et de 1' ether. Par
le Dr. J. F. Heymans, membre titulaire. [Extrait des Annates de la
Soeiete de rnedeeine de Gaud.]
Cystic Degeneration of the Muscular Fibers of the Heart. A Form
of Disease hitherto Undescribed. By Arthur V. Meigs, M. D. [Re-
printed from the Transactions of the College of Physicians of Philadel-
phia.]
A Series of Fifty Consecutive Operations for Cataract. By Robert
L. Randolph, M. D., Baltimore. [Reprinted from the Johns Hopkins
Hospital Bulletin.]
Bermerkungen zti dem Artikel des Herrn Gleitsmann : " Em neues
und einfaches Verfahren zur Beseitigung der unangenehmen Folgezu-
stande nach Gebrauch der Galvanocaustik bei Hypertrophien der Nase."
Von VV. Freudenthal, M. D., New York. [Aus der New Yorker mcdi-
cinimhi it Monatsschrift. \
Elements of Materia Medica and Therapeutics, including the whole
of the Remedies of the British Pharmacopoeia of 1885 and Us Appen-
dix of 1890. By C. E. Annand Semple, B. A, M. B. Cantab., M. R. C. P.
Lond., etc. With Four Hundred and Forty Illustrations. London :
Longmans, Green, & Co., 1892. Pp. xxxii to 480.
A Manual of Practical Obstetrics. By Edward P. Davis, A. ML,
M. D., Clinical Lecturer on Obstetrics in the Jefferson Medical College,
etc. With One Hundred and Forty Illustrations, two of which are
colored. Philadelphia : P. Blakiston, Son, & Co., 1891. Pp. 8-9 to 298.
Spectacles and Eyeglasses ; their Forms, Mounting, and Proper Ad-
justment. By R. J. Phillips, M. D., Instructor in Diseases of the Eye,
Philadelphia Polyclinic and College for Graduates in Medicine, etc.
Philadelphia: P. Blakiston, Son, & Co., 1892. Pp. viii— 1 7 to 97.
The /Etiology, Diagnosis, and Treatment of the Prevalent Epidemic
of Quackery. (An Address delivered, by invitation of the Faculty of the
Medical Department of the Buffalo University, before the Graduating
Class, May 3, 1892.) By George M. Gould, M. D., of Philadelphia.
[Reprinted from the Medical Newt.]
HI i s 1 1 II a n g .
Does Organic Disease of the Heart preclude the Use of Chloroform
in Parturition ? — This was the title of a paper read by Dr. T. Ridgway
Barker at a meeting of the Philadelphia County Medical Society held on
April 27 th :
In entering upon the discussion of a subject of such paramount im-
portance to mother, offspring, and obstetrician, one can not lay too much
stress at the very outset upon the axiom that " A good remedy will fail
of its effect if not properly administered." This fact must be kept up-
permost in our mind if we would avoid fatal results, not due, however,
to the emplo3'ment of the agent, as some would make it appear, but to
the lack of attention and care exercised in its administration. That
there is a radical difference between surgical and obstetrical amesthesia
(analgesia) goes without saying. If we consider for a moment the stages
of amesthesia, which differ only in the profoundness of the impression
— first, sopor ; second, stupor ; and, third, stertor — we can not fail to
notice that in analgesia one rarely has occasion to carry the effect be-
yond the first degree (sopor), while in the surgical variety we are obliged
to advance beyond this and keep the patient in the second stage, or that
of stupor, thus markedly increasing the gravity of the prognosis.
In this connection, let us devote a moment's consideration to the
progressive effect of chloroform vapor upon the nerve centers of the
cerebro-spinal system, beginning, as it does, at the inferior extremity of
the cord, sacro-lumbar, and gradually extending its paralyzing influence
upward until it reaches and expends its force upon the medulla oblon-
gata. These well-established clinical observations having been verified
by physiological experiment, we are justified in putting them to practical
use. What other agent, may be pertinently asked, can relieve — aye,
abolish — pain so quickly and safely, yet leave reflex muscular contrac-
tility unimpaired, as chloroform ? Ether and ethyl bromide have found
favor with some practitioners, but neither can displace chloroform.
Fordyce Barker states in his writings : " I may say here that I have
long regarded chloroform as the best and safest anaesthetic in obstetrics,
and that since 1850 I have used no other."
The danger from the employment of chloroform in this department
of medicine depends more upon the carelessness with which it is admin-
istered than to any toxic effect inherent in it. The four cardinal points
to be borne in mind when giving this amesthetic are : First, plenty of
pure atmospheric air; second, liberation of a small amount of the vapor
at a time ; third, attention to the respiration ; and, fourth, frequent ob-
servations as to the force and frequency of the cardiac action. That
the recorded cases of death have been due in a great measure to satura-
tion of the residual air in the lungs to a fatal degree can scarcely be
doubted. A few deep, forced inspiratory efforts will quickly produce
such a condition. Withdrawal of the agent under these circumstances
can not prevent the further entrance of the chloroform vapor into the
Juno 4, 1892.]
MISCELLANY.
G43
circulation, for it already fills the air-cells. Nor will attempts at arti-
ficial respiration prove effectual, since but a small quantity of the re-
sidual air can be forced out of the lungs, while that which enters fails
to sufficiently dilute the vapor owing to the tardiness of diffusion. Let
us not suppose, however, that because we administer to the parturient
female small amounts of the drug continuously, therefore no risk is in-
curred, for experiments directed to solve this important question go to
prove that even small doses, when continuously inhaled, tend to produce
dangerous, and at times fatal, cardiac exhaustion. Far different is the
result when given intermittently, as is the unalterable rule in obstetrics.
Should we seek authority for the statement that the dangers from the
carot id administration of chloroform in labor are too insignificant to war-
rant its refusal, we have only to turn to the American Si/stem of Obstet-
rics to find therein the following: " The danger when chloroform is used
only to the extent of mitigating or abolishing pain in childbirth is prac-
tically nil." Lusk, quoting from Bert's experiments, states that " chloro-
form might be intermittently administered for an indefinite period with
safety." These remarks do not apply to its use in the third stage of
labor, for, as is well known, after delivery of the child it is likely to
occasion relaxation of the uterus, thus favoring post-partum hajmor-
« rhage.
Offering the foregoing as a preface to my remarks on the judicious-
ness of employing chloroform when the parturient female suffers from
organic cardiac disease, it now remains for us to consider the effect of
parturition upon this enfeebled circulatory organ, thereby securing a
scientific basis for our conclusions. In the first stage of labor we find
the muscular contractions confined to the uterine muscular layers and
directed toward overcoming the circular fibers of the cervix, while in
the second or propulsive stage not only does the uterus exert its power
to the utmost, but also the abdominal and respiratory muscles are
brought into action by the will of the parturient in her efforts to expel
the foetus. The diaphragm is forced down and its movements paralyzed
by the female holding her breath.
The other respiratory muscles are likewise unable to act, and hence
imperfect oxygenation of the blood results. As a consequence, the car-
diac movements are accelerated, greater resistance is met with in the
pulmonary and aortic circulations. Moreover, a tendency exists to
venous congestion, as evinced by the hue of her face and swollen veins.
Owing to the excruciating pain experienced when the head passes
through the cervix, the parturient is further tempted to make addi-
tional muscular efforts, which only augment the difficulties met with.
Under normal conditions this strain is of such brevity that it can not be
considered of any importance, but when complicated by disease of the
heart it is of far greater gravity. If the condition is one of fatty de-
generation due to a previous pericarditis or myocarditis, resulting in
faulty nutrition and enfeeblement of the heart's action, as evinced by
weak impulse, venous stasis, confused and irregular sounds, anaemia
alike of brain and other organs, with faintness and oppression on the
slightest exertion, this interference with circulation and respiration may
readily tax its powers too far, and so cause speedy death from paralysis.
Here the conditions which pertain in surgical anaesthesia are absent.
The indications present are to allay excessive muscular action and res-
piratory spasm which is threatening the over-stimulated heart.
To allow the female to continue such efforts is to permit her to com-
mit suicide ; to warn her to desist is useless when in such agony ; while
delay is likely to be fatal. How can we overcome this condition of
nervous excitement ? Can we accomplish it by the administration of
chloroform ? Yes ; of the two evils, for we must acknowledge there is
an element of risk in giving chloroform, we can only choose the lesser,
and so promptly proceed by inhalation to relieve the accessory muscles
of parturition of their strain. By the abolishment of pain we lessen the
work required of the laboring heart, which, instead of beating at the
rate of one hundred and forty or more a minute, may diminish in fre-
quency to ninety or one hundred.
What has been said of fatty heart is equally applicable to condi-
tions of hypertrophy and dilatation.
The equilibrium, if disturbed, is almost certain to result disas-
trously. That sense of fullness in the chest and oppression due to
bronchial congestion, if relief is not afforded, becomes most distressing.
The cyanosis from deficient aeration is greatly exaggerated, while the
insufficient blood-supply to the brain causes syncope and may be suc-
ceeded by coma if the excessive reflex disturbance be not removed.
Nor are the indications for the administration of chloroform materially
different in the case of females in labor with valvular disease. Whether
it be mitral in the young adult or aortic in the aged primipara, the car-
diac strain must be relieved if we would save our patient. As is well
known, all forms of valvular disease ultimately develop a condition of
ischsemia on one side with corresponding low tension, while on the other
side is stasis with high tension. While by compensation life may run
on for years, yet, when the strain of parturition cones, it will soon be
overthrown if precautions are not taken to prevent it.
Of what benefit will be our knowledge of the value of cardiac
" physiological rest," as laid down by Fothergill, if we do not apply it
under these conditions ? We all appreciate the importance of securing
" quietude of mind and body " when such pathological states exist.
Then why not employ the quickest and safest means to obtain it by the
inhalation of chloroform ? If the danger is great from " active exer-
cise— climbing mountains, running up stairs, lifting heavy bodies, and
all kinds of exercise involving heart strain " — how much greater, aye,
how immeasurably so must it be when the parturient female forces,
with the anguish of despair, every muscle to its utmost in her desire to
deliver her child. From a study of chloroform anaesthesia in obstetric
practice we have seen how it should be administered and how it acts.
Surely none will deny that in its employment under these circumstances
we act otherwise than for the best interest and safety of our patient.
That one may not be charged with being a blind adherent to theory,
one has only to turn for support and justification to the teachings of
the late lamented Fordyce Barker, who states : " It seems to be almost
accepted as an axiom, with both the profession and the public, that the
inhalation of chloroform is dangerous for any woman with disease of
the heart. For more than thirty years I have been convinced that this
opinion is quite erroneous, and I have so taught in my lectures and in
former writings."
He goes on further to say : " I have seen several cases, complicated
by dangerous heart lesions, which terminated favorably, as I think,
solely from the use of chloroform."
Snow, likewise, is of this opinion : " In all forms of valvular disease,"
he says, " chloroform, when carefully administered, causes less disturb-
ance of the heart and circulation than does severe pain." To quote
from Championniere : " If," he says, " I recognized an organic affection
of the heart, without pulmonary complications, I should rather give the
woman chloroform than let her suffer." Were further proof necessary
as to the propriety of employing chloroform anaesthesia, one might in-
clude among this group of clinical observers Vergeley, who expresses
himself thus : " Diseases of the heart are not a contra-indication to the
use of anaesthesia." Macdonald states : " In almost all cases of heart
disease with labor chloroform has been given, and apparently with bene-
fit, during delivery. If carefully administered, I think it can not but be
useful in all cases." Since such eminent authorities advocate its em-
ployment, can we justify ourselves in refusing our patients the benefit
and comfort this agent affords ? What is the danger from chloroform
compared to the state of exhaustion and collapse into which the par-
turient female will inevitably fall ? If this heart is forced to the verge
of paralysis from overwork and excitement, why shall we not use the
means at our command to lessen that strain ? Let us have a reason for
the faith that is in us, and not hesitate to fearlessly employ extreme
measures to overcome extreme dangers.
Chloroform by inhalation can and will, if properly administered, save
the lives of parturient females, suffering from organic disease, when
death seems imminent from over-stimulation of its ganglia through re-
flex nervous action. Organic heart disease, then, does not preclude the
use of chloroform in labor, but rather is a condition calling for its care-
ful administration.
The Dietetic Treatment of Heart Disease. — Dr. Felix Hirschfeld,
says the Therapeutic Gazette for May (in an abstract of an article pub-
lished in the Berliner kliiiischc HWe nachrift for March 1 1th), while oc-
cupied with the investigation of the assimilation of corpulent people,
observed that with the progressing loss of bodily weight there was also
a loss of organic albumin. This loss is not prevented, or even greatly
644
MISCELLANY.
[N. Y. Med. Jocr.
lessened, by the consumption of larger quantities of albuminates. Every
Banting process is to be looked upon as a diminished nourishment, with
the added fact that the assimilation is considerably increased by great
muscular exercise. The loss of albumin is greatest in the first week of
Banting. With a loss of weight of from four to five pounds troy, there
will be a loss of four to eight drachms of nitrogen, corresponding to
thirteen to thirty ounces of muscle.
The loss of nitrogen is considerably greater when the patient is ple-
thoric than in the case of an anaemic person.
It is remarkable that, in spite of the loss of albumin, physicians have
found almost always an increase of muscular strength, especially of the
heart, during gradual Banting processes.
To determine whether this would continue to be the case, Dr. Hirsch-
feld tried experiments upon himself and other healthy persons, and found
that with their food reduced to a half or one third the usual quantity,
there was no weakening of the heart ; this was true of thin and not
specially strong persons, as well as of those who were moderately stout
and strong.
The lessening of nourishment makes also a|change in the circulation.
In the first place, the volume of blood is diminished, for the blood does
not become more watery ; the quantity is of the same concentration but
smaller. With the smaller quantity of blood, the demands upon the
heart are less, this bearing an analogy to cupping, in which case the
lessening is more rapid.
Another point seems even more important. Whenever food is taken,
the processes of the glands and of the muscles of digestion demand
an increase of oxygen, which the heart must provide by increased ac-
tivity ; the more frequent and the larger the meals, the higher the de-
mands upon the heart. The slight weakening of other organs is not to
be deprecated in comparison with the favorable result for the heart.
For example, in the case of valvular trouble following rheumatism, it
has been customary to allow but small quantities of food, but present
knowledge demands that the nutrition be kept up by abundance of
easily digested food, especially milk,
Hirschfeld quotes various authors who have used the milk-cure for
heart trouble. This is simply a " hunger-cure," and is in general sel-
dom used, because opposed to the prevailing idea of nourishing the
organism as much as possible. He finds in the results quoted another
proof of the value of diminished nourishment, another means available
to lighten the labor of the weary heart. While seeking to increase the
power of the heart, the course is made easier by making the demands
upon it as slight as possible.
Hirschfeld thinks the strengthening of the heart-muscles by exer-
cise, as practiced at Marienbad, is decidedly dangerous. The whole
" cure " being often made in six weeks, necessitates a rapidity which is
not safe. It is quite possible that corpulent persons repeating this
" cure " yearly, or every second year, bring about a weakening of the
heart's walls. Often these very persons, pleased with the rapid loss of
weight, console themselves, as soon as their six weeks are over, with an
added luxury of living and richer food. The strengthening of the
heart by muscular exercise should be accomplished slowly.
In the treatment of corpulency there often occurs, in spite of the
loss of albumin, an increase of muscular power, especially of the heart.
The smaller amount of food produces conditions of the circulation which
lighten the work of the heart.
In strengthening the heart by means of exercise, especially in cor.
pulent persons, it only should be gradually increased. When the heart
is urged to oft-repeated exertions in a short time, there is a tendency to
dilatation of the heart by a weakening of the heart walls.
The New York Academy of Medicine, — The special order for the
meeting of Thursday evening, the 2d inst., was a paper on the Conserva-
tive Treatment of Salpingitis, by Dr. Paul F. Munde.
At the next meeting of the Section in General Surgery, on Monday
evening, the 13th inst., papers are to be read as follows: On the Me-
chanical Treatment of Ununited Fracture of the Neck of the Femur
with Traction Apparatus and Direct Lateral Pressure over the Tro-
chanter Major, by Dr. Newton M. Shaffer ; and Further Experience in
the Treatment of Inoperable Carcinoma of the Uterus with Pyoctanin
Injections, by Dr. H. J. Boldt.
At the next meeting of the Section in General Medicine, on Tuesday
evening, the 21st inst., Dr. J. K. Crook will read a paper entitled Ob-
servations on the Diagnostic Significance of Vascular Murmurs in the
Neck, based on Examinations of 1,500 Persons.
Homoeopathic Soup.— A correspondent of the Cri/ic says that the
following verses were published in some newspaper — what one he (or
she) does not remember — a number of years ago :
Take a robin's leg, Set the kettle on,
Mind, the drumstick merely, Get it well a-boiling,
Put it in a tub Skim the liquor well
Filled with water, nearly. To prevent its oiling.
Place it in a spot When the soup is done,
That is cool and shady ; Set it by to jell it ;
Let it stand a week — Then, three times a day,
Three days for a lady. Let the patient smell it.
Put a spoonful then If the patient die,
In a five-quart kettle: 'Twas disease that did it;
It should be of tin, But if he survive,
Or, perhaps, bell-metal. Give the soup the credit.
To Contributors and Correspondents. — The attention of all who purpose
favoring us with communications is respectfully called to the follow-
ing:
Authors of articles intended for publication under the head of " original
contributions " are respectfully informed that, in accepting such arti-
cles, we always do so with l/ce understanding thai the following condi-
tions are to be observed: (1) when a manuscript is sent to this jour-
nal, a similar manuscript or any abstract thereof must not be or
have been sent to any other periodical, unless we are specially notified
of the fact at the time the article is sent to us ; {2) accepted articles
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published as promptly as our other engagements will admit of — we
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new conditions can be considered after the manuscript has been put
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articles which, although they may be creditable to their authors, are
not suitable for publication in this journal, either because they are
too long, or are loaded with tabular matter or prolix histories of
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All letters, whcl/ier intended for publication or not, must contain the
writer's name and addrtss, not necessarily for publication. No at-
tention will be paid to anonymous communications. Hereafter, cor-
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and that can properly be given in this journal, will be answered by
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Secretaries of medical societies will confer a favor by keeping us in-
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ings will be inserted when they are received in time.
Newspapers and other publications containing matter which the person
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^ inserting the substance of such communications.
All communications intended for the editor should be addressed to him
in care of the publis/iers.
All communications relating to the business of the journal should be ad-
dressed to the publishers.
THE JSTEW YORK MEDICAL JOURNAL, June 11, 1892.
Original Communications.
FIVE CASES OF
THE PIN SENSATION IN THE THROAT.
By JOHN DUNN, M. D.,
RICHMOND, VA.
Case I.— Miss A., milliner, aged twenty-nine. The patient
complains that there is, whenever she " swallows," the sensation
in her throat as though there were a pin or the bristle of a brush
sticking her. The sensation is well localized and never changes
place ; is referred to the right side of her throat, upon a level
with the deepest part of the hyoid fossa. It is not a surface
sensation, but seems to have its seat deep in the throat. This
sensation is increased in unpleasantness whenever she catches
cold. It never leaves her, although the pin or bristle seems to
scratch the surrounding parts more at times than at others.
Miss A. has no remembrance of having ever swallowed a pin or
a bristle, but, from the sensation, is " certain that it must be the
one or the other." She has often swallowed crusts of bread to
try to dislodge this "pin." The sensation has existed for eight
or ten years, and no treatment she has received has been able
to relieve her. At times this place must ache, since Miss A.
says that it gives her neuralgia down her neck to the collar
bone, in the shoulder, and of the scalp behind the ear. She is
constantly clearing her throat to remove this "pin." Miss A.
is ansemic, and has the appearance of being nervous and over-
worked. The nose is normal, except that the mucous mem-
brane is too pale, and the middle turbinate of the right side
is hypertrophied enough to lie against the saeptum anteriorly.
The nasopharynx is clear. The left tonsil is normal. The
right tonsil is somewhat hypertrophied at its lower end. The
pharynx is normal, except that just behind the posterior pillar
on the right side, opposite the lower end of the tonsil, is an
area, about two millimetres broad and five millimetres long,
which has the appearance of being slightly thickened, is slight-
ly redder than the adjoining mucous membrane, and looks as if
it might be subject to some irritation. I made a note of this
condition at the time, but in no way connected it with the
"pin sensation" felt so distinctly lower down. The laryngeal
region was normal, except that there appeared on the right
side of the epiglottis a very small, whitish area, to which some
little mucus was adherent. There was no demonstrable trouble
in the external canal or inner ear. There was no bad tooth.
The teeth were examined because of the presence of the neck
neuralgia. I took a probe and touched the tonsil of the right
side. Miss A. said the trouble was lower. I then touched
various points along the left side of the base of the tongue, and
each time Miss A. said I had not gone far enough down. I then
examined the external neck carefully, and especially the point
to which the sensation was referred. Nothing abnormal could
be found, except that deep pressure over the skin at one point
on the side of the larynx was said to be painful, but there was
no sign of inflammation to account for this. There were no
enlarged glands. Examination of the lungs revealed some louder
breathing than normal. Finally, the part that the hysterical ele-
ment might play came up before my mind. The sensations, how-
ever, were too definite, and the patient was too willing to have
anything done for relief, for me to believe that there was not
some definite cause for the sensations, which I believed to be
plainly reflex. I told Miss A. that I could not h'nd anythingin her
throat that might cause such a sensation, but, if she would sub-
mit, I would remove everything, as far as I could, that was abnor-
mal in the throat, and that some one of these conditions might
be the cause of the trouble. She was willing to submit to any-
thing, and asked me if I would not give her chloroform and cut
down on the spot she touched with her finger and remove
whatever it was that was sticking in her throat. Speech,
breathing, powers of deglutition, etc., were perfectly normal,
and I would not leave the impression that there were any symp-
toms which seemed in any way to threaten life, but what there
were were a constant source of annoyance to the patient.
The treatment and results were as follows :
September 28th. — Removed the hypertrophied lower end of
the right tonsil. The patient said immediately after the re-
moval that the "pin sensation" had disappeared. I feared,
however, that the disappearance was due to pain caused by re-
moval. It proved to be so, as the "pin sensation" returned as
soon as the cut place was healed.
October 6th. — I passed a horse-hair probang into the cesoph^
agus, well down ; opened it and pulled it out. This was done
on a hint from an older physician, who took the hysterical
view as to the cause of these sensations. Furthermore, her
physician told me Miss A. had lateral curvature of the spine,
and suggested a connection between the neuralgic conditions
of the neck and this condition of the spine. Passing of the
probang, however, failed to relieve Miss A.
9th. — Removed with a snare the hypertrophied anterior end
of the middle turbinate.
16th. — Pin sensation still present, together with neuralgic
tenderness and numb sensations in the parts supplied by the
greater and lesser mastoid and auricular branches of the super-
ficial cervical plexus; this sensation at times also goes to the
parts supplied by the supra-acromial and supraclavicular
branches of the same plexus.
I did not see Miss A. again until December, when she in-
formed me the same sensations were still present. I examined
the throat again, and touched with the point of a probe the
small, reddened area just behind the posterior pillar, at the level
of the lower end of the right tonsil. "That is the place,"
said Miss A. Here, then, in this small reddened area was the
origin of the sensations which Miss A. referred to a position in
the neighborhood of the lowest part of the hyoid fossa of this
side. I took a bent probe and touched various points in the
mucous membrane below this inflamed area, as far down as the
middle of the hyoid fossa. The resulting sensation was de-
scribed by Miss A. as being above the sensations which origi-
nated from the reddened area. " The place is farther down
still," but as soon as I touched this place, opposite the tonsil,
Miss A. would say, "There it is." With the electric tip I cau-
terized thoroughly this area, with the result that immediate
relief was experienced, and this relief lasted until the burned
place healed, when the "pin sensations" returned as before.
Three times was this whole area burned out with the cautery ;
each time Miss A. experienced relief until healing took place,
after which the " pin would return to her throat." Treatment
has furnished absolutely no relief. On April 20, 1892, Miss A.
told me that "the same pin " was in her throat, and that she
suffered as much as she had before treatment, was begun. There
is one point of further interest in regard to the case. When
this area is first seen it appears to be redder than the surround-
ing parts, but if it is touched with a probe it immediately be-
comes of a deep red, and swells from the blood sent to it, so as
to bo in marked contrast with the neighboring mucous mem-
Inane. I can give no explanation as to the cause of this phe-
nomenon.
Case II. — This case came to the clinic in November, 1891,
while Miss A.'s case was still in my hands. The patient, Miss
646
DUNN: THE PIN SENSATION IN THE THROAT.
[N. Y. Med. Jodh.,
B., aged seventeen years, complained of exactly the sensation in
the left side of her throat that Miss A. had in the right — that of
a pin or a bristle sticking in it. In the case of Miss B., how-
ever, this sensation had lasted only a week, and was referred to
a dinner, where she must have swallowed " a pin or something
like it." The place of the sensation was again at the side of
the throat behind the upper part of the larynx, and was more
or less constantly present. Examination of the nose and naso-
pharynx revealed tbe picture common enough, where there are
adenoid hypertrophies, enlargement of the third tonsil, hyper-
trophied turbinates, etc. To this it may be added that there were
also enlarged tonsils ; but, as these conditions had existed for
years, while the pin sensation had made its appearance within
a week, they were excluded from the possible causes of the
trouble. There was nothing in the hyoid fossae, nothing in the
larynx, to give rise to this sensation. I told the patient that
perhaps something she had swallowed had scratched the throat,
and that the trouble would wear off in a few days; if not, to
return. A week later Miss B. returned, saying that the pin was
still there in the same place.
"While making a laryngoscopic examination tbe mirror was
pressed against the upper part of the left posterior pillar.
" There is the place! " exclaimed Miss B., and touched with her
finger the side of the throat opposite the thyreoid cartilage.
•Closer examination showed just above the enlarged tonsil on the
left side a small " granulation," somewhat inflamed. On touch-
ing this with a probe the patient said that that was the place
■where she felt the pin. When asked, however, to swallow and
then put her finger over the spot, she always carried her finger
to the side of her throat opposite the thyreoid cartilage, and it
was here that she felt the pin sensation when the granulation
was touched. Tbe granulation, inflamed, was certainly the cause
in this case of the sensation. It was removed, and the patient
was told to return after a few days if she was further troubled.
She did not return, and the inference is that she was relieved.
Case III. — This case is one of a young man about thirty
years of age, brought to me by Dr. Lewis Wheat, of this city.
The history is as follows: A few hours before, be had between
his teeth a bent pin, which, owing to his suddenly bringing his
teeth together, had sprung from between them " down his
throat." He was " certain " he had " swallowed it," for he had
"looked all over the carpet" and could not find it, and then,
too, he had "felt it when it went down." And, besides, he
"felt it sticking in " his throat whenever he swallowed. There
was no constant pain present ; no pain save a slight pricking
sensation on swallowing; no cough; no obstruction to the
passage of food into the stomach. The patient, however, per-
sisted in affirming that the pin was in his throat, and would
place his finger on the left side of his throat opposite the upper
back part of the thyreoid cartilage as the point where the pin
was sticking. Examination of the larynx and the hyoid fossa?
revealed nothing. (And let me say by way of parenthesis that
the best way to obtain a perfect view of tbe hyoid fossae, in
patients where from oversensitiveness of the supralaryngeal
structures, a view of them is shut out, is to make the patient
laugh while the examination is being made. The fossae then
open and may be viewed in every corner.) The pharyngeal
and rhino-pharyngeal examinations revealed nothing to indicate
the presence of a pin. Opposite the left tonsil, between the
posterior pillar and tbe pharyngeal wall, was a small mass of
hypertrophied lymph tissue, slightly inflamed, and identical in
position with that the cause of the trouble in Case I. I touched
this with a probe. "That is about the place," said the patient.
To convince him no pin was there, I swobbed the area with a
cocaine solution, when, after a minute, the pin sensation was
gone. A moment later he said the feeling was on the other
side of the throat. " The feeling " was, however, too evidently
a forced one to need attention.
Case IV. — Dr. R. came to me saying that he had a " bristle
in his windpipe." The only symptom was a sensation of some-
thing sticking in the throat every time he swallowed. Exami-
nation of the pharynx showed a single acutely inflamed granu-
lation of the pharynx opposite the center of the tonsil on tbe
side upon which the "bristle" was felt. This sensation had
been present several days. When this granulation was deadened
with cocaine, the " bristle " could no longer be felt in the
throat. The granulation was pinched with a forceps, and Dr.
R. had no more trouble. The point to be noticed is, that the
sensation was referred to a point at least, two inches below the
place from which the sensation originated.
Case V. — Miss M. complained that she had swallowed a pin,
which was sticking in her throat, and, as in the preceding cases,
the pin was located in the region of the larynx. Examination
of the pharynx revealed on the posterior wall an acutely in-
flamed granulation near the lower end of the tonsil. This was
cocainized and pinched with a forceps. The next day Miss M.
returned, saying the pin was still in her throat. Examination
revealed, just below the granulation I had pinched the day be-
fore, a second smaller granulation. This was pinched as the
other one had been and Miss M. had no further trouble.
These five cases have been reported because physicians
so frequently have patients who have "just swallowed a
fish-bone," or a " chicken bone," or " a pin," which is now
sticking in the throat. To the physician's eye there is no
urgent symptom — no cough, no difficulty in swallowing
solids or liquids, no place painful on pressure — and yet
these patients insist upon the presence of the foreign body
in the throat, since they " feel it every time they swallow,"
for their imagination, sharpened by their ideas of choking
to death, magnifies any slight abnormal sensation of the
throat into a real evil. And, further, it happens sometimes
that the physician, although he assures his patient that " it
has gone down," has in his mind a great deal of uncertainty
as to whether it has or not.
In Cases I, II, and III the sensation was that of a pin
sticking in the throat ; to each patient the sensation was
definitely localized in the side of the larynx. In the first
case, though the probe was used extensively about the root
of the tongue, the patient always said " the pin is lower
yet," while when it touched the inflamed area, although
higher up, it brought forth the exclamation, " There it is ! "
In the last two cases the sensation could be produced by
" swallowing," but the knowledge that the act of " swallow-
ing " would cause the sensation caused the patients to repeat
continually this act to convince themselves that the pin was
still present.
In Cases II, III, IV, and V the sensation was due to an
acutely inflamed " granulation " of the pharynx. In Case I
the sensation originated in a localized area of the post-
pharyngeal wall, which area from some cause remained
more or less constantly irritated. In all, the sensation
could be produced at will by touching with a probe the
inflamed areas, or by making the patient swallow. In the
first case the nervous element may have played a prominent
part. In the third case, Dr. Wheat had some years ago
performed laparotomy for a wound of the intestines, and,
though the operation was eminently successful, the patient
June 11, 1892.]
VOUOHT: A CASE OF SYRINGOMYELIA.
647
had obtained -a more intimate acquaintance with bis intes-
tines than is voucbsafed most men, and it made him regard
with apprehension the possibility of a foreign body finding
its way into them, and thus he was willing to magnify any
sensation that would seem to justify his fears.
The reason why in these cases the patients insist that
the pin sensation is in the throat at the side of the larynx
is probably to be sought in the facts that they know noth-
ing of the anatomy of the throat, and that the " pin " is
felt only in the act of " swallowing," when the larynx and
its adjacent parts are lifted, and there is a general contrac-
tion of the muscles at the back of the throat, at which time
to the patient a definite localization of the sensation in an
unknown region is difficult. These cases seem to show
that, in the cases of " pin sensation in the throat," the cause
is a definite one and not altogether imaginary ; that, in a
certain proportion of cases, the cause is to be sought in the
neighborhood of the tonsil, and is either an acutely inflamed
" granulation " or an hypertrophy in the lymph chain be-
hind the posterior pillars of the fauces of the side upon
which the sensation is felt. These cases further show that
searching will discover the origin of these sensations, and
that when it is found we can state accurately to the patient
the cause of the trouble, which will be more gratifying to
him than to hear that " it scratched the wall of the oesopha-
gus in going down and all will be well when the scratch
heals," or something similar.
A CASE OF SYKLNGOMYELIA.
By WALTER VOUGHT, M. D.,
CHIEF OF CLINIC, DEPARTMENT OF NERVOUS DISEASES
(CLINICAL ASSISTANT, DEPARTMENT OF GENERAL MEDICINE),
VANDERBILT CLINIC, COLLEGE OF PHYSICIANS AND SURGEONS.
Several points in this case make it worthy of record.
The onset of the disease, the dissociation of sensory symp-
toms, and the fact that the syringomyelia was added on to
a condition of chronic hydrocephalus, place it among the
unusual cases of this disease.
The history was as follows :
William S., the second of five children, twenty-four years of
age, single, and a machine operator by occupation, was first seen
by me January 1, 1892. The patient's mother, who is alive, is
of a nervous temperament and, while pregnant with the pa-
tient, was often hysterical. Outside of this she has always been
a healthy woman. His father has at the present time tubercu.
losis, and seven others of his family have died of this disease.
The patient was born normally without instruments, and was
a bright, healthy baby until one year of age. At this time his
head began to enlarge abnormally, and continued to do so for
several years. He cut his teeth without difficulty, and as an
infant and young child never vomited or had convulsions. As
a young child he was always sleepy, would fall asleep anywhere
and at any time, and when sent out by his mother to play would
sit down and fall asleep. Up to his sixteenth year there was
some impairment in his gait, as he often fell in walking, and it
was difficult for him to run.
At sixteen ho had his first general convulsion. This was
not followed by any paralysis. Soon after this he began to have
momentary attacks of twitching of the right band only, accom-
panied at times by the secretion of a large amount of saliva.
During these he never lost consciousness. These attacks lasted
for three years and occurred at intervals of about two weeks.
At the end of the three years, or when he was in his nineteenth
year, he had a general convulsion. This began in the right
hand and thence extended to the whole body ; he bit his tongue,
passed water, and slept after the attack. Since his nineteenth
year these convulsions have occurred at intervals of three weeks
to six weeks. In the past year they have become more fre-
quent, and, instead of having one, there have been eight or nine
at a time. The attacks are at the present time preceded by an
aura of a frightened, nervous feeling and are accompanied by a
cry, and immediately after he loses consciousness. Following
the attacks he is very much exhausted, and for two or three
days after is unable to continue at his occupation.
Six years ago, while in his eighteenth year and one year be-
fore the onset of the general convulsions, he noticed that he
could not feel objects with his right hand as well as with the
other. At the same time there was a loss of pain sense in the
hand, for he would burn or cut himself without experiencing
pain, and only by the blisters or bleeding present was he cog-
nizant of any injury to the part. There was also loss of heat
sensibility, hot and cold water being indistinguishable with the
right hand. .Four years ago there was added further difficulty
in walking. This began on the right side and has been pro-
gressive ever since.
Three years ago numbness and weakness began in the righ„
hand. The numbness soon extended to the right leg, and short-
ly after the right side of the face became similarly involved.
To these symptoms was added wasting in the hands, which was
of about simultaneous onset in both.
He has always complained of much headache, which has
been worse in the past five years. For three weeks he has had
some difficulty in his vision. He is unable to distinguish ob-
jects well at a distance, and there has been much dizziness.
He has always had rather imperfect control over his bladder.
This has not been more pronounced of late.
His intellectual capacity is of a low order, and it has never
been possible to teach him more than reading and writing.
Examination shows a short, stocky man, with well-marked
hydrocephalic-shaped head. On the parts of the body where
there is no muscular atrophy the muscles are well developed
and firm.
Examination of the Muscles. — There is marked atrophy of
the thenar and hypothenar of both hands, which is greatest on
the left side. The muscles of the forearms are atrophied slightly
and of soft, flabby consistence.
There is main en griffe in both hands, more pronounced in
the left.
There is atrophy and paresis of the anterior portion of the
deltoid muscle of the right side.
Fibrillary twitching is present in the muscles of both arms.
Electrical Examination. — The reaction of degeneration is
present in the muscles of the thenar and hypothenar of both
bands. In the anterior portion of the deltoid of the right side
AnCC = CaCC.
Reflexes. — The tendon reflexes of tho upper extremities are
wanting. The knee-jerks are both exaggerated, R > L. There
is ankle clonus in both lower extremities, more marked in the
right.
The epigastric reflex is absent; all other skin reflexes are
present.
The eye muscles are normal. The right pupil is larger than
the left ; both react to light and accommodation.
The muscle and stereognostic senses are good.
Ophthalmoscopic examination of the eyes was not obtained.
Sensory Disturbances. — Tactile sensibility is nowhere com
648
RANNEY: ' ' E YE-STRA IN" AND NERVOUS DERANGEMENTS.
[N. Y. Med. Jocb.,
pletely abolished, but over the shaded areas (Fig. 1) there is
great impairment in this sense.
Fig. 1.
TJiermal Sensation (Fig. 2). — Over the areas shaded by hori-
zontal lines there is loss of appreciation of both heat and cold.
Over the dotted areas there is diminished sensibility to heat.
Over the areas shaded by vertical lines sensibility to heat is lost
while that to cold is retained.
Fig. 3.
Pain Sensation (Fig. 2). — Over the areas shaded by horizon-
tal lines there is complete loss of pain sensation. This area on
the face and scalp is very sharply defined by the median line.
Taste and smell are normal.
The patient wears a 7| hat.
He was put upon the use of potassium bromide, which post-
poned but did not prevent his epileptic attacks.
His general health steadily failed. On February 10, 1892,
he had convulsions for six hours, and died two hours afterward
from exhaustion. No autopsy was obtained.
Reviewing the symptoms present, it is found that a
healthy baby developed at one year of age chronic hydro-
cephalus, which continued to manifest itself by the shape
of the head, mental and physical hebetude, and unsteadi-
ness in walking until his sixteenth year. At this time epi-
leptic convulsions appeared, and for three years were fol-
lowed by attacks of petit mal. At nineteen years of age
general epileptic convulsions began again and continued,
causing death at the age of twenty-four. Six years before
death the symptoms of the syringomyelia began with sen-
sory disturbances, and three years after, the muscular
atrophy appeared. Both diseases progressed, the hydro-
cephalus the more rapidly.
The development of syringomyelia upon a chronic hy-
drocephalus has been considered probable, but no case has
as yet been met with by us in the literature of the subject.
The almost unique dissociation of the temperature sense
is an interesting phenomenon, and but one similar case has
been thus far reported.*
The posterior columns of the spinal cord appear in this
case to have been the parts first affected, which is contrary to
the general rule that the gray matter of the cord around the
central canal is the part primarily affected.f
12 West Tenth Street.
SOME PREVALENT ERRORS RELATING TO
" EYE-STRAIN"
AS A CAUSE OF NERVOUS DERANGEMENTS, j
IWITH ILLUSTRATIVE CASES.
By AMBROSE L. RANNEY, A. M., M. D.
The view that " eye-strain " may be a frequent and ex-
tremely important factor in causing many forms of nervous
derangements — even in some that are quite commonly re-
garded by medical men as organic diseases, such, for ex-
ample, as epilepsy, St. Vitus's dance, and insanity — seems to
be steadily gaining ground in spite of the bitter opposition
of those who have for years unsuccessfully combated this
view.
So strongly have many progressive practitioners in medi-
cine, as well as oculists, both here and abroad, been im-
pressed of late with the wide application of this view to the
treatment of obscure nervous disorders, that they are at last
beginning to discard the rash and often injudicious admin-
istration of drugs that has hitherto prevailed, and to search
more scientifically for the underlying causes of nervous dis-
eases.
But a few months since, one of the leading medical
journals of this country published in its editorial pages,J
in strong advocacy of this method of treatment, several
columns under the following heading : " A Great Medical
Discovery ignored." From this editorial I quote the fol-
lowing paragraphs :
* Dejerine. La Semaine medicate, 1891, No. 6.
f New York Med. Journal, Nov. 21, 1891.
\ Medical News, December 12, 1891.
June 11, 1892.]
RANNEY: "EYE-STRAW" AND NERVOUS DERANGEMENTS.
649
There are few medical truths that have been discovered
fraught with more possible and incalculable good to humanity
than one that is ignored by the great body of the medical pro-
fession.
There are explanations and sufficient reasons for this anoma-
lous fact. Among them may be noted these:
1. The discovery has come about slowly and silently. It has
been made hy no one man and has come with no flourish of in-
ternational congressional trumpeters. So softly and slowly has
it crept into scientific medicine that its own advocates are but
half aware of it, and do not yet realize its almost unparalleled
value.
2. It is a therapeutic measure that depends for its exercise
upon an exactness of knowledge of delicate mysterious physio-
logical and psychological functions that few possess, and upon a
subtle discrimination and judgment with which, by character
or education, few are endowed.
3. It has the misfortune to depend for its promulgation and
practical application upon the specialist, and almost upon the
specialist of a specialty — and this in a profession and in an
epoch in which it is fashionable to sneer at specialism, and at
the specialist who dares plead for the truth he knows— and that,
at first at least, only he can know.
Not long ago I received from one of the most distin-
guished medical teachers of this country a letter that indi-
cated a decided " change of heart," based, as is too often
the case, upon some very startling disclosures that scientific
eye-tests had revealed in his own visual apparatus and that
several oculists of eminence had previously overlooked. He
says in this letter :
Dear Dr. Rannet : I send you as a patient Mrs. , a con-
firmed sufferer from intractable neuralgia! Personally, I have
ceased to treat neuralgia like a d — d fool.
Gratefully yours, .
Most of the medical contributions that have lately ap-
peared as antagonistic to the view that " eye-strain " con-
stitutes an important factor in the neuropathic tendency,
and that functional nervous diseases can be relieved or
modified by eye treatment, are based largely upon statistics
derived from the observations of those who are either mani-
festly ignorant of the later methods of examination or who
fail to employ them from bigotry and prejudice.
It is well known by searchers of the truth that in most
of our large eye dispensaries the refraction of eyes is de-
termined chiefly by the ophthalmoscope (a rapid and very
imperfect method even in good hands) ; that ill-fitting spec-
tacles are commonly bought by these patients, and in con-
sequence the glasses are not accurately centered to the
pupils ; and that errors in adjustment of the muscles of the
eye which exist in many of the patients are not even sought
for in most dispensary clinics. The multitude of patients
that swarm in and out of these institutions require more
time than can be bestowed upon them. They are touched
up with astringents — boric acid, etc. — by the score for
granular lids, corneal ulcers, etc., without any effort to deter-
mine the underlying cause for these common conditions (that
either remain chronic or tend to constantly recur in the
same individual); when in almost every case some hidden
error of focus or malad justment of the muscles of the eye
is an exciting cause of these conditions, and a cure can gen-
erally be obtained by the removal of this cause.
Perhaps the most common experience that I personally
encounter in my office is to have patients tell me that either
their doctor or some oculist whom they have consulted has
said to them that " their eye trouble is the result of their
physical weakness and not a cause ; that the relief of the
eye trouble can have nothing to do with their recovery ; and
that all statements to the contrary are not supported by
facts."
It is for the purpose of demonstrating the counter-
proposition, of showing that " eye-strain " may be the
cause of obscure diseases and not its result, and of turning,
if possible, the channel of medical thought so as to benefit
suffering humanity, that I raise my voice again in defense
of a method of treatment that will often accomplish what
drugs will not, and that is based upon science rather than
therapeutical speculation and empiricism.
The few cases which I report here in detail I have se-
lected from a very large number on my private records, in
order to demonstrate most positively my view of the points
at issue. They have been seen by many physicians from
time to time. They are of such a varied character as to
shed light upon and confirm, I think, many disputed state-
ments. To many of these patients the verbal or written,
opinion of prominent medical men had been given prior to
my seeing them, " that organic disease unquestionably
existed, and that the eyes had nothing to do with the causa-
tion of the symptoms."
In some of these cases no possible explanation of the
facts here recorded can be suggested, except to admit that
the correction of an existing " eye-strain " caused a cessa-
tion of the leakage of nervous force that had been going on
for years ; and, by so doing, the sufferers had been enabled
to regain their normal condition.
These patients took no drugs ; they continued in their
customary vocations ; and they got well. All former ex-
periments with drugs and doctors had failed to bring about
a like result. Most of the females had had their wombs
treated by the latest recognized methods ; all had taken
medicines of various kinds ; and several had been pro-
nounced by conscientious medical advisers as incurable.
Among the cases reported in this paper are four typical
cases of epilepsy ; several of nervous prostration of so
severe a form as to justify the most serious doubts in any
medical man as to a perfect recovery being possible ; one
case of mental collapse to an extent which rendered the pa-
tient unable to dress himself until told which article of ap-
parel to put on first, and who would chew on a bolus of
food for an hour, if not told to swallow it ; one case of
melancholia with morbid impulses, who walked about the
streets touching every tree, lamp-post, and ash-barrel ; one
case of epileptic mania, for whose use a room padded with
mattresses was kept; several in which confirmed inability
to sleep, severe neuralgic paroxysms, car-sickness, constant
headache, etc., formed an important feature in their clinical
histories ; one case of St. Vitus's dance that was followed,
before I saw her, by an entire loss of power in the right
arm and partial in both legs; one case of terrific neuralgic
paroxysms of the face that drugs would not control ; and
other cases of various conditions that were equally distress-
650
RANNEY: "EYE-STRAIN" AND NERVOUS DERANGEMENTS. [N. Y. Med. Joue.,
ing to the patient and that had withstood all therapeutical
measures.
In the light shed upon a field of scientific inquiry by
such a set of remarkable cases, is it not a justifiable source
of surprise that many oculists of prominence, in full pos-
session of the facts, refuse to-day to follow implicitly, and
others even to try, a method of treatment whose details
have been quite fully described in medical literature ?
The sad results, viewed from the standpoint of suffer-
ing humanity, that are entailed by indifference and preju-
dice in men of scientific reputation can not be estimated.
By giving expression to others of their opinion con-
cerning what they have not properly investigated them-
selves or will not see, thousands of sufferers are doomed to
a life of misery.
Such patients naturally believe that abnormal eye-fac-
tors in their own case have been sought for by the latest
methods and found to be absent by one who stands high in
his profession. They quote to their friends the positive
assertions of him (whom they believe infallible) that " eye-
muscles are not worth investigating " ; that " all deviating
tendencies of the eyes are invariably due to errors of re-
fraction " ; that " Javal's instrument has been used, and
that settles the question forever " ; and other similar ex-
pressions, indicative either of inexperience, bigotry, or
prejudice, that too often come to my own ears.
Now, may I ask what has actually been done by the
oculist in many such instances to give him a basis for any
of the conclusions quoted above, that lead often to despair
and life-long suffering on the part of the patient ?
To save time and trouble, in most public dispensaries,
and, unfortunately, in the private consultation rooms of
some occulists of repute, the patient is generally taken into
a dark room after reading a test-card (which is often omit-
ted), and a concentrated beam of light is first cast into each
pupil with an ophthalmoscope for the purpose of determin-
ing, in an approximate fashion only, the refractive condi-
tions of the eyes. Glasses are frequently prescribed on in-
formation thus obtained.
Then, if the eye muscles are examined at all (and they
are often totally disregarded), the patient is frequently put
through a series of tests that have little, if any, scientific
value, and which ought to have been discarded years ago —
such as following with the eyes some small object (usually
the point of a pen or pencil) held in the hand of the ocu-
list, and subsequently looking at the " line-and-dot " card
at the reading point through a prism.
It is well known and generally acknowledged to-day
that the ophthalmoscope is not an instrument of precision *
* There are two sources of error which are possible in all ophthal-
moscopic examinations as a step toward the determination of refrac-
tion. The first of these is that the observer may not be able to per-
fectly relax his own accommodation while using the instrument. Most
oculists of large experience believe that they can do this with certainty
— a belief which is perhaps not always well founded. The second
source of error lies in the accommodation of the patient. This can not
always be relaxed by instructing the patient to look at an object twenty
or more feet distant from the eye. I am satisfied that mistakes in the
determination of refractive errors by the ophthalmoscope are far more
frequent than are generally supposed. For the past seven years I have
when the refraction of an eye is to be positively deter-
mined. The greatest ophthalmoscopist of his day in this
country tried some years ago to determine the refraction
of the writer's own eyes by this instrument and made a dis-
mal failure — as he himself had to confess after atropine
was employed.
The ophthalmoscope has its proper uses and is a valua-
ble instrument ; but for the determination of anomalies of
refraction it is too unreliable to be of value in cases where
careful investigation is demanded.
One of the leading oculists of this city has lately written
an article * in which the remarkable statements appear that
in cases of asthenopia, hypermetropia of two diopters and
a half may be ignored in young subjects ; that if cylindric
glasses are ordered the existing hypermetropia may be ig-
nored ; and that mydriatics may be dispensed with if
Javal's instrument is employed.
The conclusions of this writer are advanced, fortunately,
by him only in reference to those patients who suffer from
difficulty in using the eyes (asthenopia). While few ocu-
lists of prominence, I think, will accept these conclusions
from even this limited standpoint, I am personally satisfied
that they are absolutely untenable if applied to more severe
types of reflex nervous phenomena dependent upon eye-
strain.
The author of this article can bear witness personally to
the effect of spherical glasses, which caused an instantane-
ous cessation of all symptoms of complete nervous prostra-
tion that came upon himself gradually some twelve years
ago without apparent cause. The eye-defect that existed
in him had eluded the detection of several skillful oculists,
and was only brought to light by the use of atropine. To
spherical glasses alone he owes his present health, comfort,
and ability to labor.
If it were necessary, in my judgment, to multiply illus-
trations here to prove that spherical glasses as well as
cylindrical glasses have important curative results upon
serious nervous disturbances, I could adduce hundreds of
examined the eyes of almost every patient intrusted to my care by the
aid of test-type after the pupils have been fully dilated by atropine.
I am not aware that I have ever lost a patient by the use of this drug.
In my experience intelligent persons are always willing to submit
to a temporary inconvenience for the purpose of obtaining positive in-
formation respecting any point that is deemed of scientific value in
relation to themselves. I have personally come to regard the ophthal-
moscope as an unreliable instrument for the determination of refrac-
tion. Its use is rendered compulsory, however, in very young children,
and in those who, from ignorance or feeble mindedness, are unreliable
in their reading of test-type. It is generally accepted, furthermore,
among our best oculists that astigmatism (a recognized source of nervous
perplexity) is always estimated more accurately with the pupil widely-
dilated by atropine than with the normal pupil. The reasons which I
have already given must suffice to explain why the use of atropine con-
stitutes a most important preliminary step to the detection and estima-
tion of any error in the eye muscles, although many other arguments
might be brought forward to prove its advisability in some subjects.
Again, the view is held that no examination for suspected muscular
error in the orbit should be regarded as conclusive for diagnosis, or as
a basis for any surgical procedure, until the eye has been proved to be
free from refractive error, or rendered as nearly emmetropic as possible
by properly selected glasses.
* D. B. St. John Roosa. Medical Record, March 26, 1892.
June 11, 1892.]
RANNEY: " EYE-STRAIN" AND NERVOUS DERANGEMENTS.
651
illustrative examples from the records of my private
patients. I prefer, however, to refer the reader to my
brochure upon the treatment of headache and neuralgia,*
and also to one that relates to the cure of sleeplessness,! for
illustrative cases that bear upon this subject.
So iong as eye examinations are made in a careless and
perfunctory way ; so long as a careful and accurate deter-
mination of the refraction of the eyes is not made under
atropine ; so long as abnormal conditions of the eye-
muscles are not diligently sought for by the only scientific
method that has yet been devised for that purpose ; so long
as careful records of each test and the power of the indi-
vidual eye muscles are not kept so as to admit of compari-
son between conditions encountered in any patient from
time to time ; so long as bigotry and intolerance blind the
eyes of eminent men to a proper sense of justice to others ;
so long as the general medical practitioner neglects to
study the principles of testing eyes sufficiently to dis-
criminate between careful work and perfunctory work
— so lono- will the treatment of nervous affections be rele-
gated exclusively to drugs, the sufferings of thousands
be unrelieved because the cause is not searched for, and
the progress of medical science be seriously hampered
and retarded.
I quote from a late brochure of mine the following
paragraphs :
" One thing is evident — viz., the view that ' eye-strain ' can
and frequently does cause serious nervous conditions must be
either true or false.
" If it be false, then it has made steady progress in spite of
its weakness and against organized and bitter opposition ; if
false, then the growing list of converted advocates among the
younger oculists and neurologists is incapable of explanation; if
false, then the thousands of suffering humanity are deceived
who believe that they have cause for the deepest gratitude in
the recognition and relief of an existing ' eye-strain.' It is con-
trary to all precedent that a mere 'fad ' should steadily nourish
and gain strength year by year over a period of many years ;
neither does the statement that some cases have failed to be
benefited by this treatment have any weight in argument.
Every method of treatment of disease sometimes fails to relieve
individual cases ; yet no one attempts to discard all therapeuti-
cal efforts in consequence of this fact, because such a deduction
would be manifestly illogical."
In the reported cases that follow, some terms are employed
that may require explanation to the general practitioner, al-
though they would be easily understood by the oculist. These
are comprised in the following table :
f Hypermetropia (far-sightedness). A shal-
low eye (from the front to the back),
causing an imperfect focus of objects.
Myopia (near-sightedness). An elongated
eye (from the front to the back), caus-
ing an imperfect focus of objects.
Astigmatism. An irregularly curved cor-
nea or lens, causing distortion of
images on retina.
I Emmetropia. A perfectly constructed eye.
* Medical Record, June 22, 1889.
f N. Y. Medical Journal, March 28, 1891.
Terms related to
the focus of the
eye (refractive
terms).
Terms related to
the muscles which
move the eyes
(muscular terms).
Various forms of
glasses employed
by oculists.
Esophoria. A tendency of one or both
eyes to deviate toward the nose.
Exophoria. A tendency of one or both
eyes to deviate toward the temple.
Hyperphoria. A tendency of one eye to
rise above the level of its fellow.
Orthophoria. Normal adjustment of the
eye muscles.
Adduction. The power of the internal
muscles of the eyeballs. It varies in
health between 25° and 60°.
Abduction. The power of the external
muscles of the eyeballs. It should be
8° in health.
Sursumduotion. The power of the verti-
cal muscles of the eyeballs. The right
and left should be alike.
Spherical. Ground upon a convex or con-
cave sphere. Used to correct hyper-
metropia and myopia.
Cylindrical. Ground upon a convex or
concave cylinder. Used to correct as-
tigmatism.
Prismatic* Two plane surfaces of glass
meeting at an angle. The thick side
is termed the base of the prism. Used
to relieve errors of adjustment of the
eye muscles.
* Prismatic glasses are not only inadequate as satisfactory remedial
agents in most cases, but they may be positively injurious to certain
classes of patients. Strict limitations upon their field of usefulness
(not generally taught) seem to be rendered probable by late investi-
gations. A careful study of the different movements of the eyeball,
and of the combination of muscles required to produce some of them,
must impress even the most casual reader with the idea that an
agent (such, for example, as a strong prism) which tends to restrict
the movements of any one muscle may do harm if persistently worn.
Some patients are peculiarly susceptible to such influences. I have en-
countered a large number of patients whose eyes refused to tolerate a
prismatic glass. Their symptoms were at once made worse whenever
they attempted to correct an existing muscular anomaly by wearing a
prismatic glass. On the other hand, many patients are benefited at
once by the use of prisms, and suffer no inconvenience of any kind
from them. What are we to infer from this statement ? Are we to
surmise that the prisms were either injudiciously selected or improperly
placed, simply because the patient could not tolerate them ? I think
not ! Such might possibly be the case in the hands of a novice, but
presumably it is not the case in the experience of one skilled in eye ex-
aminations. My own experience in several such instances has shown me
that a tenotomy of the muscle exhibiting the greatest tension has been
followed by a complete cessation of the nervous symptoms for which
the patient sought relief, in spite of the fact that prisms prescribed to
correct the same error have proved intolerable to the patient, and have
markedly aggravated the symptoms.
There is, however, a practical and important field for prismatic
glasses. It is veil to keep, ax a part of a physician's office equipment, a
la rye numlier of prisms t>f dijf'i rent aityles. These can lie slipped into a
frame with the base inward, outward, upward, or downward, as the ex-
igencies of any case seem to demand. They may be loaned from time to
time to patients, Cor the purpose either of verifying a diagnosis or of de-
veloping a latent muscular error which the physician may be led (by re-
peated examinations of the patient) to suspect. When they are well
tolerated, the physician may often learn a great deal by their protracted
influence. When they are not well borne, it is advisable, as a rule, to
discontinue their use at once. It is often wise to prescribe a prismatic
glass, also, for a class of patients who are unable (for one reason or
another) to submit at the time to tenotomy. Sooner or later, I find that
652
RANNEY: "EYE-STRAIN" AND NERVOUS DERANGEMENTS. [N. Y. Med. Jooh.,
Several months ago, in an article published by me in
reference to the causes and cure of sleeplessness, I made
use of the following illustration as a means of making the
bearing of "eye-strain" upon the general health clear to
the reader :
Any expenditure of nervous energy in excess of that generat-
ed from day to day (irrespective of where t lie excessive expendi-
ture occurs) may in time so deplete the reserve capital of nerve
force in any individual as to embarrass the workings of some
part or parts of the nervous system without any actual disease
being present. The result of this temporary "nervous bank-
ruptcy " is peculiarly apt to disclose itself in some derangement
of the normal function of the weakest part — as an echo is heard
far from the source of the echo.
Let us cite, as an apt illustration of what I mean, one of our
every-day experiences :
An upright business man, with a stated income, has, from
certain extravagances, etc., spent not only in excess of his in-
come for many years, but has gradually encroached upon his
capital. He grows moody, reticent, and irascible, and becomes
almost imperceptibly an altered man. His friends, ignorant of
the cause of the change, gradually become distant and fewer in
number. Social estrangements, domestic unhappiness, a gen-
eral loss of esteem, and many other complications then begin to
arise day by day and month by month, until the individual falls
from the high position that he once occupied with warrantable
pride. Now, what has caused this fall, and what is the reme-
dy? Unquestionably, to every thinking mind, the initial and
underlying factor in all the ultimate results would be the exces-
such patients usually return. As a rule, they do so for one of the
following reasons: (1) Because they have developed an additional
"latent " muscular error, which the prisms naturally failed to correct ;
(2) because they do not tolerate them well, and are made decidedly
worse by their use ; (3) because they prefer a tenotomy to the incon-
venience of a glass which has to be constantly worn; and (4) because
they suffer from eye-fatigue on account of the disturbance to co-ordi-
nate movements of the eyeball. There is no doubt that very many per-
sons with nervous diseases are materially helped (if not radically cured)
by the aid of prismatic glasses ; but the question naturally arises to my
mind in this connection, " Would they not have been more rapidly
benefited and permanently relieved with far less inconvenience to the
patient by tenotomy ? " The view is held that a graduated or complete
tenotomy is the only means of permanently relieving abnormal tension of
a muscle in the orbit. There are only two ways of overcoming an abnormal |
tendency of the visual axes to deviate from parallelism whenever the eyes I
are directed upon an object more than twenty feet off. One of these j
is by the aid of a prism ; the other is by tenotomy of the muscle which
directly aids in producing and perpetuating the deviating tendency.
Whenever prisms are prescribed, they afford relief practically in the
same way as a " rubber muscle " does in orthopaedic surgery ; in other
words, they compel the muscle which is opposed to the base of the
prism worn by the patient to overcome the antagonistic muscle, and
also to so adjust the eye as to compensate for the refractive effect of
the prism. They practically act, therefore, as a " pulley-w eight " — a
mechanical device seen in all gymnasiums. Now, if the wearing of
prisms had no deleterious action upon those particular muscles, which,
in each case, are not at all at fault, and if they invariably exerted only
beneficial effects, this principle of treatment could be more generally
applied with benefit. Even then the existence of " latent " insufficiency
might, unfortunately, remain unrecognized for a greater or less period
of time, possibly to the serious detriment of the patient. On the other
hand, if it is satisfactorily demonstrated that tenotomy has been ren-
dered a safe and accurate method of correcting muscular anomalies in
the orbit, a fact has certainly been noted that opens a new and shorter j
route to relief. Such a step enables us, moreover, to decide the ques- |
tion of " latent " muscular defects in any given case.
sive expenditure of money. The cure, moreover, lies in stop-
ping the initial cause, witli the hope that time and prudent liv-
ing will restore not only the impaired business capital, but like-
wise the cheery nature and honest manhood that originally
gained the individual his high position, and that can alone re-
store it to him.
When we stop to reflect, we can understand how every let-
ter on a printed page, as well as every object on the street, or
in our homes, that we become cognizant of by the sense of
sight requires a more or less perfect adjustment of the compli-
cated muscular apparatus that so regulate the eyes in relation to
each other as to enable them to see with both and yet perceive
but a singe image.
The total aggregate of such visual perceptions during the six-
teen hours of each day that we use the eyes is enormous ; and
it means a proportionate number of accurately performed ad-
justments of two cameras (the eyes) upon a single object, per-
formed often with marvelous rapidity, and involving in many of
the adjustments a complete change of combinations in the eye
muscles that are successively brought into play. It is not much
of a task to lift a penny once, but no living being could lift a
penny a million times each day.
Now, Nature has so accurately balanced the relative power
of each of the various eye muscles in a perfectly constructed be-
ing, and has so beautifully constructed the eyes as regards their
focus, that the expenditure of nerve power (in the case of such
an individual) required to perform the necessary eye movements
throughout each day is reduced to a minimum, although neces-
sarily very large as compared wdth the amount expended upon
any other organ in the body.
But, when the adjustment of the eye muscles or the con-
struction of the eyes themselves is so imperfect that the main-
tenance of single vision (when both eyes are simultaneously
used) is the result of an excessive expenditure of nerve-force (far
greater than Nature intended in tnany cases), any individual so
afflicted begins from birth either to draw from the "reserve
capital of nerve-force" that Nature has stored up for emergen-
cies, or the eyes must be run at the expense of a proper nerve-
supply to some other part (Peter being robbed to pay Paul).
Three factors then enter into the proposition as to how long
a time can elapse before the serious influences of such a leak of
nervous energy will be felt in any given case where the eyes or
the eye muscles are abnormal : 1. How much excess of energy
over the normal amount is required to compensate for the de-
fects connected with the sense of sight. 2. How much " reserve
capital " of nerve-force the individual starts out in life with.
3. How much nerve-force the individual can generate day by
day to meet the daily expenditure.
A child inheriting one hundred thousand dollars at birth
could have expended upon him one thousand dollars per year in
excess of his income without feeling the lack of money for one
bundl ed years; but if the excess of expenditure be increased to
five thousand dollars over his income, bankruptcy would stare
him in the face when he attained his majority.
A serious defect of construction in one or both eyes, or a
decided tendency of one or both eyes to deviate from parallel-
ism with its fellow, may entail upon an individual a leakage of
nervous force that is apt to produce in time very sad results
upon the general health.
We are now prepared to pass to the consideration of
some cases that I have selected from my case-books in or-
der to demonstrate, if possible, beyond cavil (1) that a di-
rect relationship between " eye-strain " and some extreme
forms of nervous disturbances can exist; (2) that the cor-,
red ion of "eye-strain" may be followed by very marked
\
June 11, 1892.]
RANXEY
EYE-STRAIN" AND NERVOUS DERANGEMENTS.
653
benefit in some instances ; (3) that it is the duty of a physi-
cian to have the eyes of all patients afflicted with abnormal
nervous disturbances examined early by some oculist who
is familiar with and employs the latest methods ; and (4)
that errors of adjustment of the eye muscles are quite as
important to detect and rectify as are marked errors of re-
fraction.
(1 a se F. — Mr. P., aged forty-one, manufacturer, married.
Family History. — Both parents died at seventy-five years of
age. Mother was of nervous temperament. One brother died
of Bright's disease.
Patient has seven children, all unusually healthy.
Eye Defects. — Hypermetropia and astigmatism. O. D. +
0-50 s. C + 0-75 c. axis, 90°. O. S. + 1-25 s. 3 + 0-50 c. axis--,
90°. Left hyperphoria, 4°. Esophoria, 7°. Adduction, 22°.
Abduction, 4°. Right sursnmduction, 2°. Left sursumduc-
tion, 8°.
History of Case. — This patient w as brought to me by his wife
from Canada at the suggestion of their physician Dr. B., who
had good cause to suspect an advanced case of softening of the
brain.
For several months prior to this visit the patient had taken
but little if any medicine and had steadily lost flesh. His mental
condition had become alarming and his doctors had practically
regarded the case as hopeless. He had to be taken care of by
his wife, who paid all the bills and looked after him as she would
a child. While dressing, he had to be told what clothes to wear
and which to put on first. At the table he would chew his food
until told to swallow it. His demeanor was extremely apa-
thetic, except at intervals when he would start suddenly from
his chair, grab his head in both hands, and walk in an agitated
manner about the room, complaining of great pain in his head.
For twenty years he had had severe attacks of neuralgia af-
fecting the left eye and left side of the face, and for many years
he had been annoyed by flowing of tears over the cheek in cold
w-eather. For six years he had had marked symptoms of indi-
gestion, flatulence, and constipation. Eating was followed by
severe pain in the region of the stomach, and he had been obliged
to restrict his diet for some years in consequence.
For six months prior to this visit he had not visited his place
of business and had suffered terribly with insomnia. To such
an extent did the insomnia exist that his wife would sit by him
and fan him during cat-naps until noon of each day.
As he was not in condition to stand the excitement of a hotel,
he was forced to lodge with friends where absolute quiet could
be insured.
Great difficulty was experienced during my first few inter-
views with the patient in getting any reliable eye-tests, although
his expression indicated a marked degree of left hyperphoria and
esophoria.
After reading only a couple of lines on a test-card, he would
■leap from his chair, grasp his head with his hands, and say that
he would come in the next day and read some more.
The case certainly looked most unpromising, and bis mental
condition was such that I could not divest myself of the belief
that organic brain disease existed and that the case was proba-
bly incurable.
After several interviews and the free use of atropine to dilate
the pupils, the eye-tests became more satisfactory. I advised the
wife to consider the propriety of an operation for the hyper-
phoria with the hope of easing his pain and improving his
sleep.
I distinctly impressed upon the wife the fact that I did not
think this step would prove in any way curative ; yet I could
not but feel that four degrees of manifest hyperphoria was a
strain that ought to be at once removed — especially from so
weak an invalid.
Treatment and Results. — As his wife expressed a desire to
try what a correction of his hyperphoria would do for him, a
graduated tenotomy was performed upon the left superior rectus.
The result was a great surprise to his friends as well as myself.
The night following the operation he slept soundly all night.
He arose the next morning, dressed himself without aid, and
drank three goblets of milk before the rest of the family were
up. He then sat down and ate a good breakfast, finishing as
quickly as any one.
Within a week he demanded his money from his wife, saying
that he would not have her pay his bills for him ; and a short
time afterward he began to come daily to the office from Brook-
lyn without any one to accompany him.
Two weeks after the operation patient reported that he
" wrote a long letter (the first in over four months), that he eats,
well, sleeps well, takes an interest in the newspapers, and is mar-
velously improved in every way." A full correction of his errors
of refraction was ordered and he was instructed to wear his
glasses constantly.
Some weeks later a graduated tenotomy was performed on
the right internal rectus for the relief of the esophoria, and the
patient returned to Canada to take charge of his business.
For the past two years patient reports that he has had no
return of his old symptoms, but is considerably annoyed by
headache, which at times is quite severe. He has been very in-
constant in wearing his glasses. This may account for the con-
tinuance of his headaches, although there is reason to suspect
that some hyperphoria still remains.
Case II. Epilepsy and Epileptic Mania of an Aggravated
Type. — Mr. S., aged nineteen. First seen by me on November
27, 1888.
Family History. — Mother has frequent and severe sick
headaches, and her sister is a martyr to them also. The brother
and sister of the patient have headaches. The paternal heredity
could not be accurately given by the mother, who brought the
boy to me for treatment. No phthisical tendencies had ever
manifested themselves in any of the patient's ancestry, as far as
known. Every known relative on the maternal side suffers
from headache.
History of the Case. — The patient is a tall, finely developed
young man of five feet ten inches, weighing about a hundred
and fifty pounds, and with a good color. His mother gives the
following facts :
Up to the fourteenth year of age the patient was in perfect
health. He then had his first epileptic seizure, following upon
an attack of so-called "congestion of his brain," for which no
cause could be found except a fall while skating. He was then
at school in Paris.
Within the next year, in spite of bromides, he had three
"fainting attacks," lasting an hour each.
He was then removed to a school in England, and had a
number of severe epileptic seizures in spite of large doses of
bromides.
In August, 1887, he was sent to America and placed in a
select school, where he could be carefully watched over and his
habits of life regulated. He had taken every day for the previ-
ous year not less than sixty grams of potassium bromide and
tilt een grains of sodium bromide, and at times much larger
doses.
During the year prior to his visit to my office the seizures
had become more frequent and extremely violent— so violent
that three men could not restrain the patient, and a room had
been padded with mattresses and specially kept for the protec~
tion of the patient when thus seised. Into this room he would
654-
RANNEY: "EYE-STRAIN" AND NERVOUS DERANGEMENTS. |N. Y. Med. Joce.,
be placed and allowed to thrash about, until attack after attack
would prostrate the patient. All medical treatment seemed of
no avail, and the father was asked to remove the boy from the
school.
Medical advice was then taken, and it was deemed advisable
to commit the patient to an insane asylum as an incurable and
uncontrollable case of dangerous epileptic seizures. At the
earnest solicitation of friends, the parents were urged to make
a trial of the " eye treatment " in the hope that it might possi-
bly avert so horrible a fate for the boy, even if it did not mark-
edly affect the frequency of the fits.
As the absolute cessation of the bromides was insisted upon
by myself, from the date of the first visit, the boy was with
some reluctance admitted at my solicitation to a private hos-
pital, so that he could come to my office with an attendant and
be protected from injury if the fits became very frequent or
severe.
A record kept by the principal of the school [showed that
thirty-four fits had occurred in the twelvemonths that preceded
my care of the boy, in spite of extreme doses of bromide salts
and chloral at intervals in addition to his regular daily doses.
Eye Defects. — On the 17th of November, 1888, patient
showed normal vision in both eyes, adduction 54°, abduction
5° — , right sursumduction 2°—, left sursumduction 2°—, eso-
phoria 2°, left hyperphoria 1°.
In accommodation, patient showed esophoria 10°.
November 18th. — Under atropine, patient showed a latent
hypermetropia of one half diopter. Esophoria 2°, left hyper-
phoria \°.
Treatment and Results. — The patient carried his head, as his
mother said he always had done, very markedly to the left side
(justifying a suspicion that right hyperphoria actually existed),
aud his esophoria was very palpable to a careful observer.
Later on, my suspicion of an existing right hyperphoria became
confirmed by most positive tests.
Here, then, was a boy who showed at the onset almost per-
fectly constructed eyes, with only a slight tendency inward (ap-
parently), and a suspicion of hyperphoria, yet he was having
terrific epileptic seizures that were uncontrollable by drugs. His
power of abduction was low, however, and prisms of 1°, base
out, were placed for twenty-four hours over each eye.
At the third visit, on the following day, he showed esophoria
of 7°, and the prisms were increased to 4°.
In three days more he showed esophoria of 10°, with uncon-
querable double images, and the tendon of the right internal
rectus muscle was freely relaxed by a graduated tenotomy.
This improved his deviating tendency inward; but some eso-
phoria still disclosed itself.
On November 24th the opposite internal rectus was likewise
operated upon, and his esophoria was apparently totally cor-
rected for some time after the operation, his [adduction being
normal (8°).
On November 27, 1888 (ten days after the cessation of bro-
mides), the patient had a fainting attack in my office without
tremor, but with a total loss of consciousness for some ten min-
utes. The habit of carrying the head toward the left shoulder
had been persistent up to this time. An examination of the
eyes disclosed a right hyperphoria (as was originally suspected)
of quite a high degree.
From this date until February 12, 1889, patient was treated
by prismatic glasses and no return of epileptic seizures had oc-
riimd. I then determined upon a third operation, and let out
the right superior rectus as far as 1 deemed it wise to do so,
although I failed to perfectly correct his right hyperphoria by
so doing. Prismatic glasses were again resorted to, as a step
toward correction of the existing ''eye-strain."
The boy then returned to his former school.
On July 1st, when the boy had passed over seven months with-
out an epileptic seizure, I received a letter from his mother, from
which I quote as follows :
" I want to tell you how very grateful I feel for the great
good you have done my boy. It is really wonderful how he has
improved in health since he has been under your care. He writes
me that he has not had a single attack since I left New York.
This seems almost a miracle when one remembers how the boy
suffered before coming to you."
On July 7, 1889, over nine months had passed since an actual
convulsion had occurred, and nearly eight months since the
"fainting attack " in my office. He had been some time with-
out prisms or any eye treatment, when he imprudently used a
lawn-mower violently on a very warm day for several hours.
As a consequence, he was seized with one of his "old-time at-
tacks," having three severe convulsions and two light ones in
the next forty-eight hours. They were accompanied by marked
gastric disturbance and fever.
On visiting me, I found some remaining right hyperphoria,
for which I again operated upon the right superior rectus
tendon.
On October 14, 1889, the patient engaged in a cross-country
run of several miles, after school exercises, and became greatly
overheated. He was again seized with a severe convulsion, and
had two light ones later in the day. He had again marked gas-
tric disturbance. Fourteen weeks had elapsed since the pre-
vious attack.
On December 26, 1889, the patient was again seen. He had
experienced no return of attacks, was in excellent health, and
had taken no medicine for thirteen months. He still shows 1°
of right hyperphoria, esophoria of 2°, adduction 58°, abduction
7° — , right sursumduction 4°, left sursumduction 1° + . He is
wearing prismatic glasses for 2° of esophoria.
On April 2, 1892, this patient reported last at the office. He
is still wearing 2° prism for the remaining esophoria. He had
passed over ten months without an epilepjtic seizure, and only one
attack had occurred in nearly tiro years.
Now, what has been done for this boy thus far by " eye
treatment ? " He has already passed nearly four years
without recourse to poisonous drugs ; he has been saved
thus far from a life in a lunatic asylum and restored in use-
fulness and health ; he has had, except on three occasions,
complete immunity from his horrible disease in spite of
the total cessation of bromides ; he has returned to his for-
mer association with his school companions ; and he is to-
day able to go about without an attendant, or the dread of
impending disaster and possible confinement.
He has happily learned, I trust, that excessive and vio-
lent exercise is dangerous to his comfort, as it tends to cause
an epileptic attack, and also to derange his digestive appara-
tus seriously. Had it not been for such extreme impru-
dence, he would probably have been entirely free from at-
tacks during the past year.
Do we know that this remarkable change is due to the
eye treatment ? Most certainly !
The patient had never before passed so long a time
without attacks as he has since eye treatment was begun,
although he had been constantly drugged, according to the
most approved fashion of the present day, for his epileptic
seizures. He had found in the bromides for some years
the only refuge that medicine offered to keep these fright-
ful attacks within bounds that did not seriously endanger
June 11, 181)2. J RANNEY: "EYESTRAIN" AND NERVOUS DERANGEMENTS.
655-
life. Ee naturally felt, as did his parents, that to let go
that anchor was to drift beyond aid into hopeless despair.
When, therefore, I stopped his bromides at the first visit,
every one concerned (the patient, his parents, his friends,
and myself) felt quite sure that, unless something was done
as a substitute for the drugs, the fits would surely become
more frequent and severe. This substitute for drugs took
the form of an operation for what I deemed the exciting
cause of the attacks. Another operation was done on the
corresponding muscle of the opposed eye, as soon as the
necessity for it became apparent. Then we felt compara-
tively safe, and the patient could await with greater safety
the effects of prismatic glasses.
Case III. Chronic Epilepsy {of Twenty four Yearn1 Standing).
— This case is of great interest if taken in connection with the
case that precedes it. In this instance five years and nine
months of immunity has followed eye treatment and the cessa-
tion of all drugs.
Mr. II., aged forty-three, merchant, began to have severe
epileptic fits when seventeen years of age. Had masturbated
when a boy, and had been addicted in later years to excessive
venery.
Family History. — One brother is a confirmed dipsomaniac;
the father died of paralysis; one sister is a victim to sick head-
aches ; no phthisis has existed in the family, so far as could be
ascertained.
History of the Case. — The epileptic seizures of this patient
varied in frequency from two or three a week to one in three
mouths. He came under my care in 1871 (when twenty-eight
years old), and was' treated by me for many years with enor-
mous doses of the bromides of potassium and sodium. These
salts reduced the attacks to about four a year. Stopping the
bromides invariably increased the frequency of the attacks.
Eye Defects. — In January, 1886, his eyes were examined after
his return from an extended residence in the South. He showed
under atropine a latent hyperopia of 2-50 D., and also a mani-
fest esophoria of 4°. Subsequently several degrees of "latent"
esophoria also manifested itself.
Treatment and Results. — Partial tenotomies were performed
upon both interni, and hyperopic glasses were given him. Since
the first operation (January, 1886) he has taken no bromides
and has not had a convulsion. He has twice been at "death's
door" with fevers, but he has shown at no time any epileptic
tendencies.
It may be asked, " Can this be done for the relief of
every epileptic ) " I would reply, "By no means ! "
Some epileptics owe their disease to depressed fracture
of the skull, a tumor, a cicatrix, or some other form of di-
rect irritation of the brain itself. Others, who were un-
doubtedly affected with epileptic seizures as the result of
eye-strain only at the onset, fail to apply for the relief of
that defect until after they have been drugged with bromides
and chloral for many years to an extent that has seriously
undermined the recuperative power of the patient. Bro-
mides may likewise have impaired the normal sensitiveness
of the retina, as well as the tendency of the ocular muscles
to accurately adjust the eyes for visual images. In many
other ways these drugs sometimes so complicate matters
as to make improvement slow and complete recovery im-
probable in spite of the satisfactory removal of the original
eye defect.
When a house has been partially burned, no one expects
that putting out the fire will at once restore the house. It
does, however, prevent further damage, and materially de-
creases the time and cost demanded for its restoration.
Hence it is always deemed imperative to extinguish the fire
without unnecessary delay.
We must all admit, I think, that epilepsy is certainly
the gravest of all the functional nervous maladies, and that
it is, as a rule, incurable by drugs ; hence, as I have re-
marked in a previous discussion concerning this subject,
" one radical cure of epilepsy without the aid of drugs
offsets a thousand failures as a scientific proof of a dis-
covery."
It may be well, however, for me to mention in this
connection a few of the reasons why, in my judgment, the
treatment of the eyes has totally failed, in the hands of
some observers, to relieve or modify some nervous condi-
tions that had withstood judicious medication for years ;
and why it is that subsequently, in more experienced hands-
treatment of the same patients directed to their eye mus-
cles has led not infrequently to the happiest results.
(1) I would call attention to the fact that preconceived
notions about old methods must be abandoned without preju-
dice when a new method is to be tried.
(2) Each observer must, of necessity, make himself
thoroughly familiar with all the details of the method which
he proposes to employ before he is competent to decide
pro or con respecting its merits. This can not be done ex-
clusively by reading. No one can describe with a pen the
many intricacies that are apt to arise in solving complex
optical problems. It is certainly not beneath the dignity
of even an eminent man to learn (by personal observation
of the work of another whom he perhaps thinks is misled,
and by timely suggestions thus obtained) how facts that
bear upon successful treatment may be determined that
were, perhaps, at first obscure and difficult to ascertain.
(3) With a full knowledge of the method, its intrica-
cies, and its difficulties, conclusions should never be too
hastily arrived at in any given case. It is always " better
to be sure than sorry." Those who have had the largest
experience may occasionally make mistakes in judgment
wdien a peculiarly complex problem is presented for solu-
tion.
(4) The old methods of testing the eye muscles will
have to be abandoned at no distant date. A " phorometer "
is now essential to all accurate work. Moreover, the sepa-
rate muscles should be individually tested and their power
accurately measured.
Not long since a physician who had twice collapsed
from nervous prostration at the very threshold of his pro-
fessional labors came to me for advice. He showed at
intervals an apparent condition of equilibrium in the or-
bits, but welcomed prisms for a deviating tendency of one
eye above its fellow, ami improved rapidly under their in-
fluence. Within a week lie showed unconquerable double
images without his prism, and a radical step for the cor-
rection of his vertical strabismus was advised. At the ad-
vice of friends he then consulted an oculist of international
repute, who not only failed to recognize the fact that the
RANNEY: "EYE-STRAIN" AND NERVOUS DERANGEMENTS. [N. Y. Med. J
656
patient saw double images, but even pronounced the eyes
normal in their adjustment. The description by the patient
of the rough and unscientific tests upon which that judg-
ment was made showed clearly that the oculist was either
wofully negligent of his obligations to the patient or in-
competent to decide the point at issue.
Another patient upon whom 1 have lately performed a
graduated tenotomy of the external rectus muscle with the
happiest results (as it brought about a rapid and complete
restoration to health), came to me originally with an eye
that diverged at times, when her vision was not attentively
engaged, almost to the outer canthus ; yet she bore a cer-
tificate from one of the leading oculists of America that she
had no defect in the refraction or adjustment of the eyes,
and that her terrible headaches and difficulty in using her
eyes required only constitutional treatment.
Case IV. Chronic Epilepsy {apparently Cured by Glasses
alone). — Mr. T., aged thirty-five years, clerk. This patient
was sent to me from a neighboring State as a clironic epileptic.
He stated, at his first visit, that " he could remain in New
York only a day or two, and simply wanted to see if his eyes had
anything to do with his epilepsy.^
He was a clerk in a store and had had severe fits quite fre-
quently.
The full details of his family history, frequency of attacks,
medicinal treatment, etc., were not taken at that time by me,
and can not therefore be given here.
Eye Defects. — Without atropine this patient showed a marked
myopic astigmatism in each eye that was apparently corrected
by — 2-7o c. axis 180°. Under atropine a latent hypermetropia
of + 1*50 s. was also found to exist in addition to the astigma-
tism.
Treatment and Results. — Glasses were ordered for each eye
from the following formula (in April, 1890) :
— 2-75 c. axis 180° C + 1-00 s.
The patient also showed esophoria of four degrees with the
glasses that insured a full correction of his refractive errors.
In discussing the question of treatment with the patient he
was told to wear his glasses constantly, and, if the fits continued,
to return for a correction of the esophoria. I impressed upon
him the fact that the use of atropine might have to be re-
peated, and that I could not hope and did not expect that the
glasses alone would exert any very marked influence upon his epi-
leptic seizures. I impressed upon him the fact that after wear-
ing his glasses for a month or two it was possible that his ap-
parent error of adjustment of the muscles might be modified
somewhat. He left my office with instructions to abandon all
drugs; to keep a strict record of all his epileptic seizures,
whether light or severe; and to return later for further eye
treatment in case the seizures continued to be frequent or
severe.
Since that interview about twenty-six months have elapsed.
During this time I have heard from him several times through
patients that he has sent to me and once or twice by letter.
Last week one of his friends reported that never since he had
worn the glasses that I ordered for him had he been attacked
with an epileptic seizure of any kind. This report was a verbal
one that this patient had intrusted him to deliver to me. He
is still a clerk in the same store, and uses his eyes constantly in
his business.
Case V. Chronic Epilepsy, with Serious Mental Deteriora-
tion as the Result of the Administration of Bromide Salts. — Mr.
II., aged twenty-four, single, manufacturer.
Family History. — Father has a nervous temperament.
Mother has gout badly and defective eyes. Paternal grand-
father died of bowel trouble. Paternal grandmother died sud-
denly from some unknown cause. All paternal uncles and
aunts, seven in number, lived to be from seventy-five to ninety
years of age. Maternal grandmother died of phthisis and in-
sanity (after childbirth), and was nineteen years in an asylum.
One of her sisters died of phthisis. One maternal aunt died of
phthisis at sixteen years of age. Maternal grandfather had gout
terribly, drank heavily, and died of paralysis.
Eye Defects. — This patient showed an enormous amount of
unilateral astigmatism. Bight eye + 0-50 c, axis 90°. Left eye
+ 4-00 c, axis 180° C — 1-00 c. axis 90°. Esophoria 11°, adduc-
tion 35°, abduction 3°, right sursumduction 4°, left sursumduc-
tion 4°.
History of the Case. — Patient was perfectly healthy until he
went to Exeter to fit for college. While in Exeter he had sev-
eral epileptic seizures.
He had no special aura, but usually bit his tongue.
Had masturbated before his attack, but has not since.
He then entered Harvard and stayed a year. He had, he
thinks, four attacks during that year, during which he took no
medicine.
He left Harvard in June. 1885, and in September, 1885, he
went into the draughting-rooms of his father's factory. For
eighteen months he took no medicine, and in that time had sev-
eral attacks.
While in Cuba in 1887 he had a bad attack and began tak-
ing bromides. Within two months, while in Mexico, he had
two serious attacks, cutting his chin badly in one and knocking
out a front tooth in another.
He then came to New York and consulted an eminent neu-
rologist, who increased his bromides and put him on restricted
diet. He had only one severe attack and one of petit mal dur-
ing the next year, but his mental condition became seriously
impaired.
When he came to me his whole appearance and manner
showed markedly the poisonous effects of the bromides. His
face was covered with acne. His mental condition was so bad
that an interested conversation was almost impossible. In fact,
it had become so alarming that his father, with tears in his eyes,
said that although he was his only son, he would rather see him
dead than in his present condition.
Treatment and Results. — All bromides were at once stopped.
A full correction of his astigmatism was given for constant
wear, and graduated tenotomies were performed on both in-
ternal recti for the relief of his esophoria.
During the first six months of treatment, while his glasses
were being changed and operations performed, he had five at-
tacks— four very light ones and one medium attack. All of these
occurred after excessive indulgence in rich and indigestible food
late at night, and one after indulging in too much alcohol.
During the past eighteen months he has had no attack of any
bind. He has been actively engaged in business and has gained
twenty pounds in weight. He has regained perfectly his men-
tal condition ; travels without an attendant, runs a yacht, and
is considered perfectly well by his parents and physician.
(To be concluded.)
The Kings County Medical Association.— The next meeting of
this society will be held on June 14th. The leading paper of the even-
ing will be presented by Dr. Thomas H. Mauley, of New York, on The
Therapeutical Value of the Mercurial Salts in Surgery. The associa-
tion will then take a recess until the second Tuesday in October.
June 11, 1892.]
FEB G USOX: A THE TO CHOREIC MO VEMENTS
657
ATIIETO-CHOREIO MOVEMENTS.
By JOHN FERGUSON, M. A., M. D. Tor.,
L. R. C. P. EDIN., L F. P. S. GLAS.,
DEMONSTRATOR OF ANATOMY, WINTKR SESSION, AND
LECTURER ON NERVOUS DISEASES, SUMMER SESSION, UNIVERSITY OF TORONTO.
The subject of athetoid and choreic movements is a
highly important and engrossing one. Little by little, prog-
ress is being steadily made on the morbid anatomy and
pathology underlying these movements. In all conditions
of brain pathology, and in the varied symptoms resulting
from these morbid cerebral changes, many cases must be
Carefully collected and collated with each other before any
definite conclusions can be deduced from the observed ana-
tomical changes. The lesion must be limited to one special
part of the brain in order that exact opinions may be formed.
Should there be structural change involving two portions of
the brain possessing well-known and different functions, the
study becomes more complicated by the mixing of the re-
sultant symptoms. If, however, the morbid process extends
into parts of the brain of unknown, or slightly known,
functions, it is quite impossible to disentangle the varying
features of the symptom group, and say what is due to the
pathological changes affecting one or other of the parts.
Taking the contents of the cranial cavity as a whole, there
are many sections whose functions are extremely obscure.
A definite lesion, then, of any part of the central nervous
system, where the symptoms have been carefully noted intra
vitam, is of the utmost importance as a means of guiding
medical science one step farther in the pursuit of informa-
tion bearing on the question of the localization of function,
and, consequently, clearing up points in diagnosis.
It is a well-known fact that after some attacks of hemi-
plegia these athetoid or continuous" and choreic or jerky
movements come on. Another fact is that these movements
may continue after the paralysis has passed away. From
this we conclude that the source of irritation must be located
somewhere else than in the motor areas or tracts of the brain,
but yet so placed as to indirectly affect these. W. R. Gow-
ers, in his work, says: "Regarding the nature and position
of the disease causing these disorders of movement, we have
as yet but little pathological evidence. The symptom is ob-
served after recovery from the paralysis, and hence in pa-
tients who for the most part live on and' pass out of obser-
vation. But two setiological facts are of great significance.
The first is, that these disorders of movement are far more
frequent after cerebral softening from vascular occlusion
than after cerebral haemorrhage. The second is that they
follow hemiplegia far more frequently when this comes on
in infancy or childhood than when it comes on in adult life.
Regarding the seat of the lesion which gives rise to these
symptoms, the facts are too few to permit of accurate gen-
eralization. In most of the recorded cases the disease has
been situated either in or outside the optic thalamus. Since
the optic thalamus is not in the motor path, disease limited
to this must produce the symptoms indirectly by disturb-
ing the function of the motor cortex."
At a meeting of the American Neurological Society Dr.
6. M. Hammond reported the pathological findings in the
original ease of athetosis on which I >r. \Y. A. Hammond's
description of athetosis was based. The portion involved
in the lesion was a lengthy one in the antero-posterior direc-
tion, parallel in its short axis with the internal capsule. Its
posterior end had invaded the stratum zonale of the thala-
mus in its posterior half of the internal capsule. In its an-
terior extension it had crossed the capsule, invading the pos-
terior third of the outer articulus. The author called atten-
tion to the fact that the motor tract was not implicated in
the lesion, and argued that this case was further evidence
of his theory that athetosis was caused by irritation of the
thalamus, the striatum of the cortex, and not by a lesion of
the motor tract. Dr. Spitzka reported a case in which the
lesion was found in the same situation as in Dr. Hammond's
case. Dr. E. C. Seguiu also gave a paper on athetoid and
choreic movements in a patient. The post-mortem revealed
a glioma of the left thalamus and internal capsule, the move-
ments having been on the right side. The author's views
were that all cases of athetoid and choreiform movements
following hemiplegia were due to injuries of the thalamus
and adjacent capsule.
To the foregoing cases I shall now add the details of one
that was under my own observation in which the athetosis
was well marked and was not clouded by any other motor
or sensory disturbances.
The patient was a tall, thin man, of about thirty years. On
December 3, 1890, I saw him for the first time, and made the
diagnosis of diabetes mellitus. For this he was under treatment
to the time of his death, in January, 1892.
In the early part of July, 1891, he was taken ill with the
continuous movements of his right arm and leg, which lasted
unabated to the evening of his death. The movements were
slow and continuous, rather than short and jerky ; and in these
respects more closely resembled athetosis than chorea. The
movements of the arm, hand, and fingers were extensive. The
arm would be carried witb a steady swinging motion round be-
hind the back, up over the neck and head, and round to the
front again. Flexion, extension, abduction, and adduction of
the fingers would succeed each other in endless rotation.
There were no sensory disturbances other than the existence
of neuralgic pains. The knee-jerk was wholly gone on both
sides, and sexual power was equally lost.
The post-mortem was made about twelve hours after the
death of the patient. The brain, cerebellum, medulla, and pons
were removed for examination. The left thalamus opticus pre-
sented the appearance in its substance of an old but distinct
blood clot. Around this clot there were evidences of degen-
erative changes, the thalamus being much reduced in con-
sistency. The changes in the left thalamus were both gross and
minute. The above conditions were visible to the naked eye.
Under the microscope both fresh and hardened sections revealed
abundant signs of degenerative changes. This was very patent
in the region of the pulvinar. No definite histological characters
could be made out in either the central gray matter or in the
stratum zonale, due, no doubt, to the softening caused by the
irritation of the clot.
The commissura mollis was not invaded, and the right thala-
mus perfectly normal. The disease had not extended outward
so as to involve the internal capsule, with the slight exception
of a very small amount of degeneration that extended for some
distance upward in the most anterior part of the capsule; or in
that part which constitutes the anterior peduncle of the thala-
mus, by means of which it is brought into direct connection
658
ALLEN: PH TIIEIRLA SIS C ILK) h I'M.
[N. Y. Med. Jocb.,
with the frontal lobe. Along the inferior peduncle of the thala-
mus which joins it with the temporal lobe, degeneration could
be traced for only an exceedingly short distance. No patho-
logical changes could be discovered in the lenticular or caudate
nucleus. The floor of the fourth ventricle was examined, but
with negative results.
In this case there are several features of extreme im-
portance. First, we have the positive existence of athetosis.
In the second place, the occurrence of both gross and micro-
scopic changes in the left thalamus. Thirdly, the entire
absence of any diseased conditions in the motor tract, either
cortical, capsular, crustal, or pyramidal. And, finally, the
important fact that there were no sensory derangements.
How are we to account for the athetoid and choreoid
movements in these cases of lesion in the thalamus. It
would be somewhat beyond the object of this paper to
quote from all the cases that have been reported to show
the constancy of disease in the thalamus in such cases.
Gowers believes that disease limited to these ganglia causes
the movements by indirectly irritating the motor cortex.
Ross says, in his work on nervous diseases, that it is not
easy to give reasons why choreiform movements are so
liable to occur when the lesion is situated in the region of
the posterior external optic artery. Two probable explana-
tions of these clonic spasms suggest themselves. The first is
that fibers connecting the cerebrum with the cerebellum are
injured by these lesions, so that the regulation between the
tonic (cerebellar) and clonic (cerebral) actions of the body
is lost. The second is that the spasms are caused by par-
tial injury of the fibers of the pyramidal tract, wdiich regu-
late the fundamental movements of the body. The funda-
mental actions are regulated from the convolutions near the
longitudinal fissure. Fibers from these] convolutions would
descend on the inner side of the internal capsule, and conse-
quently on the side in contact with the thalamus. They
would therefore be more liable to injury, or irritation, in
disease of the thalamus than the fibers lying more external.
With regard to these views of Dr. Ross, it may be re-
marked that though the latter might explain some of the
cases, it could not explain the one I have recorded in this
paper, as the internal capsule was entirely free from disease
of any kind, and therefore the fibers governing the funda-
mental movements could not have been in any way inter-
fered with. The former view is negatived by my case also,
as there was no disease or degeneration in the peduncular
fibers leading to or from the cerebellum. It is not pos-
sible to say whether or not Gowers's view is true, as the
thalamus is so extensively connected with the cerebral cor-
tex. My own view is that the gray matter of the thalamus
must be regarded as cortical in function, and therefore
an originator of nervous energy, and not merely a trans-
mitter by means of the numerous bundles of fibers connect-
ing it with other portions of the central nervous system. If
it originates movements, when diseased, they partake of the
purposeless character of athetosis or chorea. In the case
now recorded there was no motor paralysis ; but the athe-
toid movements were greatly increased by all attempts at
definite voluntary actions. This fact alone, taken in con-
junction with the other considerations of positive disease in
the thalamus, while there was no disease elsewhere, goes to
show that the thalamus must have some regulating function
to fill toward our voluntary motor impulses. When this
regulating function is lost, we are able to originate move-
ments, but no longer able to so harmonize these move-
ments as to execute a regulated and purposive work by their
aid. I would therefore regard the thalamus opticus as an
originator of movements ; and, secondly, as a regulator, in
some way, of the movements emanating from other motor
areas. The thalamus may have other functions besides the
above ; but I think the two mentioned can be safely inferred
from my case.
PHTHEIRIASIS CILIORUM.
By CHARLES W. ALLEN, M.D.,
SURGEON TO CHARITY HOSPITAL, ETC.
In the Journal of Cutaneous and Venereal Disease for
July, 1886, I reported a case of pediculi upon the eyelids.
I had observed the condition a number of times previous to
this, and have seen quite a number of instances since ; still,
the location must be considered an unusual one in compari-
son with phthiriasis pubis. The parasite is the same in
both situations. I have not yet met with an instance of the
pediculus capitis located upon the ciliary margin of the lids.
Nor have I seen the nits of the head louse upon the lashes.
The following case, just observed in my service at the hos-
pital, has one or two points of interest :
Dora K., twenty-one years old, was admitted with mul-
tiple chancroids and one indurated sore upon the vulva.
She also presented a pigmentary syphilide upon the neck.
Five weeks ago she noticed something on the eye-
lashes and tried to wash it off, thinking it was dried secre-
tion. There has never been the slightest itching, or symp-
tom of irritation of any kind referable to the lids or eyes,
and, as no complaint was made by the patient, she had al-
ready been in the hospital for some time before the atten-
tion of the house staff was directed to the quite extensive
deposit of eggs upon the lashes. Even then the pediculi
themselves were seen with difficulty, so closely were their
flat bodies applied to the margin of the lid.
My method of treatment consists in removing all the
pediculi and their nits at a single sitting by mechanical
means, stripping off the hairs with a small, sharp-pointed
forceps, which will permit the nit to be drawn the whole
length of the hair without making traction enough to pull
the lash out. The pediculi cling so tenaciously to the hair
whose follicle furnishes the receptacle for the animal's head
that in removing them the hair is often sacrificed. The
farther back the body of the louse is grasped, the more
readily is its hold relaxed. In this case about a dozen
pediculi and probably fifty nits were removed. The re-
moval having been accomplished, attention must be directed
to the axilke and pubic region. Pediculi are almost invaria-
bly found in both these situations, and often too in some
other portions of the body. I have seen them as far down
as the ankles. Removal with the forceps can be practiced
here as well, unless the pediculi are too numerous ; then a
chloroform spray, inunction with mercurial ointment, appli-
June 11, 1892.]
PFINGST : OBSTRUCTION OF
THE SUPERIOR VENA CAVA.
659
cation of strong bichloride solution (1 to 100), or petroleum,
staphisagria, sabadilla, etc., will be required.
In regard to the frequency of phtheiriasis ciliorum,
much depends on the source of statistical information.
Jullien says it occurs but once in five thousand cases of
eye diseases seen in clinics, while out of five thousand nine
hundred and seventy-four eye cases seen at the Good Sa-
maritan Dispensary, in this city, during 1891, where most
of the patients are Russian Poles, there were no fewer than
eighty-five instances of pediculi of the eyelashes, or four-
teen per mille. Subjects of this affection do not come
much to the dermatologist, and are discovered by the gen-
eral practitioner, often only by accident.
696 Madison* Avenue.
A CASE OF
OBSTRUCTION OF THE SUPERIOR VENA CAVA.
By A. O. PFINGST, M. D.,
HOUSE SURGEON, LOUISVILLE CITY HOSPITAL.
On October 11, 1891, an apparently healthy man, forty-
five years of age, was admitted to the surgical ward of the City
Hospital, complaining of a sense of pain and weight in the neck,
and a feeling of fullness over and between the orbits on assum-
ing a stooping posture, which he attributed to a blow on the
occiput received a month previous.
On examination, a point in his skull was found somewhat
depressed, but no symptom whatever of compression was pres-
ent; and if there was at this time any interference in the circu-
lation, it was so slight as to be overlooked. He was thought
to be feigning sickness, and was consequently discharged by the
visiting staff officer.
On November 27, 1891, this being about a month after his
discharge, he was readmitted to the hospital, when there was a
decided cyanotic condition of the upper extremities. The ex-
ternal jugular vein on each side was very much dilated, but
non-pulsating. As this condition grew worse, the subclavian
vein became similarly involved. His neck gradually became
larger, as did also his arms and hands, both being decidedly
cyanosed, but not cedematous.
The lower extremities were never affected. The patient has
grown gradually weaker, suffering more or less from insomnia,
with considerable cough and impaired digestion. His principal
symptom, however, was a feeling of dizziness upon stooping or
on muscular exertion, or, as described by the patient, as a feel-
ing as if there was a rush of blood to the front of his head
which caused a dizziness and partial blindness.
The previous history of the patient is good, having always
been a stout, healthy man, accustomed to leading an active
life. He had an attack of pleurisy on the left side, for which
he was aspirated in December, 1890. Outside of this and the
blow on the head, he gave no other history, having no specific
history.
On physical examination, the apex beat of the heart was
found displaced to the left and downward somewhat, the im-
pulse having a heaving character. There was no heart murmur.
The pulse was full and strong. The lungs showed no abnormity.
The cause of the obstruction is very obscure. No pulsation
could be detected by pressure between the intercostal spaces to
indicate an aortic aneurysm, and there was no bruit discernible
by the use of the stethoscope. There was no pain or sense of
constriction in the chest or elevation of temperature to indicate
a mediastinal tumor of some other character, nor was there
any dullness on percussion over the region of the superior vena
cava.
The attack of pleurisy, which occurred on the left side, could
hardly be consideredjas a cause for this disturbance on the right
side. The condition could be brought about by a vaso-motor
disturbance, although such a disturbance is usually more gen-
eral. By the exclusion of these probable causes and by the
progressiveness of the case, it leaves a thrombosis of the supe-
rior vena cava as the most likely cause. The patient was on
no medicinal treatment until December 23, 1891, when he was
put on full doses of bromide of potassium until symptoms of
bromism were produced. There was from this on an apparent
improvement in his condition for several days, his neck becom-
ing smaller, as also the varicosities, while the cyanotic condition
almost entirely disappeared.
When the effect of the bromide had worn off, however, the
same conditions were again present, and they have grown gradu-
ally worse until at present the least exertion causes a blueness of
almost the entire face. For the past two weeks there has been
an overflow of the blood of the upper extremities, evidenced
by a varicose condition of the superficial veins of the abdomen,
with the flow of blood toward the lower extremities.
A PRECOCIOUS DEVELOPMENT.
By W. R. HOWARD, M. D.,
FORT WORTH, TEXAS.
On the 16th of April, 1891, Mr. H., of Zephyr, Brown
County, Texas, brought his son to my office by request. The
boy was born on October 20, 1887, and was at this time three
years and a half of age. He was born in Mills County, Texas,
and his age is sworn to be-
fore the county clerk at Gold-
thwaite, the county seat.
He is three feet ten inches
in height ; waist measure,
twenty-eight inches and a half ;
circumference of head, twenty-
one inches and a half ; neck,
twelve inches; arms over bi-
ceps, ten inches ; calf of leg,
eleven inches and a half;
weight, sixty-six pounds. Hair
on his head very thick and
dark ; eyebrows heavy ; downy
moustache ; hairs under arms,
about the nipples, and on the
lower half of the abdomen ;
heavy growth of hair on the
pubes; penis and testicles those
of an adult, well developed.
Glans penis naked, and during
erection the penis is four inches
and a half in length and four
inches and a half in circumfer-
ence.
His body and limbs are well
developed ; pulse rate, 84 ; res-
piration, 18; respiratory and circulatory organs, normal. He
has a deep bass voice ; face, teeth, and mental development those
of a child.
I have had his photograph made and present him to the
readers of the Journal in representation of the production and
resources of Texas, the greatest State in America.
060
THE
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by Edited by
D. Apfleton & Co. Frank P. Foster, M. D
NEW YORK, SATURDAY, JUNE 11, 1892.
NEW MEXICO AS A RESORT FOR CONSUMPTIVES.
Dr. A. Petin has contributed to the Journal of the Ameri-
can Medical Association a strong commendation of New Mexico
as offering peculiar advantages to certain classes of consump-
tives. He states that a great variety of climatic conditions can
be found in that Territory, but that which has pleased him best
is found in the southern and southwestern counties ; he has ob-
served there the most sunshine, a minimum of humidity, and
the least amount of dust in the air when put in motion by the
winds. This latter feature of dust-laden winds was, in his ex-
perience, a troublesome one along the Rio Grande, in the valley
of whicb there was almost always a dust, "'brought by the
river, which is so fine as to fly at the smallest breeze." Malaria
was also reported along that river by some of the older resi-
dents. Not until he found the district in which are situated
the San Augustin plains was Dr. Petin quite satisfied. At Las
Cruces he found some cases of cured consumption in permanent
residents of that part of the country, some of whom, when they
first came to the San Augustin plains, had not been able to
walk alone. Most of them had speedily begun to improve, and
had been in the enjoyment of good health ever since. "There
is a peculiarity in this country," he says; " no sooner does any
one get there than he begins to feel happy I The amount of
rain in three years was an average of about four inches a year.
Fogs are entirely unknown, and very seldom is there great
wind. There is plenty of game of all kinds, good fishing, and
beautiful shade trees at the foot of the mountains. There any
patient can sleep out of doors eight months in the year without
fear of taking cold."
These plains have an altitude of 4,800 feet above the sea,
and are surrounded by mountains from 1,200 to 1,500 feet
higher. The water supply is unsurpassable. There are mineral
springs, one of which contains a large proportion of iron and
manganese, and others have various sulphates in unusual quan-
tities. The plain is quite level, 170 miles long by 80 miles
wide, supporting the palm, the cactus, the Panama plant, and
an endless variety of flowering vegetation, " w ith every kind of
flowers all the year round." The temperature is most even,
averaging about G2° F. all the year through, with hardly any
snow-fall in the winter. When the snow does fall it does not
last more than an hour or two. The soil is porous and absorb-
ent, so that there is no ponding of rainfall and no malaria.
Exercise on horseback or in any kind of vehicle can be had at
all times.
Dr. Petin has traveled extensively in Central America and
South America, as well as through the Pacific and Western
States of our own country, and was for a time a resident of
[N. Y. Med. Jock.,
Colorado; but all these places, many of them very interesting
and attractive, fail, lie says, to combine the same number of ad-
vantages for the cure of the invalid that are afforded by the
sheltered yet elevated plains of southwestern New Mexico.
According to his experience, there are few sections that are at
all available to consumptives where life can be passed in the
open air to the same extent as in the San Augustin valley. And
it is probably this opportunity for open-air life, together with
the dry and rarefied atmosphere, that contributes to that feel-
ing of '• happiness " or exhilaration spoken of as being so com-
mon among those who have recently come to those plains.
The bounteous sunshine is agreeable also to almost all visitors
from the East, and the "tonic effect of hope" adds its influence
when the patient sees that his old habits of expectoration,
cough, and embarrassed respiration have been broken in upon.
POST-FEBRILE INSANITY.
Dr. Henry M. Hurd read a paper on this subject at the re-
cent annual meeting of the Medical and Chirurgical Faculty of
Maryland. The Maryland Medical Journal for May 28th con-
tains the full paper, in which the author mentions the recorded
cases, from Chomel's, in 183-1, to the present time, and reports
three cases observed by himself and Dr. Thayer at the Johns
Hopkins Hospital. Of the three new cases, one was a case
of melancholic insanity coming on during convalescence after
typhoid fever; the second was one of insanity developing from
pneumonia, with systematized delusions originating in the de-
lirium of fever ; and the third was one of maniacal excitement
following the removal of two diseased ovaries. In this last
case there was incoherence lasting several months, after which
complete recovery took place. The second case — not a hospi-
tal case — was marked by hallucinations, and delusions affecting
the patient's husband; she believed that he and the female
nurse had improper relations in her presence, and her embitter-
ment against him became so extreme that she was placed in an
asylum. After a year of confusion and delusions recovery set
in, and she was restored to perfect mental balance.
Dr. Hurd offers the following suggestion as to an improved
classification of post-febrile mental disorder: 1. Cases of insani-
ty following shock. 2. Those developing from diseases due to
specific poisons — such as puerperal fever, pneumonia, uraemia,
and the exanthemata. 3. Those originating from nervous ex-
haustion and anaemia. In this group will be found those in-
sanities, secondary to fever, that are an expression of an ex-
hausted physical state; they take the form of delusions of ap-
prehension and fear, hallucinations of sight and hearing, and
perversions of taste and tactile sensibility, at times going on to
stupidity and mental impairment.
Out of twenty-three cases that have been adequately re-
ported, eleven were of typhoid origin. In four of these deli-
rium was present during the attack; in seven, after it. Eight
patients recovered, two died, and one remained insane. The
pneumonic cases were two in number, one occurring during the
pyrexia and the other after it. Both patients recovered after a
LEADING ARTH >Z E8.
June 11, 1892.]
MINOR PARAGRAPHS.— ITEMS.
661
tedious convalescence. Nine of the twenty-three cases were
subsequent to surgical operations, and the mental trouble came
on at about the ninth day in several of them. In four cases
there was excitement, in five there was depression ; four pa-
tients recovered, four died, and one remained insane.
The author attaches no small importance to the treatment
of typhoid fever with cold baths, and considers that it is one of
the notable features of that method that so few of the patients
develop acute head symptoms. Another suggestion offered by
Dr. Hurd is that the patient after febrile disease is very fre-
quently insufficiently fed — with perhaps at the same time in-
sufficient quiet, too many friends or " callers," and a premature
sitting-up — and the prolonged abstention from food becomes
the determining factor of mental impairment. The term
" post-febrile insanity " should, in the author's opinion, be re-
stricted to cases that follow upon exhausting attacks of fever
or upon operations and the like, and should not embrace the
prolonged delirium that is engendered by toxic conditions.
MINOR PARAGRAPHS.
CHEAP STERILIZED MILK FOR TENEMENT-HOUSE BABIES.
An experiment is about to be made, during the coming hot
season, in providing sterilized milk for the poor in the vicinity
of the Good Samaritan Dispensary. Some charitably-minded
ladies and others began in 1891 the operation of a sterilizing
plant as a means of teaching the tenement-house population on
the east side that something could be done for the protection
of infants against some of the germ diseases incident to the hot
weather. This plant has been allotted a room at the dispen-
sary, and milk devoid of germs will be sold below the cost of
production, so as to enable it to compete with unsterilized milk.
THE KELVIN.
A new electrological term is the "kelvin." Says the Elec-
trical World: "The commercial unit of electricity, formerly
known as the Board of Trade unit, is hereafter to be called the
kelvin." The English Board of Trade has taken formal action
advocating the new term. This unit is one kilowatt hour — that
is, one thousand watt hours. The new name is derived from
the title of the well-known Sir William Thomson, now Lord
Kelvin.
ITEMS, ETC.
The Medico-legal Society of Chicago. — At the annual meeting, held
on June 4th, officers were re-elected as follows : President, Judge Oli-
ver H. Horton ; vice-presidents, Dr. Daniel R. Brower and Dr. James
Burry; treasurer, Dr. Joseph Matteson ; secretary, Dr. Archibald
Church.
A New Medical College in Chicago.— The Clinical College of Medi-
cine and Specialty Hospital is the title of an institution recently organ-
ized in Chicago by a company of physicians. Dr. J. E. Harper i- the
president and Dr. S. A. MeWilliams the secretary.
The Honorary Degree of LL. D. has been conferred on Dr. Fessen-
den N. Otis by Columbia College.
The Medical School of Columbia College. — It is announced that Dr.
T. Mitchell Prudden has been made professor of pathology.
The Death of Dr. William R. Birdsall is announced as having taken
place on Tuesday, the 7th inst. Dr. Birdsall was forty years old and a
graduate in medicine of both the University of Michigan and the Col"
lege of Physicians and Surgeons.
The Death of Dr. Charles E. Delavergne, of Brooklyn, took place
last Saturday from diphtheria. He was born in Brooklyn about thirty-
five years ago, was educated at the Polytechnic and the Long Island
College Hospital, taking his medical degree in 1878. He was ex-
president and councilor of the alumni of the latter college, and a lect-
urer on practice for the summer term. He was secretary of the Medi-
cal Society of the County of Kings for several years and a member of
the Board of Pharmacy of the same county. He was formerly surgeon
of the Thirteenth Regiment, N. G. S. N. Y., and a member of a great
number of societies, clubs, etc. He was a general practitioner of un-
usual prominence for one of his years, with a special tendency toward
diseases of the throat and chest.
Army Intelligence. — Official List of Changes in the Stations and
Duties of Officers serving in the Medical Department, United States
Army, from Mag 29 to June 4, 1892 :
Macaulet, C. N. B., Captain and Assistant Surgeon, is granted leave of
absence for three months.
Huntington, David L., Major and Surgeon, having reported in accord-
ance with Par. 9, S. 0. 107, c. s., Headquarters of the Army, is assigned
to temporary duty in charge of the office of the Medical Director,
Headquarters Department of Arizona, pending the absence of the
Medical Director, Colonel Joseph R. Smith, Surgeon.
O'Reilly, Robert M., Major and Surgeon, Fort Logan, Colorado, is
granted leave of absence for fifteen days, to take effect in the early
part of next month.
Walker, Freeman Y., Captain and Assistant Surgeon, Fort D. A. Rus-
sell, Wyoming, is granted leave of absence until June 30th instant,
to take effect on arrival at Fort D. A. Russell of Captain Julian M.
Cabell, Assistant Surgeon.
Society Meetings for th» Coming Week :
Monday, June 13th : New York Academy of Medicine (Section in Gen-
eral Surgery) ; Lenox Medical and Surgical Society (private) ; New
York Ophthalmological Society (private) ; New York Medico-his-
torical Society (private) ; Boston Society for Medical Improvement ;
Gynaecological Society of Boston ; Burlington, Vt., Medical and
Surgical Club ; Norwalk, Conn., Medical Society (private) ; Balti-
more Medical Association.
Tuesday, June lJ^th : Delaware State Medical Society (first day —
Dover) ; New York Medical Union (private) ; Kings County Medical
Association ; Medical Societies of the Counties of Chemung (annual
— Elmira), Chenango (semi-annual), Delaware (annual), Erie (semi-
annual— Buffalo), Genesee (annual — Batavia), Livingston (annual),
Onondaga (annual — Syracuse), Oswego (annual — Mexico), Rensselaer,
St. Lawrence (semi-annual), Schenectady (semi-annual — Schenectady),
Steuben (annual — Bath), Warren (annual — Lake George), and Wyo-
ming (Warsaw), N. Y. ; Newark, N. J., and Trenton (private), N. J.,
Medical Associations ; Baltimore Gvnaicological and Obstetrical So-
ciety; Northwestern Medical Society of Philadelphia.
Wednesday, June 15th : Minnesota State Medical Society (first day —
St. Paul) ; Delaware State Medical Society (second day) ; North-
western Medical and Surgical Society of New York (private) ; New
York Academy of Medicine (Section in Public Health and Hygiene);
Harlem Medical Association of the Cit\ of New York ; Medico legal
Society; Medical Societies of the Counties of Alleghany (annual)
and Tompkins (annual — Ithaca), N. Y. ; New Jersey Academy of
Medicine (Newark); Philadelphia County Medical Society,
Thursday, June 10th : .Minnesota State Medical Society (second day)
New York Academy of Medicine; Brooklyn Surgical Society; New
Bedford, Mass., Society for Medical Improvement (private).
FRIDAY, June 17th ; Minnesota State Medical Society (third day) ; New
York Academy of Medicine (Section in Orthopaedic Surgery); Balti-
more Clinical Society ; Chicago Gymecological Society.
Saturday, June ISth : clinical Society of the New York Post-graduate
Medical School and Hospital.
\
662
PROCEEDINGS OF SOCIETIES.
[N. Y. Med. Jour.,
prorccLirngs of Societies.
AMERICAN MEDICAL ASSOCIATION".
Forty-third Annual Meeting, held in Detroit on Tuesday,
Wednesday, Thursday, and triday, June 7, 8, 9, and 10.
1892.
The President, Dr. Henry O. Marcy, of Boston, in the Chair.
The Case of Dr. Potter, of New York State.— The meet-
ing was practically opened by the session of the Judicial Coun-
cil on Monday, to consider the matter of charges against Dr.
W. W. Potter, of Buffalo, late president of the Medical Society
of the State of New York, and two years ago Chairman of the
Section in Obstetrics and Gynaecology of the American Medical
Association. Dr. Potter has been a permanent member of the
association for fifteen years, and heretofore his rights as a
member have never been questioned. At the annual meeting
at Washington last year he was elected by the association as
one of its trustees. This was the signal for the preferment of
charges against him as a member of the unaffiliating New York
State society. Instead of the presentation being in writing,
as the by-laws require, the charges were made verbally, and
were not reduced to writing until two weeks after the adjourn-
ment of the meeting. The Council then referred the matter to
Dr. N. S. Davis, of Chicago, as a committee, who brought to
the meeting on Monday the decision of Dr. Potter's ineligi-
bility, and this decision was sustained by a vote of seven to
three of the Council. This nullifies the action of the association
in electing Dr. Potter to the trusteeship, and virtually, if not
actually, expels him from membership. Of course it must
affect in a similar way all other members of the dissenting New
York society who belong to the association, and logically dis-
franchises all who believe that its present code of ethics is anti-
quated and worn out. They include a large number of its most
influential and valuable members, and, judging from the ex-
pressions of discontent which are heard on all sides, the issue
may be more serious than was expected by those who have
precipitated the disturbance.
Thejmeeting was formally opened on Tuesday morning with
an address of welcome Jby Dr. Walker, chairman of the local
committee.
The President's Address on the Evolution of Medicine
was then read. He had observed that the wise student prof-
ited by the history of the past, and drew inspiration from its
pages as he confronted the present and with earnest en-
deavor shaped the future. We were too apt to forget the past
in our exultation over the achievements of our own time. We
should not forget that much that was appropriated by us as
modern had been quite clearly comprehended by our prede-
cessors.
Concerning the status of the association, it had been wisely
enacted that it should consist largely of delegated members,
thus making it a representative body. As such, it was the ex-
ponent of the thought and progress of the medical profession of
the United States. Such an organization needed its inherent
law, or code of ethics. This determined only in a general way
the proper relationship of the members of a great profession to
each other and to the body politic, but it had furnished for
many years, and was likely for years to come to furnish, a ques-
tion for discussion upon which able and honest men differed.
A distinction should be made alone between ignorance and
knowledge, for it was only fair to grant that considerable classes
of men devoted to a common calling must be adjudged alike
honest, and that their own selfish interests in the attainment of
success in any given profession must be determined by the
adaptation of what they considered the best means to a given
end.
The warping of the judgment by conservatism and prejudice
had oftentimes in medicine, as in the allied professions, retarded
rather than encouraged independent original observation and re-
search. The lines of future progress must be based upon scien-
tific data, upon the abolition of -isms and -pathies. and upon the
introduction of a more or less accurate interpretation of scien-
tific laws as to the proper treatment of disease. The so-called
homoeopathic school of medicine owed its existence largely to
two factors — unreasoning prejudice in the minds of a narrow,
conservative medical leadership, which called forth the sympa-
thy of t lie public, and an appreciation of t lie advantages obtained
by public sympathy and the determination to make the most
from a haughty, supercilious assumption of superiority by its
critics. Under competent leadership there had resulted the most
popular homoeopathic school of medicine, with a four-years1
graded course of instruction, with restrictive, critical examina-
tions in all the fundamental branches of medical science, until
the homoeopathic part had been reduced to a mere addendum to
the section of materia medica. Homoeopathy had been given
an opportunity to demonstrate its alleged superiority in the great
universities of Europe, and the result had been that its profes-
sorships there were vacant and that one must come to the Mod-
ern Athens of America if he would learn of the development of
the new art. As the indirect outgrowth of sectarian medicine
and its influence upon the profession in a general way. the anom-
alous condition of the Medical Society of the State of New York
was mentioned, under the leadership of men who openly declared
that the" future progress of our profession demanded the aban-
donment of restrictive rules of polity. This society had with-
drawn from affiliation with the association. The speaker, after
diligent inquiry during the past year, especially in New York
city, had heard only universal deprecation of tbe present society
relationships of the profession, coupled with the pronounced
opinions that the time was ripe for early readjustment and har-
mony. He had hoped that this greatly to be desired end would
be consummated during the period of his administration, and
advised moderation in the council of the association, that such
an end might be attained. The outgrowth of the differences
in New York had been the development of the New York State
Medical Association, which was entirely in harmony with the
national organization. The formation of the American Congress
of Physicians and Surgeons, composed of societies of limited
membership and including members who were devoted to special
lines of work, was approved of and believed to be helpful, espe-
cially to those who were bound by the common tie of special
study and research ; but neither this nor any other similar soci-
ety should overshadow the work of the American association,
which was the representative body of the entire American medi-
cal profession. The interest of the State societies in the na-
tional association, especially in the East, was not so great as it
should be. It was suggested that measures be instituted for
developing a much closer relationship between them than now
existed.
The condition of the Journal of the American Medical Asso-
ciation was believed to be entirely satisfactory, but it should be
our aim to make it the leading journal of the world. It was
believed that too much time in the general sessions of the asso-
ciation was wasted in the discussion of subjects of minor im-
portance. Encouragement should be given on all sides to the
work that was done in the sections, for here was where the
chief power of the association should be felt.
The valuable work of the American Academy of Medicine
in stimulating an appreciation of the value of a thorough pre-
June 11, 1892.]
PROCEEDINGS
OF SOCIETIES.
663
liminary training prior to the study of medicine was acknowl-
edged. The publishing of the details of surgical operations in
the daily press was deprecated. The importance of developing
and encouraging State medicine was forcibly dwelt upon, and in
particular the necessity for the revision of the coroner laws in
the different States.
The question of intemperance was one that was engaging
the attention of many physicians, and the organization which
had been effected among physicians for the study of this sub-
ject and the best methods for its repression was commended
to the sympathy and attention of the members. The organiza-
tion of a national board of health, with a secretary who should
hold a position in the Cabinet of the President, was believed to
be a great desideratum. The bill that was at present before
Congress for the prevention of adulteration of food and drugs
was also heartily commended. The great value of intercom-
munication of thought between physicians of all nations, as ex-
emplified in the ten International Medical Congresses of the
past thirty years, was regarded as a happy evidence of progress
in medical science. The great progress which had been made
in bacteriology and preventive medicine was also deemed a sub-
ject for grateful felicitation. Allusion was made to the losses
of the association and the world in the deaths of members dur-
ing the past year. Special mention was made of the deaths of
four ex-presidents, Dr. Campbell, Dr. Storer, Dr. Bowditch, and
Dr. Richardson.
Dr. Mubdock, of Georgia, moved that the president's address
be referred to the Committee on Publication for consideration
of its recommendations. Seconded and carried.
Dr. GinoN, of the navy, moved that letters of condolence
be sent to the families of all the ex-presidents who had died
during the past year, and added to the list of deaths mentioned
in the president's address that of Dr. Brodie, of Detroit.
Dr. Bbay, of Canada, president of the Canadian Medical
Association, was introduced to the meeting, and an invitation
was extended by him to the members to attend the next meet-
ing of its sister organization.
The Secretary's Report was read by the secretary, Dr. W.
B. Atkinson, of Philadelphia. An important point in it was
the question as to the status of delegates from societies other
than State medical societies. The by-laws recognized only those
who came from duly accredited State societies, and it was rec-
ommended that other societies should come into sufficiently
close relations with the State societies, or that an amendment
to the by-laws should be made whereby the members of such
societies could become eligible for membership.
The Report of the Committee on Sections was read by Dr.
Mabshall, of Chicago. It was urged that the association ap-
preciate the importance of developing the work of the sections,
some of which were suffering from lack of interest and enthusi-
asm. An amendment was proposed (as a substitute for an
amendment offered last year by Dr. Culbertson) that each sec-
tion have an executive committee composed of three members
to serve one, two, and three years, respectively, and that as
these members retired their places should be rilled by the retir-
ing chairman of the section, the committee subsequently being
supplied with membership in that way. The committees of the
sections collectively should constitute a nominating or executive
committee which should nominate officers of the association.
This motion caused a most intense and heated discussion, in
which, but for the admirable and temperate chairmanship of
Dr. Willis P. King, of Kansas City, Mo., the meeting would
have been strongly suggestive of pandemonium. The amend-
ment was finally adopted with the exception of the last clause.
The Committee on Public Health reported that a hill had
been introduced into both houses of Congress proposing a
bureau of public health, with a presiding officer who should be
a member of the Presidential Cabinet.
The Report of the Judicial Council was read by the secre-
tary of the association. It was occupied entirely with a state-
ment as to the relation of Dr. W. \V. Potter to the association.
[The facts in the case will be found in the first portion of this
report.]
Dr. Reynolds, of Kentucky, moved that the report be laid
upon the table. Seconded.
Dr. N. S. Davis, of Illinois, objected that a report of the
Judicial Council was final, and could not be debated or laid
upon the table.
Dr. Reynolds then moved that the case of Dr. Potter be re-
ferred back to the Judicial Council, with a request that the
causes for its action in this matter be specified. This was ruled
out of order, and the secretary read the by-law defining the
finality of the action of the Judicial Council.
Dr. Reynolds then appealed from the decision of the chair
to the association as an authority superior to the Council.
Dr. Gihon, of the navy, rose to a question of privilege, and
declared, amid much excitement and many interruptions, that
the status of permanent members who had registered year after
year and against whom no charges had been preferred during
that period, as in the case of Dr. Potter, could not be legitimately
acted upon by the Council as it had done in the case of Dr.
Potter. He cited the precedent of the case of the members
representing the navy who were refused recognition at the
meeting in New York in 1880 by the Council, but Dr. S. D.
Gross objected, the association unanimously sustained the ob-
jection, and the members were received. The meeting sus-
tained the chair in the ruling that the action of the Judicial
Council was final.
The Report of the Committee on the Pan-American
Medical Congress, to be held in Washington, in September,
1893, was read by the secretary-general. Dr. C. A. L. Reed, of
Ohio. An organization had been effected, a bill for the incor-
poration of the Congress had passed the United States Senate,
and was now in the House. The members of the association
were appealed to to register as members of the Congress. The
secretary of the association read the names of the members who
had been appointed to the committee on nominations.
Dr. Van Deeveee, of New York State, asked for informa-
tion as to the present status in the association of members of the
Medical Society of the State of New York, who were also per-
manent members of the association. The action in reference to
Dr. Potter had made their standing indefinite, and he desired to
know whether their membership, which in some cases had ex-
tended over many years, was now to be considered invalidated.
He expressed the belief that but for the action of the Council in
the case of Dr. Potter, the differences between the association
and the New York State society would have been adjusted in
the course of the coming year.
Dr. Davis, of Illinois, repeated the statement that all such
matters were adjudicable by the Judicial Council alone and with-
out debate. If the by-laws were wrong they should be changed,
but as they stood at present the matter was not under discus-
sion.
Dr. 0. A. L. Reed, of Ohio, moved that the inquiry of Dr.
Van Derveer be referred to a committee to be appointed by the
chair, to report, if possible, to the present meeting.
Dr. IIemenway, of Illinois, moved as a substitute that the
matter be referred to the Judicial Council, to be reported on to-
morrow'.
Dr. Reynolds, of Kentucky, moved as a substitute that the
Judicial Council decide whether permanent members were eligi-
ble to office, and whether the accepted registration of such mem-
664
RE POUTS OX THE PROGRESS OF MEDICINE.
[N. V. Med Jock..
bers, year after year, should not be taken as evidence of their
rights and privileges as members of the association.
Dr. King, of Missouri, proposed as a substitute that a com-
mittee of five be appointed by the association to confer with five
members of the Medical Society of the State of New York to
discuss the question proposed by Dr. Van Derveer, and report
upon that and all kindred issues at the next annual meeting of
the association.
Dr. Davis proposed as an amendment that five members of
the New York State Medical Association be added to this com-
mittee of conference.
Dr. King replied that he thought no assistance from the
New York State Medical Association was needed in the matter,
there being no question concerning its status in the association.
Dr. Hemenwat objected to Dr. King's substitute, believing
that it did not cover the original motion. The substitute was
accepted in lieu of the original motion.
Dr. Gihon moved as an amendment to the substitute that
those members of the Medical Society of the State of New
York who had registered should be entitled to all the privileges
in the association which they had heretofore enjoyed pending
the decision of the question at issue. This proposal met with
the almost unanimous approval of the meeting.
Dr. Truax, of New York State, believed that the New York
State Medical Association should have a voice in the settlement
of this question, and that five of its members should be added
to the proposed committee. The previous question was then
called for, and was put and carried. Dr. King accepted the
amendments proposed by Dr. Gihon and Dr. Truax.
The Address in Surgery was delivered by Dr. John B.
Hamilton, of Chicago. The subject was The General Princi-
ples of the Surgery of the Human Brain and its Envelopes.
The diseases and injuries of the seat of the soul could never be
a matter of indifference to the physician or surgeon ; mental dis-
eases must occupy the highest place in pathological study.
Though injuries to the cranium had long been the subject of
surgical measures of treatment, the brain itself had seldom re-
ceived such attention. Numerous quotations from the ancient
writers were made, showing the methods of treating cranial in-
juries which were in vogue among them. The present century
had the benefit of the knowledge of past ages in respect to this
department of surgery, but it had also improved vastly upon
them, and would transmit to posterity a precious inheritance
that it had developed and acquired.
The term "cerebral localization" was criticised as inapt in
reference to the diagnosis of disease and injury of the brain.
Diagnosis was difficult according to the location of the brain
lesion. With some lesions the symptoms were too obscure to
admit of accurate diagnosis. Oppenheim had formulated the
proposition that in cases in which there were rhythmic con-
tractions of the velum palati, the vocal cords, and the muscles
supplied by the lower branches of the facial nerve, without ac-
companying eye lesions indicating the presence of a tumor, there
was probably a purulent center resulting from encephalitis.
The causes of abscesses of the brain were now definitely known
to be directly infectious, except when there were infected em-
boli and in most eases they followed aural or ethmoidal disease
or traumatism. Robin had also observed that such abscesses
were seldom uncomplicated. They had frequently been suc-
cessfully treated by trephining, incision, and drainage.
Horner's conclusions from the consideration of the reports
of a hundred cases of intracranial abscess due to aural disease,
nine operations, and ninety-one necropsies were given in detail.
An abstract of the recent literature was also given, with
reference to the subject of cerebral injuries and intracranial
hemorrhage. Asepsis and drainage were the principal factors
in the treatment of such conditions, and a number of most in-
teresting cases were quoted in which a correct diagnosis as to
the seat of the lesion had been followed by a successful opera-
tion and the recovery of the patient.
Cases were also quoted in which a correct diagnosis of
tumor of the brain had been made, the cerebral and cerebellar
tumors being usually associated with optic neuritis and in some
instances causing epilepsy.
Cerebral injuries in the new-born, due to pressure, had been
recently studied to a certain degree, but the results of operative
interference had as yet been negative.
Craniotomy for intracranial pressure, incorrectly termed
craniectomy, was also an innovation of importance. Lan-
nelongue, the author of the operation, had performed it twenty-
five times, without very definite results as yet.
Spinal laminectomy had recently been proposed by Take as
the ideal surgical measure for the relief of intracranial fluid
pressure. This would seem to be a reasonable procedure before
performing the more radical operation of craniotomy. Tre-
phining for mental disease had recently been revived as an
operative procedure, but doubt was expressed as to the per-
manency of benefit to be obtained by it. The same could be
said with reference to a similar method of treating epilepsy.
Horsley and Agnew believed that five years should elapse after
an operation for epilepsy before a conclusion should be reached
as to the status of the subject of the operation.
Intracranial neurectomy had also recently been performed
in a number of instances for the relief of neuralgia and paralysis,
and such operations would occasionally offer good prospects of
successful result. Thus it would be seen that much progress
had been made in brain surgery, but much still remained to be
perfected.
(To be concluded.)
Bcports on tin progress of fflcbirinc.
OTOLOGY.
By CHARLES ST EDM AN BULL. M. D.
A Case of Living Larvae in the Ear. — Baxter (Arch, of Olol., xx, 1)
reports a case of a man, aged thirty-four, a farmer, who stated that, four
days previously, a fly had crawled into his right ear. He removed the
dead fly, and there was no feeling of pain or discomfort until two nights
later, when the ear commenced to bleed, and at the same time an in-
tense pain began. On inspection, the auricle was found red and swol-
len, the bandage was saturated with blood, and the meatus was full of
squirming larva;. The ear was immediately syringed with warm water,
and twelve larvae were thus removed. The auditory canal was abraded
throughout its entire length, and the membrana tympani was red, in-
flamed, and macerated, but not perforated. At the end of a week the
hearing was normal, and all appearances of inflammation had subsided.
The larva? averaged six mm. in length and two mm. in breadth. They
were of a yellowish-white color and filled with blood. They remained
alive for over twelve hours in the water to which about three per cent,
of chloroform had been added.
Operative Measures for the Relief of Impaired Hearing. — Deuch
(Arch, of Otol., xx, 1) reports four cases of suppurative inflammation
of the middle ear in which improvement in the hearing followed incis-
ions through dense membianiform adhesions surrounding the ossicula
and their articulations. He recognizes the fact that every case of im-
paired hearing due to suppurative inflammation in the middle ear can
not be improved by operative interference. In none of the cases re-
ported were the operations followed by inflammatory symptoms, and the
pain in all was insignificant. He concludes that it seems but just, in
June 11, 1892.]
REPORTS ON THE PROGRESS OF MEDICINE.
665
any case where there is a possibility of improvement by simple opera-
tive measures not attended with risk, to {rive the patient the benefit of
the doubt, after explaining that the matter of improvement is a matter
of conjecture. In cases, also, not dependent on suppurative disease,
but upon catarrhal inflammation, with the formation of adhesions with-
in the tympanic cavity, he thinks it justifiable to open the tympanic
cavity, using antiseptic precautions, and to attempt the liberation of the
ossicular chain, either by disarticulation of the incudostapedial articu-
lation, or the division of existing adhesions, or by Miot's brisement
force.
A Blow upon the Ear followed by Death in a Week. — Heiman
(Arch, of Otol., xx, 1) reports the following interesting ease: A soldier,
aged twenty-one, had been struck on the left side of his face and ear,
which caused severe vertigo. The blow caused severe ha'morrhage
from the ear, which, however, came on forty hours after the blow. The
ear had previously at times discharged pus, The patient died delirious
on the seventh day after the injury. The autopsy showed pachymenin-
gitis interna purulenta diffusa, numerous small subarachnoid hemor-
rhages, hyperemia of the substance of the brain and its membranes,
and circumscribed basilar meningitis. A decolorized thrombus was
found in the superior longitudinal sinus, and dark-red thrombi were
found in the transverse sinus and internal jugular vein. Three small
openings were found on the inner surface of the pyramid which led to
the tympanum. The upper surface of the mastoid was found sclerosed,
and here there were several small softened areas containing pus and
particles of bone. The tympanum and mastoid process were filled with
thickened pus. In the mastoid were several large cavities containing
pus. Pseudo-membranous bands were found in the middle ear, and the
mucous membrane was ulcerated. There was a small perforation in the
anterior part of the drum-head.
A Rare Case of Auditory Reflexes. — Steinbriigge (Arch, of Otol,
xx, 1) reports the case of a man, aged forty-four, who suffered from a
remarkable reflex spasmodic condition, involving the respiratory appa-
ratus in particular. This spasm follows every sort of sensory, optical,
and auditory impressions of a sudden character ; the patient moves both
legs in a kicking, spasmodic manner, suddenly jumps up, and then
makes expirations through the nose, rapidly following each other, the
mouth being closed during each expiration, but making a kissing sound
during each inspiration. The respiratory movements are at first very
rapid, and subsequently become slower and shallower. The patient
walks like an ataxic, and has been impotent for years. Vision, pupils,
sensibility of skin, smell, taste, and muscular sense are all normal.
Acuteness of hearing is slightly diminished. On both sides there is
moderate galvanic hyperesthesia of the auditory nerves, with paradoxi-
cal reaction. The case was regarded as a functional neurosis, induced
by a reflex spasm in certain muscles of the thigh.
A New Aural Retractor. — Barth (Arch, of Otol, xx, 1) describes a
new retractor for separating the divided soft parts during the operation
of chiseling into the mastoid process. It consists of two bars, each
provided with three sharp-pointed hooks ; these bars are connected by
two rods and a screw in such manner that when approximated the
hooks form a single line. After having divided the soft parts, includ-
ing the periosteum, and having separated the latter from the bone, the
hooks of the retractor are applied so that the points touch the bone at
the spot where we wish to continue to operate. Then they are sepa-
rated ; the points of the hooks grasp the deeper soft parts, while the
arms from which the hooks spring separate the more superficial soft
parts and especially the divided integument, and push the auricle for-
ward. When completely separated, the space included between the
two arms presents a clear field for operation.
The Route of Respired Air through the Nose. — Kayser (Arch. >>f
Otol., xx, 1) asserts that during inspiration in the normal nose the bulk
of the air passes along the septum, above the inferior turbinated bone,
describing a semicircle in its course, and extending upw ard nearly to the
roof of the nose. The general opinion that the current of air passes
through the pars rcspiratoria is erroneous. The division of the cavit)
of the nose into a pars rcspiratoria and a pars olfactoria is permissible
anatomically, but not justiliable physiologically.
Bacteriological Examinations of the Contents of the Tympanic Cav-
ity in Cadavers of New-born and Young Infants, — Gradenigoand IVn/.o
(Arch, of Otol., xx, 2) conclude from their investigations that the changes
which are found very frequently in the tympanic cavity in new-born and
young infants depend, in the majority of cases, upon the rapid decom-
position which the delicate tissues of the middle ear undergo at this age,
and not upon inflammatory processes, since no pathogenic micro-organ,
isms are found.
Some Points concerning the Opening of the Mastoid Process. —
Heiman (Arch, of Otol., xx, 2) sums up the indications for the operation
as follows : 1. In acute purulent otitis media, complicated with inflam-
mation of the mastoid process, when the inflammatory symptoms do not
yield to antiphlogistic treatment and Wilde's incision. 2. In acute and
chronic purulent otitis media, when the escape of the secretion is im-
peded by granulations in the middle ear or stenosis of the external audi-
tory canal, or when there is a suspicion of inflammation of the mastoid
process. 3. When the mastoid process is apparently healthy, but the
removal of pus or cholesteatomatous masses through natural channels is
impossible, and symptoms dangerous to life manifest themselves. 4.
In congestive abscesses and fistulas in the region of the mastoid process
5. In persistent, continuous pain in the mastoid process, yielding to no
other treatment, especially when it seems sensitive to pressure. 6. As
a prophylactic operation, in symptoms of retention of secretion and in-
flammation of the mastoid process, when death is to be feared on ac-
count of imperfect disinfection. 7. In acute purulent otitis media, in
which there is no inflammation of the mastoid process, and no retention
of secretion, but in which the discharge is very profuse, does not yield
to the usual methods of treatment after a certain time, or even increases.
8. When there are distinct symptoms of inflammation of the brain and
the meninges.
Heiman has used the trephine d crhnailliere of Pasteur for opening
the mastoid, and has received the following impressions from its use .
1. The removal of the compact portion of the mastoid process is much
more rapid than with the mallet and chisel. 2. The edges of the wound
need not be rendered smooth after the operation. 3. The different
size of the trephines permits the formation of a wound in the bone of
the desired size. 4. Shock is entirely obviated. 5. The depth of the
wound can be graduated with exactness.
Operation for the Relief of Deafness, Noises in the Head and Ears,
and Vertigo, due to Chronic Catarrh of the Drum of the Ear. — Sexton
(Arch, of Otol., xx, 2) reports seven such cases with results obtained
from the operation suggested and practiced by him. He considers that
in certain cases the advance of progressive sclerosis, and consequent
deafness, tinnitus, etc., can not be arrested, nor, indeed, can any perma-
nent improvement in hearing be made by means of any known local
medication directed either to the ear itself or to the throat. The deaf-
ness due to progressive ankylosis of the ossicula may be arrested in most
cases by an operation, however, and where the operation does not im-
prove the hearing, the further increase of deafness is thus prevented.
The operation, performed under narcosis, is not attended with any pain,
and there is seldom any reaction or feeling of soreness in the ear after-
ward. Where there is a difference in the hearing power of the two ears,
Sexton usually selects the worse ear for the operation, but this rule is
by no means always to be observed. The operation itself is entirely de-
void of danger. Antiseptic precautions are always to be taken. He
does not always attempt to remove the incus, since it sometimes lies be-
yond the range of vision. As an immediate result of the operation, it
will generally be found that the hearing for high tones has been im-
proved sometimes very greatly. The ability to hear low tones is not
always improved at first, but develops gradually. There is in some cases
a consciousness of an entire change in the transmission of sound, which
is confusing. More sound enters the ear, and it seems distant or crude.
Sometimes tinnitus is increased for the first few days, but it gradually
Subsides. The drum of the ear requires no special after-removal of the
drum-head, its lining soon being transformed from a mucous membrane
to a dry, insensitive one, of a cicatricial or dermoid character. In some
cases, after repair has taken place, an exfoliative process goes on for a
short time in the drum or adjacent portion of the external auditory ca-
nal, giving rise to discomfort and even slight deafness, w hen, the epithe-
lial layer thus formed detaches itself. Fur a lew hours after the opera-
tion the patients should remain in a recumbent position, and afterward
confine themselves to the room for a day or two. Regeneration of the
666
REPORTS OX THE PROGRESS OF MEDICINE.
[N. Y. Med. Joub.,
drum-head can not be prevented from taking place in a certain number
of cases, and when this occurs deafness returns, but the other symp-
toms, as a rule, do not return.
A Contribution to the Histology of Aural Polypi. — Klingel (Arch,
of Otol., xx, 2) reports an examination of fifteen cases of aural polypi.
A purulent otitis was the cause of the polypi in all the cases. He con-
siders that the majority of polypi are developed by chronic (more rarely
acute) middle-ear suppuration, and primary inflammation of the external
auditory meatus. The structure of the specimens showed three kinds
of tissue: Myxofibroma, angeio-fibroma, and granulation tissue. The
growth of aural polypi appears to take place in the separate lobules and
particularly at the surface. The basal tissue is usually denser, poor in
cells, and appears to cease to develop. Growth takes place chiefly in
the recent, many-celled areolar tissue, in the granulation tissue, at the
periphery of the tumors. The neighborhood of the vessels in the in-
terior of the growth consists of granulation tissue, and it is by no
means disproved that these are not the beginnings of vascular and
other new formations. As regards retrograde changes, in addition to
some haemorrhages and pigment formation, there are small vitreous
spots, w hich gave the impression of amyloid degeneration.
Two Cases of Adenoma of the Sebaceous Glands of the External
Ear. — Klingel (Arch, of Otol., xx, 3) reports two such cases, in which
the tumors were of equal size, about as large as a pea, soft and sponge-
like to the touch, with slightly roughened surface, and showing a few
scattered hairs. The sections of these growths showed connective-
tissue tumors covered w ith epidermis, in which there is seen a marked
new formation of glandular elements, similar in character to normal
glands. These growths should not be classed as papillomata, although
the warty exterior, and the fact that they arise from the subepithelial
connective tissue of the skin of the auricle, might suggest this view.
But, in addition to the warty hypertrophy of the papilla\ there is a
marked new formation of glandular elements. Hence these tumors
should be called adenomata sebacea fibrosa.
A Contribution to the Morphology of the Human Auricle. —
Gradenigo (Arch, of Otol., xx, 3) calls attention to an anomaly occa-
sionally met w ith in the human auricle, a minute stripe, which belongs
to the set of longitudinal stria?, in the so-called triple division of the
antihelix. This is represented by the third anomalous division starting
from the locality of the usual bifurcation of the antihelix, or about the
middle of the upper limb, and running backward and upward toward
" Darwin's tip." The oblique striae in transverse sections in the longi-
tudinal axis of the auricle are less distinctly represented in man, but to
this group belong the body and upper limb of the antihelix, and the
lower limb of the antihelix. Gradenigo has also recognized the ex-
istence of two well-marked striae, which must be regarded as accessory
antihelices. One of these marks the elongation of the lower limb of
the antihelix downward and forward, so that the stripe runs almost
parallel with the antihelix itself, and terminates on the floor of the
cymba conehae directly over the crus helicis. The second very rare
stripe is concentric with the body of the antihelix.
Remarks on the Use of Styrone in Chronic Suppuration of the
Middle Ear. — Spalding (Arch, of Otol., xx, 3) recommends the use of
styrone, a compound of styrax and balsam of Peru, especially in cases
of perforation of Shrapnell's membrane. It has a somewhat pleasant
odor, which masks that of the most disagreeable discharges from the
ear. It can be used, largely diluted with alcohol (one per cent, to five
per cent.), to syringe out the meatus. It reduces the amount of the
discharge and overcomes the latter's disagreeable odor.
The Lesion in Deafness due to Mumps.— Gelle (Arch, internal,
de larynyologie et d'otoloyie, iv, 2) concludes from his observations that
the infectious process, in the graver complications of the ear in paroti-
tis, invades especially the nervous apparatus, and thus destroys the
function of hearing. The delirium, vertigo, tinnitus, and absence of
gross objective lesions seem to indicate the labyrinth as the seat of this
destructive lesion. The atrophic sclerosis of the tympanic membrane
and of the tympanum may also be the consequence of mumps.
Two Cases of Carcinoma of the Auricle. — Valyor (Rev. de larynyo-
loyie et d'otoloyie, Feb. 15, 1891) reports two cases of this rare disease.
The first was a man, aged sixty-two, who ten years ago had noticed
a moist, whitish, hard, wart-like mass, as large as a bean, near the in-
cisura intcrlrayica of the left auricle. It was covered with a scab
which he occasionally removed. Nine months before he presented him!
self the mass had begun to increase in size and to ulcerate, and eight
months later he began to have severe pain in it. When Valyor saw
him the whole auricle was thickened and increased in size, was in-
durated, and of a purple color. In the concha was a hard tumor, the
size of a walnut, w hich extended upward to the crus f areata inferior,
outward to the margin of the helix, and downward to the antitragus.
The whole concha projected outward, was uneven, ulcerated, and bathed
in pus, and was apparently divided by a broken margin, continuous with
the auditory canal. Below the tumor was a flat, round, hard surface, as
large as a walnut. The hearing was markedly diminished. An oval
incision was made in the upper third of the helix, in a line with the
center of the fo.isa intcrcruralis, as far as the outer margin of the
concha ; thence behind the auricle to the skin of the cranium, thence
beneath the lobe of the ear to the incision made along the anterior
plane of the concha. Having removed the latter, a curette was passed
into the auditory canal, and all the carcinomatous masses were removed.
The wound healed rapidly, and for eight months there has been no re-
turn of the growth.
The second case was a man, aged seventy, who for two months had
noticed an increase in size of one of his ears. The auricle was purple
in color, and looked as if it had been frozen, and was involved through-
out its entire extent in a carcinomatous growth. All surgical interfer-
ence was contra-indicated, on account of the great extent of the tumor,
and the age and cachectic condition of the patient.
An Electro-acoumeter. — Cheval (Rev. de laryngohgie ft d'otoloyie,
July 15, 1891) gives a description of an electrical acoumeter devised
by himself, which consists simply of three spools or bobbins — the cen-
tral one fixed, the other two movable in a slot or gutter. The electric
current traverses the first spool or coil and reaches a commutator, which
has three parts — an electro-diapason, a microphone, and an interrupter.
Each of the induced coils may be attached to either of two telephones,
which the patient keeps constantly in contact with his ears. The dia-
pason and the microphone, when connected in the primary circuit, in-
terrupt or modify its intensity, and consequently give rise to induced
currents in the movable coils, which vary in intensity with the distance
between the movable and stationary coils. The instrument permits (1)
the operator to vary not only the intensity of the sound, but also the na-
ture of this sound ; (2) it allows of the verification of the patient's state-
ments ; (3) the course of the coils is more than 600 mm. ; (4) the inten-
sity of the sound is inversely to the square of the distance; (5) the
hearing may be examined for any sound — for a musical note, for a com-
bination of harmonic sounds, for the human speech, for the watch, or
for the metronome.
Deafness caused by Dry Inflammation of the Middle Ear and 0s-
sicula, and the Surgical Treatment of the Same. — Jliot (Rev. de laryn-
yoloyie et d'otoloyie, August 1 and 15, 1891) thinks that the extirpation
of the tympanic membrane and extraction of a part of the ossieula,
though a modern operation, has great advantages in certain cases, and
he gives the following indications and contra-indications for performing
the operation: The operation is indicated (1) whenever an artificial per-
foration sensibly ameliorates the hearing; (2) when the chain of bones
and the drum-head have lost their motility ; (3) when the patient has a
paradoxal deafness, and hears the tuning-fork on the vertex best in the
worse ear ; (4) in cases of unilateral deafness, with vertigo and violent
tinnitus. The operation is contra-indicated in cases of unilateral deaf-
ness without other objective symptoms, and in all cases where the tin-
nitus and deafness seem to be of nervous origin, reflex or central. He
draws the following conclusions : This operation is the last resource to
be employed in the treatment of dry catarrh of the ear. The removal
of the drum-head and jmalleus may suffice whenever the membrane is
much thickened and the motility of the bones is free. The malleus
and incus must be removed in all cases of rigidity of the chain of bones.
The result of the operation is generally very favorable, both as to tinni-
tus and deafness.
A Case of Osteoma of the Cartilaginous Portion of the External
Auditory Canal — Liehtenberg (Rev. de larynyologie et d'otoloyie, Oct.
1, 1891) reports a case of this kind occurring in a man, aged twenty-
five, who had been very deaf for a year and had suffered great pain and
June 11, 1892.]
REPORTS ON THE PROGRESS OF MEDICINE.
667
unbearable tinnitus in the left ear. There was a smooth, red tumor, com-
pletely filling the left auditory canal, eight millimetres long, and movable
on its pedicle. It looked like a polypus, but there had never been any
discharge from the ear. An exploration with the sound proved that it
was attached to the internal wall. The case was removed easily by a
snare without much haemorrhage. It was as hard as stone, and covered
by a smooth, reddish capsule. An examination showed it was a neo-
plasm, containing a bony nucleus, surrounded by periosteum. It weighed
eighteen centigrammes, was eight millimetres long, six millimetres wide,
and five millimetres high. It proved to be an osteoma.
Avulsion of the Stapes in Animals. — Botey {Ann. des mal. de Vore-
ille et du larynx, xvii, 1), draws the following conclusions from his ex-
periments : 1. The avulsionof the stapes in animals is an entirely in-
nocuous operation. 2. Whether the oval and round membranes are
torn or not, and whether labyrinthine fluid flows out or not, a new mem-
brane, much thicker, is always formed after this operation. 3. In all
cases, after removal of the stapes, the animals hear well, but at a
shorter distance than before. 4. In animals which have neither drum-
membrane nor columella, hearing is a little better than in those in
whom the drum-membrane has been removed, while the stapes is left in
place. 5. This operation would probably be equally innocuous in man,
if it were possible to execute it equally well and under strict antiseptic
precautions. 6. The drum-membrane and ossicula are not indispensable
to hearing, but they simply re-enforce the intensity of sound-waves.
A Theory of the Functions of the Sinuses of the Face, the Cells of
the Ethmoid, and the Mastoid Apophysis. — Coiietoux (Ann. des mal. de
Voreille et du larynx, xvii, 3) gives the following epitome of his views
on the above subject : The ethmoid is primarily a respiratory and olfac-
tory organ. The sinuses of the face share in this role, and later dimin-
ish its influence. Olfaction seems to owe its mechanism to the ate of
the nose and the vault of the palate. The ethmoid aids in the forma-
tion of the nasal fossae, and preserves them from the deforming effects
of aspiration in diffusing them. The moist and overheated air which
it contains pushes the odoriferous particles toward the convexity of the
middle turbinated bone. The sinuses, being developed with the olfac-
tory sense, share with the ethmoid in its functions of diffusing the de-
forming effects of the negative pressure due to olfactory respiration.
In the adult the sinuses leave to the ethmoid the first place. The mas-
toid cells relieve the tympanic membrane from the deforming effects of
the barometric vacuum, which is due not so much to the olfactory res-
piration from which the narrowing of the Eustachian tube already pro-
tects it, as to the effects of this narrowing, which coincides with the de-
velopment of olfactory respiration.
Removal of a Revolver Bullet from the Temporal Bone by the Use
of the Chisel ; Recovery, with Preservation of Hearing.— Wolf (Arch,
of Otol., xx, 3) reports the case of a girl, aged seventeen, who was shot
by a revolver on October 15, 1889, the bullet entering the right ear. She
fell, but did not lose consciousness, and was able to rise soon. There
was but little haemorrhage from the ear and not much from the wound.
Moderate facial paralysis developed on the eighth day, and there was a
slight purulent discharge from the auditory canal. The bullet had en-
tered just in front of the tragus, had crossed the external auditory
canal obliquely, penetrated the posterior wall near the drum-membrane,
and had lodged in the temporal bone. Wolf operated sixteen days
after the injury. The auricle was detached posteriorly and pushed
forward, the periosteum of the bony auditory canal was loosened, and
the posterior wall of the canal was chiseled away in a backward direc-
tion. Constant oozing of blood from the bone interfered with the view
of the bottom of the hole, and, as the porcelain-tipped probe did not
locate the bullet, it was decided to postpone the completion of the opera-
tion for forty-eight hours. Two days later a good view of the depth of
the hole was obtained and a small, shining, metallic point showed the
position of the bullet. The bone was chiseled away around it, and
after much difficulty it was removed by a pair of dressing forceps. An
examination showed that the bullet had rested directly on the sinus.
The auricle was reattached, the lower end of the wound being left
open, and the subsequent course of the case was favorable. After
three weeks, faradization of the facial was begun and caused a gradual
improvement. The bony canal became pervious and the hearing dis-
tance became normal. During the operation no important parts con-
cerned in hearing were injured. The canal which was chiseled in the
bone was located close behind the annulus tympanicus, so that the
various parts of the tympanum and the semicircular canals remained
intact. The facial nerve seems merely to have been compressed and
not torn by the bullet. The occurrence of facial paresis only after
several days was due to a neuritis from pressure, and when this sub-
sided the nerve became again capable of conduction.
The Use of Electricity in Chronic Affections of the Middle Ear. —
Baxter (Arch, of Otol., xx, 3) reports ten cases of disease of the middle
ear treated by the constant current. He thinks that when improvement
takes place it is most noticeable in the increased ability to understand
speech, the tinnitus is lessened, the feelings of pressure, fullness, and
dullness are lessened or removed. The method of application is as
follows : After placing the patient with the head inclined the external
auditory canal is filled with warm water, the aural electrode (a small
wire insulated to within two millimetres of its point) is introduced into
the auditory canal and retained there by the fingers of one hand, leav-
ing the other hand free to manipulate the switch, rheostat, and pole-
changer ; the other electrode, covered by a sponge, is held in the
patient's hand. The current is then switched on and gradually in-
creased, watching the milliamperemeter until from five to ten milliam-
p&res of current are passing through the parts ; then, retaining the
electrodes in position, the poles are changed two or three times a minute.
From three to six minutes suffice for an application. The ear is then
dried and the patient kept quiet for a short time to recover from any
possible vertigo.
The Symptomatic Value of the Pulsations noticed in the Ear by
the Endotoscope. — Gelle (Ann. des mal. de I'oreille et du larynx, xvii,
9) draws the following conclusions from his observations : By the aid
of the endotoscope the state of the circulation of the blood in the
tympanic cavity can be studied ; in active congestion of the tym-
panic mucous membrane this instrument shows pulsations isochronous
with the pulse. This demonstration is especially useful when the ob-
jective symptoms are wanting. The pulsations of the endotoscope
actually show the activity of the inflammatory process in the middle
ear. They disappear when the process declines, but persist as long as
the abnormal vascularity lasts. Hence they have an important prog-
nostic value in chronic diseases. Their absence in certain cases of sub-
jective affections of congestive appearance enables us to localize the
seat of the exudation in the deeper parts of the organ, or to recognize
the purely nervous origin of the phenomena.
Diagnosis, Prognosis, and Treatment of Progressive Deafness due
to Chronic, Non-purulent Otitis Media. — Gradenigo (Ann. des mal. de
Voreille et du larynx, xvi, 12) summarizes as follows: Chronic catarrhal
otitis media is generally characterized by a slowly progressive morbid
process, which is usually located in the middle ear, but which often ex-
tends to the internal ear, and causes more or less complete deafness.
As regards the prognosis, two principal circumstances are to be con-
sidered: 1. The existence or absence of functional lesions attributable
to the internal ear, in addition to functional lesions located in the trans-
mitting apparatus. 2. The existence or absence of retraction of the
drum-head.
Some cases are distinguished by the predominance of morbid phe-
nomena, which must be referred to the drum-head and Eustachian tube
— such as redness and retraction of the membrane. In other cases the
lesions are generally located in the vestibular wall — such as ankylosis
of the stapedo-vestibular joint. In still other cases the lesions of the
internal ear predominate.
Gradenigo considers the subject of treatment under five heads, as
follows: I. Direct treatment of the ear: 1, through the external audi-
tory canal, by massage of the ossicles, by massage of the tympanic
membrane, and by intratyrapanic surgery ; 2, through the Eustachian
tube by catheterism with a simple air-douche, by injection of medicated
vapors through the catheter into the drum, by injection of liquids
through the catheter into the drum, or by the methodical introduction
of bougies and massage of the Eustachian tube. II. Local treatment
of the nose. III. General constitutional treatment. IV. Treatment by
the electric current.
Cholesteatoma of the Ear. — Kuhn (Arch, of Ootol., xx, 4) reports a
case of " true cholesteatoma " — that is, a tumor which originated pri-
668
REPORTS ON THE PROGRESS OF MEDICJXE.
[N. Y. Med. Joint,
marily iu the mastoid process, and which had during many months, and
perhaps years, grown to its tremendous dimensions. The symptoms
which appeared during the last year (tinnitus, dizziness, and deafness)
were due to erosion of the external portions of the ear, and to pressure
on the cerebellum. Exposure toward the end caused the acute symp-
toms of inflammation and disintegration of the tumor, which had then
extended to the posterior wall of the auditory canal. The presence of
a membrane lining the bony cavity is not proof of the primary origin of
the tumor, for it may have been due to the pressure of the tumor on the
periosteum and bone. Cholesteatoma of the temporal boue is either a
true heteroplastic neoplasm, or it may develop in the course of chronic
suppuration of the middle ear, from epidermis which had grown into
the tympanic spaces from the perforated drum or external auditory
canal, which has slowly and continually shed its horny layer, thus form-
ing the stratified eholesteatomatous mass.
The Treatment of Cholesteatoma of the Middle Ear. — Bezold (Arch,
of Otol., xx, 4) thinks that if in these cases the cavity is rendered free
by a large opening into the wall of the canal or of the mastoid process,
suppuration ceases, and so also does the hyperproduction of epidermis.
More than half the cases are complicated by polypoid granulations,
usually exposed by pressure from the eholesteatomatous masses which
act as foreign bodies. Only a portion of the granulations is found in
the canal, the greater part being at the margin of the perforation. On
this account it is frequently impossible to remove all the granulations
with the snare. The operation of excision of the malleus and incus is
an aid in the treatment. It seems absolutely necessary to use Hart-
mann's or some other tympanic syringe in all cases, not only therapeu-
tically, but also for the purpose of diagnosticating the existence of
eholesteatomatous masses. Bezold uses an injection of a four-per-cent.
solution of boric acid. When preliminary softening seems necessary,
diluted liquor ammoniae may be used. When the size of the cavity ad-
mits, he uses a sharply bent tympanic tube of large cavity, for direct
insufflation of boric acid.
A Case of Deaf-mutism caused by Measles, with Post-mortem Ex-
amination.— Mygind (Arch, of Otol, xx, 4) reports a case of this sort
occurring in a man aged twenty-eight. At the age of eighteen months
the patient contracted measles, and during the attack a bilateral inflam-
mation of the middle ear set in, probably secondary to an acute catarrh
of the naso-pharynx. The former existence of such an inflammation was
proved by the inflammatory residua found at the autopsy, viz. : 1. On
the external wall the left membrana tympani almost entirely wanting,
while the right one was the seat of a large calcareous deposit, and there
was a bilateral purulent discharge. 2. On the posterior wall of the tym-
panum the aditus ad antrum mastoideum was closed and the mastoid
process was sclerosed. 3. The internal wall of the tympanum was the
seat of stalactitic formations which exhibited strong evidence of a se-
vere inflammation of the osseous structure of the tympanum. 4. The
normal muscles of the tympanic cavity were missing on either side. The
inflammation was propagated from the middle ear into the labyrinth
through the fenestra rotunda, destroyed the cochlea, and in its place pro-
duced sclerosed osseous tissue.
A Case of Partial Development of both Auditory Organs. — Heiman
(Arch, of Otol., xx, 4) describes an interesting ease in a child two days
old. There was complete absence of both external meatus, with an in-
complete development of the auricles. The posterior part of the palate
was absent, the articulation of the temporal bone with the zygoma was
incomplete, and the middle ear undeveloped. The skin and cartilage of
both ears were well developed. The lobules and helices were normal.
The upper border of the left helix is adherent to the facial skin. The
antihelix and crura bifurcata are replaced by a cartilaginous, ring-like
tuberosity, whose convexity is directed inward. There is a distinct de-
pression in this circular piece of cartilage. The site of the external
opening of the meatus on both sides is marked by a slight furrow. On
the right side, in front and above this furrow, are two cartilaginous tu-
bercles covered with normal skin. The cartilage of the tragus could be
plainly felt. The nasal structure was normal.
A New Universal Double-acting Snare. — Bucklin (Arch, of Otol,
xx, 4) has devised an instrument in which the wire is attached to a solid
stylet, drawn by a powerful ratchet motion. A screw motion is also at-
tached to the same stylet, thus enabling the operator to use a very slow-
cutting snare, while the ratchet motion provides a rapid-cutting one
when desired. The handle and ratchet motion may be detached at pleas-
ure. The instrument has a straight tip for the nose and curved tips for
reaching the larynx and naso-pharynx through the pharynx. The straight
cannula is armed with wire by passing it through the eyes of the slightly
projecting stylet from opposite sides. The required loop having been
formed, the stylet is drawn by the ratchet motion, and the projecting
ends of the wire are cut. The curved tips are armed with wire by bend-
ing one sixteenth of an inch of the end of the wire at an angle of forty-
five degrees. It is then passed through the first eye of the stylet into
the opening at the curve of the cannula. When the wire appears at the
opening it is twisted until the bent point is opposite the second eye in
the stylet, which it enters easily and the loop is complete.
Different Diagnostic Points between Human Olfactory Epithelium
and Respiratory Ciliated Epithelium. — Suchannek (Arch, of Otol, xx,
4) considers that the normal human olfactory epithelium consists : 1.
Of a lining membrane of finest ciliated epithelium of easily differenti-
ated, easily destroyed cilia, and therefore only to be seen in fresh speci-
mens. 2. A protoplasmic border of unpigmented and pigmented cells
containing the extreme terminations of the supporting and olfactory
cells. 3. A full development of supporting cells, and particularly of the
zone of olfactory cells, together with a row of basal cells, which, with-
out a dividing cuticle, rest directly upon the tunica propria. 4. A mod-
erate amount of pigment which surrounds Bowman's glands and the
olfactory fibers in heaps and stripes.
Aural Complications in the Course of Leucocythaemia. — Lannois
(Ann. des mul de VoreiUe et du larynx, January, 1892) draws the fol-
lowing conclusions from his observations : 1. Leueocythaemia may be
accompanied by symptoms of the presence of lesions in the auditory
apparatus. 2. These symptoms are either unilateral or bilateral deaf-
ness, accompanied or not by subjective noises and vertigo. 3. This
variability of symptoms depends upon the fact that the lesion does not
always involve the same region in the auditory apparatus. 4. In four
cases out of five the anatomical lesion is a haemorrhage. 5. These
complications are relatively rare.
Malignant Tumors of the Ear. — Charazac (Rev. de laryngologie et
oVotologie, Jan. 1, 1892) refers to the fact that all the cases hitherto
reported seem to prove that cancers of the auricle and external auditory
canal are the most frequent of all malignant diseases. Epithelioma is
the most frequent form of cancer of the ear, and sarcoma is the next
most common. Carcinoma is the least common form of malignant
disease of the ear. We meet here with both forms of epithelioma
— the cylindrical and squamous — the latter being both tubular and
lobulated.
Malignant tumors of the ear are met with at all ages, though epi-
thelioma and carcinoma are most frequently met with in declining years,
while sarcoma is more frequent in the young. Cancer of the auricle is
not more frequently met with in women than in men, though it might
be expected to occur oftener in the former, because of the piercing of
the lobules for ear-rings. Epithelioma is much more frequently met
with in men than in women.
Cancer of the ear may develop primarily in all parts of the auditory
apparatus — even in the middle ear and mastoid cells. Epithelioma of
the auricle and auditory canal sometimes occurs as the result of trau-
matism. In many eases it is developed in the course of cutaneous
diseases, like eczema, impetigo, and psoriasis. According to Politzer,
epithelioma of the auricle appears most frequently on the skin of the
upper part of the helix. Sarcoma most often attacks the lobule. In
the auditory canal the cartilaginous portion is the most frequently af-
fected.
Whatever the variety of cancer, when the parts have become ulcer-
ated the pain is often intense, radiatiug from the interior of the ear to
the corresponding side of the head. The engorgement of the pre-
auricular glands occurs sooner or later, presenting itself very late in the
case of sarcoma. When ulceration has occurred, the growth is usually
very rapid. Carcinoma, as a rule, grows very rapidly. As regards
prognosis, sarcoma is less grave than epithelioma, and the latter less
grave than -carcinoma.
Cancer of the middle ear may be primary or secondary. The latter
arises very often from a neoplasm of the auricle or canal. The prog-
June 11, 1892.]
MISCELLANY.
669
nosis is absolutely fatal, for it is impossible to extirpate the neoplasm
totally. The treatment should, therefore, be merely palliative.
Primary cancer of the labyrinth, if it exists, is excessively rare. It
is almost always secondary, epithelioma and carcinoma being the most
frequent, if derived from the middle or external ear, while sarcoma
derived from the intracranial cavity is the most frequent.
The Legal Requirements for entering upon the Practice of Medi-
cine in the State of New York. — The following report has been pre-
pared under the auspices of our State board of medical examiners,
which, in brief, outlines the law of the State and its operation since
September 1, 1891. It has been prepared more particularly with a view
to disseminating knowledge on a subject concerning which frequent in-
quiries are made, and it is thought that the profession will be pleased
to have the opportunity of reading a concise statement of the essen-
tials for entering on the practice of medicine in the State of New York,
and of knowing the result of a nine months' trial of the latest legisla-
tion.
The report is as follows :
The many inquiries directed to the regents' office and to the secre-
taries of the various State boards of medical examiners indicate that
the profession is largely interested in the operations of the law at pres-
ent governing the practice of medicine in the State of New York.
This interest is accepted as of sufficient moment to warrant the publi-
cation of the salient features of the law, and at the same time to give
the profession an insight into the methods and machinery necessary to
its proper enforcement. The law signed by the Governor on June 4,
1890, went into effect on September 1, 1891, and has been operative
since that time. It provides: "From and after the first day of Septem-
ber, 1891, any person not theretofore lawfully authorized to practice
medicine and surgery in this State and desiring to enter upon such prac-
tice" may, after the following conditions have been fulfilled, receive an
order to be examined before one of the three State boards of medical
examiners as to his medical qualifications :
1. Applicant must be more than twenty-one years of age.
2. Must present certificate of moral character from two legalized
resident (State) medical practitioners.
3. Must be a graduated doctor of medicine from some legally incor-
porated medical college in the United States, or have^eceived a diploma
or license conferring the full right to practice all the branches of medi-
cine or surgery in some foreign country.
4. Must have attended at least three full courses of lectures in dif-
ferent years in some legally incorporated medical college or colleges.
5. Must pay twenty-five dollars into the treasury of the University
of the State of New York.
6. Must present evidence of preliminary education, as follows :
Either—
(a) Usual academic degree.
(b) One year at academic degree-conferring college.
(c) Three years in a high school or academy.
(d) Be in possession of regents' medical-student certificate.
(e) Matriculation certificate required by present medical act of
Canada.
(/) Matriculation certificate from any university in Great Britain or
Ireland.
(g) Certificate of having passed examinations of any registered in-
stitution equivalent to one year in academic college or three years in
high school.
All these preliminaries having been complied with, upon proof pre-
sented by the applicant, in his or her own handwriting, to the satisfac-
tion of the regents (on blank forms furnished on application), an order
is given admitting the candidate to the next examination. Five regular
examinations are held during the year (during the year 1892 there are
still three regular examinations to be held, as follows: June 14th-17th,
September 27th-30th, and November 22d-25th) simultaneously at New
York city (21 Cooper Union), Albany High School building, Syracuse
High School building, and Buffalo High School building, and as many
special examinations are ordered as are deemed necessary by the re-
gents, depending upon the exigencies which may arise. At these ex-
aminations the candidates are examined on the subjects of (1) anatomy,
(2) physiology and hygiene, (3) chemistry, (4) surgery, (5) obstetrics, (6)
pathology and diagnosis, and (V) therapeutics, including practice and
materia medica. The candidate is allowed three hours' time in which to
answer ten from among the fifteen questions submitted on each topic ;
each answer, if correct, has a value of ten points, and each full pa-
per of ten questions answered must have a total value in markings
of at least seventy-five points ; otherwise the candidate is rejected.
There are two sessions of three hours daily, each session devoted to one
of the seven topics ; thus three days and a half are requisite for com-
pleting the examination. The candidates are examined according to
number, no name being allowed to appear on the answer papers ; the
name of the candidate is placed in an envelope marked with the corre-
sponding number, is sealed, and left unopened until the final report of
the examiners has been made.
There are three boards of State medical examiners as follows, repre -
senting the —
Medical Society of the State of New York.— William C. Wey, M. D.,
president, physiology and hygiene ; Maurice J. Lewi, M. D., 71 Lan-
caster Street, Albany, secretary, chemistry and materia medica ; William
S. Ely, M. D., anatomy ; George Ryerson Fowler, M. D., surgery ; Will-
iam Warren Potter, M. D., obstetrics; J. P. Creveling, M. D., pathology
and diagnosis ; Eugene Beach, M. D., theory and practice and thera-
peutics.
Homoeopathic Medical Society of the State of New York. — Asa S.
Couch, M. D., president, pathology and diagnosis ; Horace M. Paine,
M. D., 105 State Street, Albany, secretary, anatomy ; A. R. Wright,
M. D., physiology and hygiene ; John McE. Wetmore, M. D., chemistry ;
E. E. Snyder, M. D., surgery ; William S. Searle, M. D., obstetrics ; Jay
W. Sheldon, M. D., therapeutics, practice, and materia medica.
Eclectic Medical Society of the State of New York. — Hugh J. Linn,
M. D., president, obstetrics ; Edwin S. Moore, M. D., Bay Shore, secre-
tary, surgery ; William L. Tuttle, M. D., anatomy ; Robert Hamilton,
M. D., physiology and hygiene ; Harry B. Smith, M. D., chemistry ;
John P. Nolan, M. D., pathology and diagnosis ; John H. Dye, M. D.,
therapeutics, practice, and materia medica.
They are appointed by the regents from nominations submitted by the
State, Honueopathic, and Eclectic Medical Societies, for a term of three
years, for every vacancy two names being submitted by the societies.
The principal work of the examiners is to formulate questions for ex-
amination purposes and to mark the answers thereto. The questions
submitted at each examination are the same for all candidates, except-
ing on the seventh topic (therapeutics, practice, and materia medica),
three sets of questions being furnished at each examination, each set
representing the views of one of the three legally incorporated schools
of medicine in the State on this subject, the candidate receiving the set
for which he had expressed a wish in his original application for license.
The questions to be used at the various examinations are decided upon
as follows, those previously secured in a similar way having become ex-
hausted : The regents issue a notice requesting each of the twenty -one
examiners to forward, on or before a certain date, sixty questions on the
special topic to which each is assigned ; subsequent to this date the
questions board, consisting of six members, two from each board, is
called in session. The questions on the seventh topic are handed to the
two members representing their special board, who, as previously stated,
and as particularly specified in the law, have complete charge of this
subject. With the other six subjects, one hundred and eighty questions
having been submitted in each, the questions board acts as follows,
taking anatomy, for instance : The secretary reads a question alternately
from each of the three papers submitted by the examiners in this topic,
and, unless each receives the unanimous vote of all present, it is stricken
from the list of available questions. The one hundred and eighty ques-
tions, having passed through this process, are arranged in sets of fifteen,
each set is numbered and sealed, and thus at one sitting, lasting, how-
ever, many hours, an average of ten complete sets of questions is pre-
670
MISCELLANY.
[N. Y. Med. Johb.,
pared, thus providing for ten future examinations. These sets of ques-
tions are placed in the custody of the regents, who, as the time for the
next examination approaches, call upon the secretary of the questions
board to review the printer's work after the questions are put up in type.
The examinations proper are conducted by a sworn official of the re-
gents' office, who is not a member of any one of the State boards of
medical examiners. As soon as the examinations are concluded the an-
swer papers are delivered to the secretary of the board selected by the
candidate in his application, and by him in turn sent to the different
individual examiners, who return the papers with their markings to the
board of regents ; these answer papers thereupon become a part of the
public records of the State. If a favorable report is made by all of the
examiners on the answers of any applicant, a license is immediately for-
warded to his address, thus enabling him to register at once and com-
mence the practice of his profession. The last examination was con-
cluded on May 6tb, and on May 14th the licenses were forwarded from
the regents' office to the successful candidates. Arrangements are
now being made for the next examination which will enable the regents
to forward these licenses within five days of the close of the examina-
tions. The income accruing from this law goes to the Board of Re-
gents, who, after paying all proper expenses, will, if ever there should
be a surplus, apportion the money among the twenty-one examiners ac-
cording to the number of candidates examined by each. Graduates in
medicine who have been licensed by State examining boards of other
States of the United States only, on convincing the Board of Regents
that the standard of requirements adopted by the board of examiners
which granted them the license is substantially the same as in New
York State, may, upon the payment of $10, have such license indorsed.
The following summary of the laws has been made :
1. The University of the State of New York is the only organization
having authority to issue licenses to practice medicine in this State after
September 1, 1891.
These licenses must be registered by county clerks on application.
(Laws of New York, 1890, ch. 507, § 8-9.)
2. Licenses issued before September 1, 1891, can be registered only
as follows :
(a) A diploma granting the degree M. D. issued before September 1,
1891, by an incorporated medical college in this State is a license to
practice medicine and must be registered on application. (Laws of New
York, 1889, ch. 647, § 2.)
(b) A diploma granting the degree M. D. from a medical college out
of the State, or a license to practice medicine in some foreign country,
can be registered only if it was indorsed between June 18, 1880, and
June 24, 1890, by an incorporated medical college of the State of New
York or by the University of the State of New York, or, if between
June 24, 1890, and September 1, 1891, it was indorsed by the Univer-
sity of the State of New York. (Laws of New York, 1880, ch. 513,
§ 4 ; 1887, ch. 647, § 2 ; 1890, ch. 500.)
3. Students who had matriculated in a New York State medical col-
lege prior to June 5, 1890, and had not received the degree M. D. prior
to September 1, 1891, to be exempt, must have filed a certificate with
the University of the State of New York before August 4, 1891. (Laws
of New York, 1891, ch. 311.)
Licenses of such candidates may be registered as follows :
(a) A diploma granting the degree M. D. from a New York State
medical college issued after September 1, 1891, can be registered on
presentation of a certificate from the secretary of the University of the
State of New York that the applicant had matriculated in some medical
college of the State prior to June 5, 1890. (Laws of New York, 1891,
ch. 311.)
(b) A diploma granting the degree M. D. from a medical college not
in the State or license to practice in a foreign country, if indorsed by
the University of the State of New York, can be registered on presenta-
tion of a certified copy of a certificate filed w ith the secretary of the
University of the State of New York that the applicant had matriculated
in some medical college of the State prior to June 5, 1890. (Laws of
New York, 1891, ch. 311.)
All diplomas issued by medical colleges in this State prior to Janu-
ary 1, 1880, which are presented for registration after this date should
be referred to the University of the State of New York for examination
before being registered, and further, to quote the exact wording of the
law :
Section 10. Nothing in this act shall be construed to interfere with
or punish commissioned medical olficers serving in the army or navy of
the United States or in the United States marine-hospital service while
so commissioned, or any one while actually serving as a member of the
resident medical staff of any legally incorporated hospital, or any legally
qualified and registered dentist exclusively engaged in practicing the
art of denistry, or interfere with manufacturers of artificial eyes, limbs,
or orthopa.'dical instruments or trusses of any kind from fitting such in-
struments on persons in need thereof ; or any lawfully qualified physi-
cians and surgeons residing in other States or countr ies, meeting regis-
tered physicians and surgeons of this State in consultation, or any
physician or surgeon residing on the border of a neighboring State, and
duly authorized under the laws thereof to practice medicine or surgery
therein, whose practice extends into the limits of this State ; providing
that such practitioners shall not open an office or appoint a place to
meet patients or receive calls within the limits of the State of New
York ; or physicians duly registered in one county of this State, called
to attend isolated cases in another county, but not residing or habitually
practicing therein.
Appended will be found the examination results thus far obtained :
Total number of applicants for license to practice
medicine to date 56
Number of those who fulfilled all requirements and
received license 34
Number of applications still unacted upon 10
Rejected for failure to reach seventy-five per cent, at
final medical examination 1
Deficient in preliminary education 6
Had never attended three full courses of lectures. ... 4
License withheld because of moral reasons 1
56
Addend".
All examinations are conducted in English unless the applicant ex-
presses a desire to be examined in Latin. In that event the applica-
tion, with the reasons therefor, is placed before a committee consisting
of the presidents of the three boards, whose decision is accepted by the
board of regents. The candidate must pay the expenses of translation.
Whenever it is found necessary to obtain the opinion of the boards of
examiners, the university authorities are requested to confer with a sub-
committee of the conference consisting of the president and secretary
of each board, who are the executive committee of the boards. The
boards proper meet twice in each year.
A syllabus is in course of preparation and will be issued shortly. A
candidate having failed, whether in one or all seven branches, his ap-
plication for license is rejected. On re-examination no fee is exacted,
but the candidate must pass the examinations on all seven topics, re-
gardless of the number he passed at the previous examination. Appeal
for a reopening of any examinations may be made to the regents of the
University.
Indications point to a class of from fifteen to twenty applicants at
the next regular examination, June 14, 1892.
By order of the State board of medical examiners representing the
Medical Society of the State of New York.
Maurice J. Lewi, Secretary. William C. Wet, President.
District Nursing in Germany. — The following letter from an oc-
casional correspondent of the British Medical Journal was published in
that journal for May 21st :
Supposing a working man or a member of a family with limited
means, but not exactly paupers, were to fall ill, who would look after
and nurse the patient if his own people were not in a position to do so,
and if the case was not taken to a hospital ? In answer to this ques-
tion, I am happy to be able to point to a pretty considerable number of
extensive and well-organized institutions in the German Empire, all de-
voted more or less exclusively to this duty.
Foremost among these, at least in the Protestant parts of the Father-
land, stand the highly esteemed and meritorious Deaconesses' Homes
June 11, 1892.]
MISCELLANY.
671
(Diakonissen Anstalten). The first institution of this kind was
founded in the very humblest fashion, and under great difficulties and
privations, by the late Theodor Friedner, in Kaiserwerth, on the Rhine,
in the year 1836. From lowly beginnings, however, his work has
spread all over Germany, and even beyond the limits of Europe. At
present most of the chief towns of the empire (Berlin, Hamburg,
Dresden, Karlsruhe, Darmstadt), in all about sixty, contain similar in-
dependent centers of organization in conjunction with a hospital (Mut-
terhauser), from which the sisters are sent out to yield the aid required
in the respective provinces. The number of deaconesses at work in
Germany in 1888, exclusive of those engaged in foreign parts,
amounted in round numbers to 5,000, and is still steadily increasing.
Their duties extend a good deal beyond district nursing. They apply
themselves, if so qualified, to teaching, to taking care of little children
in creches (Krippen), etc. The institution of the last seems to be a
very useful complement to the work of district nursing, the children in-
forming the sisters of cases of sickness in the family, and, on the
other hand, the parents showing much more inclination to send their
children to the preliminary school after having made the acquaintance
of the deaconesses in illness and distress.
The working of all these homes appears to be pretty much the same
everywhere. Reputable females of all stations, not younger than eight-
een and not older than forty years of age, are always admissible to
become members. They are required, first of all, to pass a few weeks on
preliminary trial ; if found fitted, both mentally and bodily, for the
duties of the order, they are received as probationers, and are further
trained for two years or more as may be judged appropriate in each in-
dividual case. Much weight is given to the religious part of the train-
ing, but the practical portion of the education in nursing, as far as my
experience in a number of hospitals goes, is most efficient and thorough.
On entering, a novice is required to bring with her nothing but a
limited supply of clothing, her Bible, hymn-book, and prayer-book, and
a very little readv money in case of need. If received as a probationer
(Probeschwester), she is supplied with the dress of the order, and re-
ceives a small monthly allowance. The number of those who quit the
service, unless compelled to retire from failing health, is very small.
Occasionally a deaconess will resign in order to marry, or on account of
her own people being in need of her aid, but this does not happen very
often.
Although their expenses are comparatively inconsiderable, almost all
these houses are continually in want of pecuniary aid, and their sphere
of work might be vastly extended. Unnecessary outlay is carefully
avoided. Their income is derived chiefly from voluntary contributions,
their capital not being very extensive, and the income gained by
services rendered being proportionately very small, as most of the
work is done entirely gratuitously. In some places the congregation
of the district makes arrangements with the Deaconesses's Home, and
engages one of the sisters to act as nurse of the district (Gemeinde-
pflegerin) by the year, for which the home receives a small remunera-
tion. In other towns, again, there are so-called Krankenvereine— sick-
ness associations— of which the members pay regularly a small sub-
scription toward the funds of the home, which entitles them to free
nursing in case of need. As a rule, however, the sisters thus subsidized
are engaged in attending the poor of the district, so much so that the
money received is far more than fairly earned by the work done.
At some of the homes — for instance, at Wehlheiden-Cassel — ar-
rangements are now made for the purpose of supplying small towns and
villages with trained nurses in the same manner as the state provides
them with trained (and registered) midwives. Any respectable female,
between twenty and forty years of age, chosen by the authorities or by
associations willing to pay the necessary twenty shillings a month to the
home, can be received as a pupil under the same conditions as the pro-
bationers, and having received six months' education in nursing, and
having passed an examination, can return home and begin work as a
certified nurse. Similar dispositions have been made by some of the
Frauenvereine — for instance, in Karlsruhe. In this way even small
villages will be possessed of at least one inhabitant with some idea of
the necessities of a sick-bed and capable of yielding help to the desti-
tute during illness.
A new extension of the deaconesses's work in Berlin was recently
set on foot at the instigation of the Empress, and promises to prove of
great value. It consists in the formation of an extensive series of
deaconesses's stations distributed throughout the laborers' quarters,
each station to contain five sisters, whose sole duty it is to attend to
the sick poor in their own homes. All the mother houses have been
called upon to depute a number of members for the work ; here there
is certainly a wide field of labor, the homes already in activity there,
with thirty sisters engaged especially in district nursing, not being at
all sufficient to meet all the demands. It may be as well to mention
that the homes are often called by different names in the different
towns. Thus, in Berlin there are four houses — the Elizabeth Hospital,
Bethania, Lazarus Hospital, and the Paul Gerhardtstift, all conducted
independently of each other by deaconesses. In Hamburg the home is
also called " Bethania " ; in Wielefeld, " Sarepta " ; in Hanover,
" Henriettenstif t " ; in Darmstadt, " Elizabethhaus," etc. At the head
of each home is a committee composed of influential and well-known —
sometimes royal — persons, while the daily care for the institute de-
volves on the matron (or Oberin). The homes just mentioned are all
in connection with a hospital, except the Paul Gerhardtstift, which
serves chiefly as a place of abode for elderly females who are without
families. Besides the deaconesses, we have also deacons, as at the
fraternity house, Nazareth, near Wielefeld, and at Karlshohe, near
Ludwigsburg, in Wurtemberg ; but their sphere of action extends only
quite exceptionally to district nursing.
Very extensive and useful institutions are the Associations of the
Red Cross, the Prussian Vaterlandischer Frauenverein, which is ex-
tended to some of the non-Prussian German states, then the Bayerischer
Frauenverein in Bavaria, the Badischer Frauenverein in Baden, the
Alice Verein in Hesse-Darmstadt, the Marien Frauenverein in Mecklen-
burg, the Albert Verein in Saxony, the Wohlthatigkeitsverein in
Wurtemberg, and the Frauenverein in Saxe-Weimar-Eisenach. These
seven corporations constitute together the Verband der deutschen
Frauenvereine, the Conjoint Woman's Association of Germany, but
each is conducted and organized quite independently of the others.
They are under the patronage of the Landesmutter — that is, the consort
of the reigning sovereign of the land, and all persons willing to take
part in the work of the association are readily admitted on payment of
an annual subscription of six shillings. In consequence, the number of
the members is very large, and they command a very fair annual in-
come. In conjunction with the Manner Hilfsvereine, Men's Aid Asso-
ciation, their prime object is to supply the necessary means of nursing
the sick and wounded in case of war; but, besides this, they aim at
affording relief of all kinds to the needy both in case of unusual
calamities (floods, fire, famine, etc.), and also in the usual course of
things. These associations are in possession of a large number of hos-
pitals throughout the land, where nurses are educated both for volun-
tary and for paid service. The course of instruction is arranged and
conducted in about the same way as with the deaconesses, and com-
prises periods of novitiate, probation, and qualification. They, too,
have a uniform kind of dress for the sisters, who are especially distin-
guished by the brooch bearing a red cross on a white field. The pe-
cuniary remuneration is a little higher than that of the deaconesses, and,
owing perhaps to this circumstance and to the patronage of royalty,
many ladies are to be found among the sisters. Their labor is chiefly,
indeed, directed to hospital nursing, but district nursing is also largely
attended to. In the latter direction, too, a great deal of good is done
in all the branches by supplying the indigent sick with the necessaries
of life, and often, also, by procuring the necessary funds to sustain a
deaconess for the respective congregations. The Frauenvereine com-
prises both Protestant and Roman Catholic members. Of the Roman
Catholic religious orders a very considerable number are engaged in
nursing, both in hospitals and in the district, anil they are universally
most highly esteemed on account of their eminent qualities in this
respect. They are extremely reticent with regard to their organization,
and a few have, on inquiry, declined to give further information. I
am, therefore, unable to mention details with regard to them. Suffice
it to say that, as in the purely ecclesiastical monasterial orders, a novi-
tiate has to be passed, and that for their training, in consequence of
the numerous hospitals in which these orders are engaged in nursing,
ample opportunities exist. Among the most extensive orders may be
672
MISCELLANY.
[N. Y. Med. Jocb.
mentioned the Sisters of Mercy of the Order of Karl Borromaeus, with
their center in Trebnitz (Silesia) ; the Gray Sisters of the Labor of St.
Elizabeth, originally of Neisse and Breslau, and extended through a
very great part of Germany. Further, we have the Handmaidens of
Christ, of whom about 800 are engaged in district nursing here. Their
center is in Dernbaeh (Xassovia). The Sisters of the Congregation of
the Very Holiest Saint Saviour (Xiederbronn, in Alsatia) number about
1,400, including novices, and are for the greater part solely engaged in
nursing the sick poor. There are also the Sisters of St. Clement (Aix-
la-Chapelle), of St. Coelestine (Cologne), of St. Francis, in Gengenbach
(Baden), and elsewhere ; of St. Vincent de Paul, founded in Metz in
163;;, and widely distributed also in Protestant parts — districts, for ex-
ample, in Wiirtemberg. In some places associations have been formed
among the laity (for instance, in Karlsruhe, in combination with the
Sisters of St. P'rancis in the St. Bemhard House), the members paying a
small annual subscription toward the expenses of the order, and receiv-
ing in case of need gratuitous nursing in the same way as has been de-
scribed w ith regard to the Protestant deaconesses. As a rule, no sisters
of the Catholic orders are permitted to attend in cases of midwifery
unless a fortnight has elapsed since the birth of the child. An excep-
tion to this law are the Sceurs de la Charite Maternelle, established in
Metz, who make it their chief duty to attend poor mothers in child-
bed, and to supply them with the necessary help, and also, if need be,
with nourishment, medicine, and articles of clothing. Among the
monks, some of the Franciscans (Capucins) in various cities also devote
themselves to nursing ; likewise the Brothers of Mercy in Werne,
Montabaur, Straubing, Treves, Breslau, and other places ; and the
Brothers of St. Alexis (Miinster, etc.), but their number is comparatively
limited. In general, it w-ould appear that the number of institutions,
both Catholic and Protestant, founded for the purpose of helping and
nursing the sick poor, is large enough, but by almost all the same la-
ment is made — that they are unable to cope with the ever-increasing
demands made on them both for want of funds and of active members.
^^The Ideal Consultant. — When, says the Lancet, nearly a generation
ago, Sir Henry Acland in a memorable publication introduced the Oxford
Museum to the academic world and foreshadowed the benefits it would
bring to liberal culture as a whole, and more particularly to that of the
physician, he gave a picture of the " ideal consultant " which, if more
comprehensive than detailed, may be said to come as near perfection as
such compendious characterizations are capable of reaching. In a quo-
tation from Suidas he adduced the answer of the consultant Trophilus,
when asked to define the all-accomplished physician : " It is he," said
Trophilus, " who is able to distinguish between what can and what can
not be done." This definition may be said to cover every requisite in
the medical adviser in whatever circumstances the exigences of his call-
ing may place him ; but it does not, of course, enter into native apti-
tudes, or acquired dexterities, or, in short, into the ensemble of qualifica-
tions which combine in the physician who is ever ready and never at
fault. One definition, or rather indication, of what the successful con-
sultant really is was incidentally given some years ago, by an outsider,
in a strictly professional controversy — a definition which embodies the
lay belief in the personal power of the physician apart from what special
discipline can make him. " A great physician," he said, " is a great
artist." This also is true, and will be found on closer analysis to explain
the extraordinary success of practitioners whose book-learning or labora-
tory training is notoriously far inferior to their power in diagnosis and
their success in treatment. The Athenian intellect at its best and in
its most characteristic mood — essentially artistic as it was — seemed to
fulfill the requisites which from time to time attain medical embodiment
in a Sydenham, or, to come within our own day, in a Bamberger, whom,
consensu omnium, each morning's encounter with cases of every kind in
the Vienna wards found seldom or never at a disadvantage. That in-
tellect, in its combination of nimbleness with strength, of centripetal
insight with sense of proportion and judicial balance, has been described
for all time by Thucydides in his wonderful picture of Themistocles.
He dwells on the native understanding of " that Athenian of Atheni-
ans " ; on his power, without previous information or after-thought,
with, indeed, the briefest consideration of the problem in hand, to form
a picture in his mind of what it really implied and of what its solution
would yield — diagnosis, in short, and prognosis, almost improvised as to
readiness ; and again, when the problem admitted of only an approxi-
mate or provisional solution he could — " this way and that dividing the
swift mind " — alight on the better and avoid the worse interpretation,
even in the absence of previous prompting or of the data indispensable
for less artistic minds. The whole passage (Thuc, i, 138) is well worth
pondering in this connection, and will serve to explain how the idea of
an " artist " dominates the popular conception of the consummate phy-
sician— as is, indeed, involved in the German word " Arzt," which Becker
rightly derives from the Low Latin " artista." Noteworthy, too, is the
fact that the intellect here typified is always genial, always repays the
confidence it invites by possessing the patient with the belief that his
malady is indeed of personal interest to his adviser, who considers, and
pronounces, and prescribes as if he were in the other's place. That is
what Celsus means when he talks of the " hilaris vultus " of the ideal
consultant — what Horace implies by the " deformis aegrimonia3 dulcibus
alloquiis." The character thus equipped by nature becomes more and
more developed by experience, till, as statesmen and men of letters, and
indeed the moral and intellectual grandees of every age, combine in at-
testing, humanity appears in no more admirable or lovable form than in
that of the " ideal consultant."
To Contributors and Correspondents. — The attention of all who purpose
favoring us with communications is respectfully called to the follow-
ing :
Authors of articles intended for publication under (lie head of " original
contributions " are respectfully informed that, in accepting such arti-
cles, we always do so with the understanding that the following condi-
tions are to be observed: (1) when a manuscript is sent to this jour-
nal, a similar manuscript or any aljstraci thereof must not be or
have been sent to any oilier periodical, unless we are specially notified
of the fact at the lime the article is sent to us ; (2) excepted articles
are subject to the customary rules of editorial revision, and will be
published as promptly as our other engagements will admit of — we
can not engage to publish an article in any specified issue ; (3) any
conditions which an author wislies complied with must be distinctly
stated in a communication accompanying the manuscript, and no
new conditions can be considered after the manuscript has been put
into the type-setters'1 haiuls. We are often constrained to decline
articles which, although they may be creditable to l/ieir authors, art
not suitable for publication in this journal, either because they are
too long, or are loaded with tabular matter or prolix histories of
cases, or deal with subjects of little interest to the medical profession
at large. We can not enter into any correspondence concerning our
reasons for declining an article.
All letters, whether intended for publication or not, must contain the
writer's name and addrtss, not necessarily for publication. No at-
tention will be paid to anonymous co-mmunications. Hereafter, cor-
respondents asking for information that we are capable of giving,
and that can properly be given in this journal, will be answered by
number, a private communication being previously sent to each cor-
respondent informing him under what number the answer to his note
is to be looked for. All communications not intended for publication
under the author's name are treated as strictly confidential. We can
not give advice to laymen as to particular cases or recommend indi-
vidual practitioners.
Secretaries of medical societies will confer a favor by keeping us in-
formed of the dates of their societies' regular meetings. Brief notifi-
cations of matters that are expected to come up at particular meet-
ings will be inserted when they ate received in time.
Newspapers and other publications containing matter which the person
sending them desires to bring to our notice should be marked. Mem-
bers of the pro fession who send us information of matters of irUerest
to our readers will be considered as doing them and us a favor, and,
if the space at our command admits of it, we shall take pleasure in
inserting the substance of such communications.
All communications bdended for the editor should be addressed to him
in care of the publisliers.
All communications relating to tlie business of the journal should be ad-
dressed to the publishers.
THE NEW YORK MEDICAL JOURNAL, Jtoe 18, 1892.
(Original Communications.
ON THE EARLY DIAGNOSIS AND TREATMENT OF
SEPTIC PERITONITIS*
By HENRY L. ELSNER, M. D.,
PROFESSOR OP CLINICAL MEDICINE, SYRACUSE MEDICAL COLLEGE,
SYRACUSE, N. Y.
While bacteriologists and pathologists have taught us
much with regard to the various inflammatory processes af
fecting the peritonaeum, the clinician has yet much to learn
of the early diagnosis and treatment of septic peritonitis.
While we have been taught by the brilliant achievements
of abdominal surgeons that the peritonaeum is no longer a
noli vie tangere, their experience has established the fact
beyond controversy that septic material is not tolerated by
the peritonaeum. There is no serous surface which revolts
so quickly against the invasion of any agent capable of car-
rying infectious material as the peritonaeum.
In this short introduction, the time for which is neces-
sarily limited, I am to say a few words to you on the sub-
ject of the early diagnosis and treatment of septic peri-
tonitis, and in discussing it I shall confine myself strictly
to those forms of peritoneal inflammation dependent upon
putrefactive and septic agents for their propagation.
This at once involves a question which I see from your
programme you have relegated to another — whether there
exists, in fact, an idiopathic peritonitis. While my views
upon this subject may differ from those of many of you, my
clinical experience has taught me that idiopathic peritonitis
is a disease which is rarely found, and the existence of which
may indeed be doubted. I shall hold, therefore, that much
the larger number of cases of peritonitis which we are called
upon to treat are either septic from the beginning or be-
come so before they have run their course.
This being my opinion, it is hardly necessary for me to
tell you that in all forms of septic peritonitis it is the duty
of the physician to ascertain, if possible, the pathogenic
factor which was the original cause of the septic process.
While Habershon, in over five hundred autopsies, claims to
have found no single case of peritonitis in which he could
not establish the fact that disease existed in some organ be-
sides the peritonaeum, the physician finds in many cases great
difficulty in determining the source, ante mortem, of the sep-
tic process.
When we take into consideration the innumerable sources
from which a septic process may attack the peritonaeum, we
find that there is reason for our repeated failures. It is,
nevertheless, necessary for us to bear in mind the fact that
we are dealing with a secondary process, and it should be
our aim to make a most rigid inspection of all portals
through which the materies morbi may gain entrance, in
conjunction with the most cautious and searching investiga-
tion into the preceding history of the patient, as well as a
careful consideration of each and every symptom present.
* Being part of a discussion before the Onondaga Medical Society
January 28, 18!»2.
The diagnosis of those forms of septic peritonitis which
follow injury to the abdominal wall— surgical operations
either for abdominal diseases, including hernia, disease* of the
genito-urinary tract, or puerperal processes— is easily made.
We have in all of these cases the previous history, which
aids us. Peritoneal symptoms would be more likely to be
due to a septic than to any other process.
Inflammatory diseases in the neighboring organs, which
give rise to peritonitis by contiguity, are not particularly dif-
ficult of diagnosis. The cases which interest us most are
those of perforative peritonitis, which may be either circum-
scribed or diffused, and it appears to me safely considered
to be septic.
It has been my misfortune to see, in the course of my
experience, a number of cases where a septic process fol-
lowed perforation of the stomach wall, either from round
ulcer or from cancer. In these cases there was present the
collapse which followed perforation, the characteristic ap-
pearance of the patient, more or less reaction, and then the
evidence of diffuse peritonitis; all of these cases ended
fatally.
I have also had some experience with septic peritonitis,
both localized and diffused, following perforation of tuber-
culous ulcers of the intestine, in which there was no preced-
ing tuberculous peritonitis.
The diagnosis in such cases is easily made. The preced-
ing history of tuberculosis, with alternating diarrhoea and
constipation, the presence of symptoms of perforation, col-
lapse, without, as a rule, much reaction, following a short
period of septic peritonitis, with rapid death, would be suf-
ficient to warrant the diagnosis.
The most frequent cause of septic peritonitis has been
disease of the vermiform appendix, and it appears that in
this discussion our time can be best spent in considering
the early symptoms of peritonitis which follow the various;
forms of appendicitis.
The literature of this subject has grown amazingly dur-
ing the past ten years, and while many lives have undoubt-
edly been saved as a result of our better understanding of
this subject, there has not been a single article written, to
my knowledge, which can be said to offer positive signs or
symptoms for the detection of septic peritonitis, in cases
where it develops without preceding well-marked symptoms
of vermiform disease in which such disease really pre-
existed.
If this question could be solved— if we could diagnos-
ticate the condition of the vermiform appendix before its
disease makes itself manifest by the sudden development
of either a localized or general peritonitis— much would be
gained.
While we may not profit greatly from a consideration of
the frequency with which the vermiform appendix is found
to be diseased, it is, nevertheless, interesting for us to remem-
ber that the statistics of Matterstock, Toft, and Kraussold
show an amazingly large proportion of diseased appendices.
It is hardly credible that every third person whom we meet
between the ages of twenty and seventy has some trace of
inflammation in the vermiform appendix. Equally surpris-
674
EISNER: DIAGNOSIS AND TREATMENT OF SEPTIC PERITONITIS. [N. Y. Med. Jock.,
ing is the fact that five per cent, of all bodies examined
show evidences of ulceration in the vermiform appendix.
Kraussold maintains that five per cent, is too low a figure.
These statistics, and the result of our own post-mortems,
have been sufficient to arouse in us a desire to explain the
cause of this enormous amount of appendicial disease. If
all diseased appendices were followed by a perforative or
septic peritonitis, that would at once become the most fre-
quent cause of death.
If you will allow me, I will offer an explanation for these
many evidences of appendicial disease. To my mind, there
can be no doubt that there is a latent appendicitis ; that
this latent appendicitis in many cases runs its course with-
out sufficient symptoms to make its existence known ; that
it may remain latent for years ; that there may remain
within the appendix products of inflammation, foreign sub-
stances, and micro-organisms without exciting the least sus-
picion ; that in some cases a slow, chronic, but yet protect-
ive peritonitis of a localized character surrounds the appen-
dix, preparing the way for its perforation, guarding the
general peritonaeum at the same time. In other cases a
latent appendicitis may lead to the changes which are found
in patients who die from other diseases, where the appendi-
citis never gave rise to more than local and unrecognized
disturbance.
That this theory is not without foundation must be ad-
mitted when we consider the frequency of diseased appen-
dices found post mortem and the evidences which we have
all found of a perityphlitic inflammation. Remember,
please, that when I use the term " perityphlitic " it refers
to a process secondary always to appendicial disease.
On the other hand, this theory would account for those
cases in which we have, without warning, a rapidly spread-
ing diffuse and septic peritonitis as the result of perfora-
tion of the appendix. The appendicitis, latent for days or
months, suddenly causes by a fresh catarrhal inflammation
an increase in the contents of the appendix ; either dilates,
its circulation is interfered with, or, by pressure, a localized
spot becomes gangrenous, perforation results, with immedi-
ate septic peritonitis.
This explains still another fact, and that is that the seri-
ous cases of appendicitis are those in which we have the
fewest symptoms of local disease. Those cases of appendi-
citis in which there is tumor formation, well pronounced, are
more likely to have accompanying adhesive inflammation to
guard the general peritonaeum.
Experience has still furthermore established the fact
that a large number of these cases do not come to us for
diagnosis or treatment until the appendix is perforated and
the peritonitis has commenced. The diagnosis of a septic
peritonitis following perforative appendicitis, in which there
has been tumor formation, need not detain us for its con-
sideration. It would be a presumption on my part.
The difficult cases to detect in their incipiency are those
in which there is perforation without preceding tumor, and
it is these cases which we must detect early if we are to reduce
the mortality from appendicitis. A septic peritonitis follow-
ing will run its course rapidly, and with certainty lead to
death unless relieved early.
In these cases we must be guided by both subjective
and objective symptoms. Most of the patients, if closely
questioned, will give a history of preceding indigestion, both
intestinal and gastric. There may or there may not have
been preceding pain in the right inguinal region. As a rule,
there has been no appreciable elevation of temperature.
Suddenly a chilly sensation follows a few hours of pain,
localized over the right inguinal region, rarely a well-defined
chill. The pain may become intense at once, the facial ex-
pression markedly changed, the surface circulation impeded.
The patient now refers all pain to the actual seat of the dis-
ease.
As a rule, we are not even called at this stage. The pa-
tient, imagining that his trouble is a simple colic, postpones
medical attention, but septic peritonitis has nevertheless
commenced. We find the abdominal wall in the region of
the appendix most tense, tender, and possibly slight local-
ized oedema. The abdominal wall in its lower half is every-
where abnormally tense and tender also. The patient al-
ready lies on his back with knees drawn up ; the pulse is at
first tense, but does not remain so long, becoming more
rapid as the disease progresses. The temperature is slightly
elevated, rarely above 102° to 102 *5°. The McBurney point
is 2f valuable aid in the diagnosis of this form of peritonitis
when the patient is seen early.
With the above history and the presence of the McBur-
ney point the diagnosis of a peritonitis following appendi-
citis can be made. Want of time prohibits an enumera-
tion of the many other symptoms, but in these forms of
perforative septic peritonitis, either from perforation of the
vermiform or perforation of other abdominal viscera, we
have in the effacement of liver dullness a very reliable
symptom, when the perforation has not been preceded by
adhesive peritonitis to limit or encapsule the escaping gas
and faeces.
To those of you who have studied the views of the
various writers on this subject it must appear surprising to
find such a wide difference of opinion as to the value of
effacement of liver dullness in cases of perforation or air in
the free peritoneal cavity.
Flint wrote a paper in which he held that this was
one of the most characteristic signs of perforation. The
difference of opinion with regard to the effacement of liver
dullness, it appears to me, can be reconciled if we take into
consideration the two great sources of error. First, an un-
usually distended transverse colon, by its presence between
the liver and abdominal wall, yielding on percussion tym-
pany anteriorly over the area of normal liver dullness with-
out perforation existing.
Second, perforation in those cases where, as the result
of adhesive inflammation, encapsulation, bands, or from
other causes, air or gas is held within a circumscribed area,
or in the lower half of the abdomen, without effacement of
liver dullness. The careful examination of the abdomen
would reveal the presence of these sources of error by
placing the patient upon the left side and percussing in the
axillary line, on the right side over the liver, from the eighth
rib downward, the presence of free air in the peritoneal
cavity showing itself by a disappearance of dullness in that
June 18, 1892.J BARKER: PLACENTAL LOCALLZATION BY ABDOMINAL PALPATION.
675
line, while there would be a persistence of dullness if the
anterior tympany had been caused by the distended trans-
verse colon.
Typhoid ulceration, perforating, may give rise to either
general or circumscribed peritonitis. If adhesive peritoni-
tis precedes perforation sufficient to include the ulcer in a
capsule of fibrinous exudate and adherent intestinal coils,
general peritonitis may not result and liver dullness may
persist. Usually, however, there is more or less septic peri-
tonitis accompanying these rapidly fatal cases.
Recurrent appendicitis has never, in my experience,
given rise to more than localized inflammation. Indeed,
most of these cases are so surrounded by dense bands of
new connective tissue and peritoneal adhesions that the gen-
eral peritonaeum is surely guarded.
I have seen but four cases of recurrent appendicitis.
Three of these recovered perfectly ; one committed suicide
after repeated attacks, the post-mortem showing dense
bands and peritoneal adhesions, the vermiform appendix no
longer recognizable ; a thickened cord of connective tissue
was found over its original seat.
I will not dilate longer on the other early symptoms
of septic peritonitis. It does not appear to me to be neces-
sary to do so before a body of educated physicians. I wish
only to call your attention to the fact that all forms of sep-
tic peritonitis are early in their course associated with ex-
treme prostration, in many cases collapse, and that in all
cases the well-understood physical signs of peritonitis are
present.
We are not to forget those forms of septic peritonitis
in which the disease remains localized owing to preceding
adhesions. Here there is usually tumor formation, and
there may be pus accumulation. In these cases there may
or may not be perforation of a hollow viscus. There is
often, if this localized peritonitis is neglected, breaking
down of the inclosing structure, and a rapidly fatal diffuse
septic peritonitis.
With regard to treatment, the indications are offered
by the process which led to the septic peritonitis. It is
safe to say that this form of peritonitis is rapidly becom-
ing a surgical affection, and in no other disease is concerted
action of physician and surgeon more important or more
necessary. The successful treatment, whether medical or
surgical, must necessarily be instituted early.
The operative treatment of septic peritonitis, I see
from your programme, has been referred to others more
competent to cope with the subject than myself. I wish to
add, however, my disapproval of too hasty operative inter-
ference in cases where there are evidences of protective adhe-
sions, and my hearty approval of early and prompt opera-
tion in cases with or without tumor, but where a tense
abdominal wall, tenderness at the McBurney point, and
evidences of spreading septic peritonitis are present.
The tendency now, since the opium treatment of peri-
tonitis is being more and more slighted, will be to give
salines in all forms of that disease. Inasmuch as the ma-
jority of cases of septic peritonitis are due to perforation
of some one of the hollow viscera, we must warn against
the indiscriminate and careless use of any measure which
will increase the trouble, and prevent by its physiological
action the formation of adhesions or agglutination.
While I do not advocate the opium treatment which was
instituted by the late Alonzo Clark, I, nevertheless, believe
that in many cases a judicious use of morphine hypodermi-
cally materially relieves suffering and adds to the chances of
the patient's recovery. In all cases the extreme exhaustion
and collapse require judicious stimulation and a proper
liquid diet.
In conclusion, I wish to express my belief in the treat-
ment of all forms of septic peritonitis arising in the puer-
peral period by an early and thorough antiseptic cleansing
of the uterine cavity ; if a simple washing out is insuffi-
cient, let us remember that the curette has in a few alarm-
ing cases done yeoman's service.
PLACENTAL LOCALIZATION BY
ABDOMINAL PALPATION.
By T. RIDGWAY BARKER, M. D.,
DEMONSTRATOR OF OBSTETRICS IN
THE MEDICO-CHIRUKGICAL COLLEGE OP PHILADELPHIA ;
OUTDOOR OBSTETRICIAN TO THE PENNSYLVANIA DISPENSARY.
In the scientific study of any subject it is necessary
that we employ scientific means ; otherwise our conclusions
have no foundation in fact, and may be likened to the ob-
servations of the balloonist, whose statements, while they
are perhaps true, lack one essential element — verification.
With this thought uppermost in our minds, we are pre-
pared to investigate the truth of the assertion "that the
placenta can be definitely located by abdominal palpation."
It would appear extremely doubtful, however, if its position
can be determined when situated on the posterior wall of
the uterus, as the intervening tissues, liquor amnii, and
foetus must prove formidable obstacles to the practicing of
palpation with this object in view.
Should the placenta, on the other hand, occupy an ante-
rior position, then the task becomes a comparatively simple
one under favorable circumstances. In cases of placenta
prsevia this somewhat novel method of localization has been
more extensively employed than in any other form, owing
to the great importance of making an early diagnosis, there-
by materially lessening the dangers to both mother and off-
spring.
While the researches of Spencer, of the University Col-
lege Hospital, London, have been conducted with great care
and thoroughness, and have been verified in seven of his
cases by subsequent intra-uterine manual explorations, yet,
withal, other investigators have no such success to report,
though possessing equal skill and knowledge.
Duncan states that he has tried and always failed,
while Galabin agrees with Spencer in a measure, but does
not think localization can be successfully practiced invaria-
bly or as a general rule.
If we turn to Barnes in our dilemma, we find he ex-
presses himself very clearly and unmistakably on this sub-
ject, going so far as to declare that he has " confirmed
Spencer's observations, that when the placenta is situated
in the upper zones and in front of the uterus, the wall is
676
RANNEY: "EYE-STRAIN" AND NERVOUS DERANGEMENTS. [N. Y. Mkd. Jocr.,
thickened and raised above the level of the general smooth
surface of the uterus." This he has confirmed by auscul-
tation. Thus we see several unquestionably accurate ob-
servers of undoubted ability arranged on opposite sides of
the question, occupying what would at first appear irrecon-
cilable positions, but which is not really the case, for their
investigations, it is but fair to assume, were carried on
under radically different conditions. Spencer's cases of
placenta pra>via in which he was able to diagnosticate the
location of the placental site occurred in women with thin
abdominal parietes, which rendered manipulation much
easier and permitted a thorough outlining of the uterus,
while those examined by Duncan were presumably women
with large adipose deposits in the abdominal walls, masking
the contour of the uterus and materially interfering with
the efforts directed toward placental localization. One
could scarcely expect to experience Spencer's sensations
" of an elastic mass, of the consistence of a wetted bath
sponge, which keeps the examining fingers off the head "
in obese pregnant women. Nor could one define the edge
of the placenta, which is described by the same author " as
conforming to the shape of the segment of a circle in which
all is obscure to the touch, while outside the head or other
part of the child is plainly felt."
To accomplish such a delicate procedure it is absolutely
necessary that the abdominal walls shall be thin and the
uterus not unduly distended by amniotic fluid. That such
localization may be effected under favorable circumstances
in a certain percentage of cases there appears to be no
doubt.
One is scarcely prepared, however, to rely implicitly
upon this method, since mistakes have already been made,
and the knife carried through the placenta in the perform-
ance of a Caesarean section when the placenta was supposed
to be at some distant point from the line of incision. The
existence of a placenta succenturiata should also be borne in
mind in this connection. If we employ this method when
about to perform an abdominal section for the release of
the imprisoned foetus, we should not fail to take the addi
tional precautions laid down by Leopold, of Dresden, with
reference to determining the site of the placenta after
making the abdominal incision, in order to avoid including
this vascular structure in the uterine wound.
The diagnosis as to the anterior or posterior insertion
of the placenta may be made out by the following relations
of the oviducts to the fundus of the uterus : " When the
major portion of the uterus is anterior to the insertion of
the tubes, the placenta is anterior, and vice versa.''''
Thus we have a definite rule for diagnosticating the
situation of the placenta, which is less likely to mislead the
operator than that by abdominal palpation.
To sum up, then, the value of abdominal palpation in
locating the displaced placenta, one is justified in consider-
ing it an additional means of verifying the existence of pla-
centa prajvia ; and, while characterized by clearly defined
physical signs, it can only be practiced satisfactorily when
the abdominal walls are thin and the uterus is not unduly
distended by liquor amnii.
In Caesarean section, or one of its modifications, we
ought not to rely upon this procedure alone, but should
deem it necessary to re-enforce our opinion by observing
the situation of the uterus with reference to the Falloppian
tubes as laid down by Leopold.
SOME PREVALENT ERRORS RELATING TO
" EYE-STHAIN "
AS A CAUSE OF NERVOUS DERANGEMENTS.
1177-// ILLUSTRATIVE CASES.
Bt AMBROSE L. RANNEY, A. M., M. D.
(Concluded from page 656.)
Case VI. Complete Nervous Prostration (of over Eive Tears1
Duration) with Constant Pain in the Head. Inability to use
the Eyes, and to walk but a Few Steps. — Miss F., aged twenty-
one years.
Family History. — Maternal aunt and five paternal relatives
died of phthisis; two cousins had chronic chorea.
Eye Defects. — Patient had hyperopia (latent) of ] '26 D. and
exophoria (manifest) of 2°. A |latent hyperphoria of 2° was
subsequently discovered.
History of the Case. — This young lady was brought into my
office (September 29, 1886) by two assistants, who were obliged
to carry her from the carriage. For several years she had been
carried daily from her room to the lihrary of her father's house,
and, after reclining in ja chair for a few hours, she would be
again carried to her bedroom. She could manage with difficulty
to walk slowly across a room. She had not been able to write,
read, sew, or see her most intimate friends for five years on ac-
count of a constant pain in her head, which was rendered in-
tolerable by any use of the eyes or excitement. Her symptoms
began while at boarding school, from which she was removed
to her home in a recumbent posture and by easy stages.
Treatment and Results. — I used static electricity upon this
patient for some weeks with, a slight improvement in her power
of walking, but no relief to her head.
I then persuaded her to consent to a relief (by graduated
tenotomies) of her abnormal eye-tension. Tenotomies were then
performed upon her left superior rectus and both externi w ithin
the space of two weeks. From that date her improvement was
very rapid. She was sent home a few weeks later practically
cured.
A letter from her physician, received by me, says :
"Your patient is the wonder of this region. She rivals the
'Jersey Lily ' in her feats of walking."
Before this patient was sent home she ascended and de-
scended five flights of stairs daily, and averaged over a mile's
walk each day without a companion to assist her.
The last report from this case was made about one year ago
when the patient called to say that she " was engaged in teach-,
ing physical culture in a ladies' school." The improvement
gained by eye treatment has therefore been demonstrated to be
not only permanent, but progressive.
Case VII. Complete Nervous Prostration (of Sixteen Years'1
Duration), with Terrible Attacks of Neuralgia of the Stomach
and Persistent Trembling of the]Head. Face, and Limbs. — Mrs.
G., aged forty-two.
Family History. — Several blood-relatives^died of phthisis;
father and brother died of phthisis.
Eye Defects. — The patient was found to be emmetropic (when
under atropine). Esophoria (manifest) of 3° existed.
History of the Case. — This is quite as striking a case as the
June 18, 1892.]
RANNEY: "EYE-STRAIN" AND NERVOUS DERANGEMENTS.
677
one last narrated, although of a different character. The patient
had been for sixteen years a chronic invalid. She was unable
to bear the least excitement. Even the companionship of her
family for an evening was at times too great a strain upon her
nervous system. She was at times a great sufferer from severe
paroxysms of neuralgia of the stomach, and frequent attacks of
alarming shortness of breath and a sense of impending suffoca-
tion would occur. I personally witnessed one of these attacks
in my office, and it was entirely free from a trace even of
hysteria. It was of much shorter duration than an asthmatic
attack, and seemed to be due to a spasm of the larynx. She
became markedly cyanotic, and suffered alarming shortness of
breath.
In addition to these symptoms, this patient suffered from an
uncontrollable trembling of the facial muscles and limbs when
at all startled or excited. She had been for years unable to
attend places of amusement or to bear physical exertion.
Treatment and Results. — Much to my surprise (as she had a
marked phthisical history), an examination of her eyes showed
I no refractive error (even when under the influence of atropine).
She showed, however, a very high degree of esophoria, and a
partial tenotomy was performed upon both of her interni. The
effect was magical. She recovered her health completely with-
in two months, and is to-day able to endure as much as when a
young girl. One of the last reports from her, some time ago,
states that she had " shopped all day and attended the theatre in
the evening." An old friend of the family lately alluded to the
case, in my presence, as one "not of cure, but of resurrection."
Five years have now elapsed since this patient was relieved
of her "eye-strain." During this period no return of her old
symptoms has occurred ; nor has she had to resort to drugs or
doctors for relief of any physical ailment.
Case VIII. Nervous Prostration, with Symjitoms of Melan-
cholia, Confirmed Sleeplessness, Confusion of Mind, and Con-
stant Headache. — Miss B., aged forty, single.
Family History. — One sister was for over a year a victim to
" complete nervous prostration." Father is a very nervous
man.
Eye Defects. — Vision f-j}, without atropine. Under atropine,
a latent hypermetropia of + 0-75 s. in each eye. Patient had
never used a glass for reading, but accepted + 1-50 spherical
glass. Esophoria, 3° (which ultimately, under influence of
prismatic glasses, exceeded 7°). Adduction, 23°. Abduction,
5°. E. sursumduction, 1° + . Left sursumduction, 2°. The
adducting power later on exceeded 43°, and the abducting
power fell below 3°. At no time did homonymous diplopia dis-
close itself (with or without a red glass).
History of the Case. — This lady had for some years been doing
an excessive amount of mental work. Her profession required
an enormous amount of reading. This had been done largely
at night. Although small in stature, she had always been vigor-
ous and had taken an unusual amount of exercise. She had
always considered her eyes very strong, and was loath to believe,
when she first came under my care, that her eyes could consti-
tute a factor in her serious nervous condition. Furthermore,
she was strengthened in this belief by the fact that she had not
long before consulted an oculist of prominence, who had stated
that he found no defect requiring treatment or glasses, and who
had sent her to one of his friends (a specialist in nervous dis-
eases) for treatment.
The "break-down in her health" began about twelve
months before she came under my care. It was attended with
an extreme and persistent loss of sleep, a loss of emotional con-
trol, an utter inability to read or sew (which aggravated all her
symptoms), a more or less constant headache, an inability to
concentrate her intellectual faculties for any length of time, and
an aggravated type of mental depression. She feared, and had
every apparent reason to fear, that her professional labors were
imperiled and that her mind might possibly give way. The
neurologist, who endeavored to build her up by tonics, rigid
diet, rest, etc., assured her (after some improvement had oc-
curred) that he feared at first that "melancholia" might be the
end of the case. At his advice, she spent the summer at the
sea-shore; but, beyond a certain point, she failed to progress
satisfactorily, and her headache and sleeplessness would at
times be as bad as ever. Any attempt to prepare herself for
her fall engagements would cause a return of her old symp-
toms to a very marked degree, accompanied by physical weak-
ness, mental fatigue and depression, extreme despondency, and
a lack of control over her emotions. After any attempts at
study, she would frequently lie awake most of the night. This
was her condition when she first came under my care.
Treatment and Results. — In this case a full correction of the
hypermetropia was made for distance, and + 2,00 spherical
glasses were given for reading, as she showed some failure of
accommodation. Prisms of various strengths were employed
over her distance and reading glasses for about two weeks, and
7° of latent esophoria were found to exist. This was rectified
by a graduated tenotomy of one internus and the prisms were
then discontinued. During this interval the patient had im-
proved very rapidly, had become very dependent upon ber
spherical glasses, and become cheerful and hopeful of recovery.
She had, moreover, entirely regained the normal power of
sleep. During this interval she had frequently slept twelve
hours without awakening and without recourse to any drug.
As atropine had been used during the early part of the treat-
ment, she had been allowed during the two weeks of treatment
to use her eyes very little in reading or study. During the fol-
lowing two weeks two degrees more of latent esophoria dis-
closed itself. For the relief of this defect a prism was com-
bined with the spherical glass worn over the eye which had not
been subjected to a tenotomy.
For the past twenty months this patient has been able to fill
all her engagements without any return of her bad symptoms.
She has read and studied at night, attended church and places
of amusement that previously she dared not attend, has accepted
more work than for some years past, and has continued to sleep
well and enjoy perfect health. During this interval she has
taken no medicine, nor has she been restricted by me in her
diet or in any other way. Her reading-glasses have been in-
creased to + 2*50 s.
A graduated tenotomy of the internus of both eyes was
eventually performed, in order to properly adjust the balance
between the two eyes, and the right superior rectus was also sub-
jected to a graduated tenotomy for a right hyperphoria that dis-
closed itself.
During one of her last visits this patient said : " I think I
am stronger to-day and have better health than I have bad for
many years. I certainly do my work with less fatigue, and en-
joy things that my ill-health has previously debarred me from."
In a letter received a few months ago this patient says:
" I can out-eat, out-sleep, and out-walk any woman in this
place."
Just as this article is going to press, the sad news of this
patient's death reaches me. A relapse of her nervous symp-
toms occurred a few days before her death, after a very
severe winter of persistent labor attended also with great
care and much worry and anxiety. Moreover, an inquiry
into the causes of this relapse discloses the fact that she had
disobeyed my instructions and discarded her spherical glasses
678
RANNEY: "EYE-STRAIN" AND NERVOUS DERANGEMENTS. [N. Y. Med. Joue.,
for distance after her health had been apparently restored ;
that she had even read for hours daily without her reading-
glasses ; and that she had seriously overtaxed her mind and
physical strength in many ways.
Case IX. Melancholia with Morbid Impulses, associated with
Great Mental Confusion and Distress and an Obstinate Neuralgic
Affection of the Prostate Gland. — Mr. S., aged twenty-three,
unmarried.
Family History. — The mother of the patient suffers from
neuralgia and headache. The paternal grandfather had paraly-
sis. The paternal grandmother was "extremely delicate." One
brother suffers from headaches. Another brother is very ex-
citable and of a highly nervous temperament. No case of con-
sumption has ever occurred in any branch of the family.
Eye Defects. — Hyperopia (latent) of 2-50 D. Esophoria (mani-
fest) 4°. Subsequently, 12° were elicited prior to any operative
procedure.
History of the Case. — This patient bad been under medical
care for many months for a prostatic neuralgia, and had derived
no benefit from local or general treatment. He developed melan-
cholia, and would frequently retrace his steps for several blocks,
during a stroll, in order to touch some object which he felt he
should have touched when he passed it. The use of his eyes
intensified his mental symptoms markedly. He also suffered
from morbid fears. He had never had venereal disease.
Treatment and Results. — After partial tenotomies were per-
formed upon his interni, and his hypermetropia was corrected
by + 1-50 spherical glasses, his recovery was very rapid and com-
plete. He has had no abnormal mental symptoms or neuralgia
of his prostate since the first operation (now nearly six years).
His father, one brother, and a sister have since been examined
by me, and all had very marked eye defect.
In some respects this is one of the most remarkable cases I
have yet observed. The mental condition of the patient, prior
to the relief of eye tension, was such as to justify the worst fore-
bodings. Neither he nor his family had ever suspected any eye
defect in spite of the fact that his " latent " hyperopia was of a
very high degree (nearly 3 D.), and his " latent " esophoria was
of an equally high degree. His prostatic neuralgia was of a
severe and intractable type, and its cause could not be discov-
ered ; yet it disappeared at once after a free operation upon the
interni.
The change in the mental condition of this patient after the
relief of his eye-strain manifested itself at once in his desire to
assume active employment. He immediately turned his atten-
tion to his profession (that of art), in which he soon gained an
enviable fame.
Case X. Nervous Prostration, combined with Sleeplessness,
Pain in the Head, Mental Confusion, Car-sickness, etc. — Mr.
H., aged forty-six, manufacturer, married.
Family History. — Both parents lived to seventy-six years.
Two paternal uncles died of phthisis. No hereditary tendency
to nervous diseases.
Eye Defects. — Vision § £, without atropine. Under atropine
a latent hypermetropia of + l-00 s. in each eye. Patient had
never used a glass for reading. Esophoria, 5° (after using pris-
matic glasses for a short time, the patient showed esophoria of
13°). Adduction, 24°. Abduction, 4° + . Later on, the adduc-
tion exceeded 50°, and the abduction fell to 0. Homonymous
diplopia with the red glass over one eye was usually present,
and at times without the red glass.
History of the Case. — This patient had been a perfectly well
man and had carried on a very large business up to fifteen years
ago. At this time, while attending a sale in New York, he was
suddenly seized with a dizziness, faintness, and a sore feeling in
his head. These symptoms lasted for three years in spite of all
treatment, during which time he suffered severely from sleep-
lessness, extreme nervousness, and soreness in his head. He
was unable to look out of a car window while traveling without
great distress.
He had suffered all his life from obstinate constipation, and
had taken cathartics so regularly that now any cathartic water
causes intestinal haemorrhage.
When this patient first came to me he was able, by the most
careful diet, regular habits, and by retiring at eight or nine
o'clock, to carry on his enormous business only with the great-
est difficulty because of the following symptoms : Inability to
sleep at night, which at times was very distressing and persist-
ent; extreme nervousness after the slightest fatigue; mental
depression without any cause; hot flashes up and down his
spine ; pain in his shoulders and across his back. His insomnia
was often prolonged and very exhausting after any slight excite-
ment or fatigue.
Treatment and Results. — The treatment of this patient con-
sisted at first of the wearing of prisms to relieve the esophoria,
and later on of graduated tenotomies on both internal recti.
Subsequently, + 0-50 s. glasses were given for constant wear,
and + 1*00 s. glasses for near work. The improvement in his
condition was marked and continuous from the first, and he
writes that he is so busy and feeling so well that he can not find
time to have the slight remaining esophoria corrected. An ex-
tract from a letter received from him two months after the op-
eration on his eyes speaks for itself. He says: "Seemingly I
am all right, feeling better every day ; have not had a headache
for a month; appetite good and I sleep well." Over two years
have now elapsed without any return of his former ill health,
during which time he has constantly been engaged in active
business pursuits.
Case XL Complete Nervous Prostration, with One Year of
Confinement in Bed and Chronic Bladder Trouble. — Mrs. W.,
aged fifty-five, married.
Family History. — Not taken.
Eye Defects. — Hypermetropia, + 1*75 s. Presbyopia (uses
-f 4-50 s. for reading). Esophoria, 7°. Adduction, 23°. Ab-
duction, 3" +. Later on she disclosed : Right hyperphoria, 3°;
right sursumduction, G° + ; left sursumduction, 2° — .
History of the Case. — This patient is the wife of a prominent
physician, and, as such, has had the benefit of the best medicaj
talent of the State in which she resides. She had always been
a delicate woman up to the time when my professional opinion
of the case was asked. For a year or more before I first saw
her she had been a victim to nervous prostration and confined
most of the time to her bed or room. Her life had been de-
spaired of during this interval at times, and the case seemed to
present problems in diagnosis which puzzled the best medical
men whom she had consulted. When she had gained sufficient
strength to allow of her being moved with safety, her husband
was advised to take her to a Southern climate. On her way to
Florida he was advised to consult me in reference to the case,
when he passed through New York.
When 1 first saw this patient she was in a state of extreme
physical and mental depression, was unable to walk for even
short distances without great fatigue, was sleepless and despond-
ent, and was brought to my office in a carriage from a hotel not
far from my residence.
Treatment ami Results. — At the first visit prisms were given
to relieve the esophoria, and in five days a graduated tenotomy
was done on one internal rectus. The patient began to feel the
benefit of this step from the first. The second day after the
tenotomy she reported that she had walked a mile and a half —
a thing which she had not done for over a year. Five days after
June 18, 1892.]
RANNEY: " EYESTRAIN" AND NERVOUS DERANGEMENTS.
679
the first tenotomy, a second one was performed on the other in-
ternal rectus, prisms having been worn in the mean time. Two
days following this the patient walked five miles, visited an art
museum in the morning, and attended a theatre in the evening.
In spite of the unusual fatigue and excitement, she was still sleep-
ing well and feeling stronger than for many years. With the
improvement of her general health came an entire cessation of
an obstinate bladder trouble which had given her annoyance for
many years, and was probably due to her weak muscular and
nervous condition. The pain in the bladder, which was proba-
bly of the neuralgic type, ceased after the relief of the eye ten-
sion, and has never returned.
After an interval of four months, during which she had been
comparatively well, she returned to New York to complete her
treatment. A high degree of hyperphoria was found, and prisms
were combined with her hypermetropic glasses to relieve it.
With these glasses the patient passed eight months of almost
absolute freedom from distress of any kind, when a graduated
tenotomy was performed and the hyperphoria prisms removed.
At the present time she is sleeping well, is able to attend to
her household duties, can walk long distances, has taken no
medicine for over a year, and is regarded by her husband and
friends as restored to perfect health.
Case XII. Facial Neuralgia, so Severe as to prompt Suicide
and Uncontrollable by Drugs. — Mr. L., aged twenty-three, sin-
gle, minister of the Gospel.
Family History. — Father has severe headaches ; one sister
has severe headaches ; all paternal relatives have headache or
neuralgia.
Eye Defects. — Hypermetropia (under atropine), + 2-00 s.
Esophoria, 6°. Adduction, 28°. Abduction, 2°. Right sursum-
duction, 2°. Left sursumduccion, 2°.
The hypermetropia and most of the esophoria were latent.
History of the Case. — The patient began to have neuralgia ten
years ago, and for the past five years the attacks have become
more frequent and severe. They generally start in the left orbit
and extend to both orbits, and at times are frightfully severe.
They occur at intervals varying from six hard ones a year (each
with four or five days of agony) to one every two or three weeks.
He has comparatively slight headaches very often. Any exces-
sive use of eyes or overwork brings on a neuralgic attack. He
has suffered with quite constant pain in the back, and has had
some asthenopic symptoms, smarting of eyeballs, pain after
reading, etc. No drug has ever seemed to control these symp-
toms, and he was sent to me by his physician for advice. He
came during one of his severe paroxysms of neuralgia, which
had lasted for three or four days, in spite of all that his physi-
cian could do. Although hypodermic injections of morphine
had been used every night, the pain returned with increased
severity in the morning. So intense was his agony that he de-
clared something must be done at once, as he feared that he
could not restrain much longer his suicidal tendency.
Treatment and Results. — Tests were made upon his eyes as
accurately as possible under the circumstances, and atropine was
dropped into his eyes at once to determine his hypermetropia.
He was told to protect his eyes from the light by a pair of dark
glasses and return in two hours. He came in smiling at the
appointed time, saying that his neuralgia had entirely disap-
peared. Two dioptres of hypermetropia was found, and a
+ l-00s. glass was given for constant wear. Later graduated
tenotomies were done upon both internal recti for the relief of
the esophoria, and a stronger glass (+2-00s.) was given for
reading. Since then he has had no attack of neuralgia, and has
been perfectly well for two years. He occasionally, after severe
eye work, has some slight symptoms of his old asthenopia.
Case XIII. Nervous Prostration, with Digestive Disturb-
ances and Great Physical Weakness. — Mrs. W., aged forty, mar-
ried, three children.
Family History. — Father died of softening of the brain ;
mother died of phthisis ; one sister died of cirrhotic kidney and
urremic convulsions.
Eye Defects. — Hypermetropia, +1*50 (under atropine).
Esophoria. 4°. Adduction, 45°. Abduction, 4°. Eight sursum
duction, 2°. Left sursumduction, 2°.
History of the Case. — This patient had always been delicate,
and had suffered some during her girlhood from sick headache
and weak digestive functions. Six years previous to the examina-
tion of her eyes made by me, she had suffered from an attack of
nervous prostration, with extreme physical weakness. At this
time she was treated for several months by a prominent gynaecolo-
gist for uterine trouble without very marked improvement in her
general health. She was then placed under the care of Profes-
sor Weir Mitchell, of Philadelphia, and remained several months
in his hospital undergoing the " rest treatment." For about a
year her physical condition seemed to be very much improved ;
but at the end of that time her old symptoms returned in a very
marked degree. She was then treated by static electricity for
a period of several weeks without any very marked benefit.
The administration of drugs and stimulants seemed to exert lit-
tle if any control over her debilitated state.
At my suggestion, she consented to submit to a tenotomy for
an esophoria of not very high degree.
Treatment and Results. — A graduated tenotomy was per-
formed upon the left internus with very satisfactory results
upon her eye tests. Within a month she had almost entirely
regained her former vigor, and could walk several miles with-
out fatigue. During the past five years she has suffered no re-
lapse, and, in an interview lately held with her, she stated '"that
she had but little use for doctors, who formerly were constant
visitors in her household."
Cask XIV. Nervous Prostration, accompanied by an abnor-
mally Large Pupil in One Eye, Insomnia, and Extreme Physi-
cal Weakness. — Mrs. J., aged forty-five, married. Has had
three children.
Family History— Not taken.
Eye Defects. — Hypermetropia and astigmatism of + ToO s.
3 + O'SO C. in each eye (under atropine). Right hyperphoria,
i°. Esophoria, 0 — 1°. Adduction, 21°. Abduction, 8°. Right
sursumduction, 2° +. Left sursumduction, 2°.
History of the Case. — For many years patient has been a
delicate woman, becoming easily fatigued, and suffering more or
less after fatigue from insomnia and extreme nervous debility.
For the past ten or twelve years one pupil has been very much
dilated. She had consulted an oculist of prominence in Mont-
real concerning this condition, but his treatment failed to give
any permanent benefit. During the past twelve months the
insomnia and nervous prostration had become very much in-
tensified, and the patient had become so weak physically as to
alarm her family. Any attempts at walking, attending places
of amusement, or making ordinary social visits were follow ed
by a marked increase in the symptoms. Her husband, a promi-
nent physician, feared a complete physical collapse. One pupil
was found to be more than double the size of the other.
Treatment and Results. — The treatment consisted of a full
correction of the hypermetropia and astigmatism for distance
by glasses, which the patient was instructed to wear constantly.
Under these conditions her muscular tests seemed to be modified
favorably. The patient was instructed to return home and to
return for further observation after wearing the glasses for a
couple of months. Even before her return there had been a
marked improvement in her symptoms. Two weeks after her
'return the following report was made by her husband: "My
680
RANNEY: "EYE-STRAIN" AND NERVOUS DERANGEMENTS. |N. Y. Mel.. Jo
wife appears much better and more cheerful than for many
years, the pupils are of equal size, appetite good, and the in-
somnia much relieved; is able to walk two miles without fa-
tigue and enjoys the exercise, goes out evenings, and feels no
unusual fatigue from lectures, concerts, and sermons." A re-
port one month later says: "My wife appears to enjoy life as
she has not done for many years. There has been a very slight
return of her old enemy insomnia, but not to an alarming ex-
tent. She hopes to see you again in the near future."
In this case sufficient opportunity has not yet been afforded
for a complete examination of the eye muscles. It is possible
that there may be some lurking defect of equilibrium in addi-
tion to the error of focus. One thing, however, appears to be
clearly established — i. e., that her ill health and insomnia were
directly dependent upon a condition of the eyes that had ex-
hausted her vital forces and was keeping her in a state of ex-
treme physical depression.
Case XV. Aggravated Type of Chronic Chorea, accompa-
nied by Deformity, Headache, Asthenopia, and Inability to
Work. — Miss C, aged twenty-six, single.
Family History. — Not known.
Eye Defects. — Hypermetropia, 4- l>75. Esophoria, 20° (most-
ly latent). Left hyperphoria, 3°. Adduction, 22°. Abduc-
tion, 5°. Right sursumduction, 2°. Left sursumduction, 5°.
History of the Case. — The patient was a poor factory girl that
was sent to me by a medical friend (Dr. O'C.) in Massachusetts
to see if anything could be done for her. No one who had seen
her could make a diagnosis. Since her tenth year she had suf-
fered with neuralgic headaches, asthenopia, and persistent
trembling in her hands and arms. For the past four years
there has been a stiffness and rigidity of the neck, accompanied
by severe pain in the neck and "choking spells" when she at-
tempts to speak or when excited. There is also marked con-
tracture of the hands and arms.
Her appearance when she came to me was one of remark-
able deformity. Her chin seemed to be held firmly in the
region of the fourth button of her dress. Both upper limbs
wrere contractured in the state of semiflexion at elbows, wrists,
and fingers, and trembled excessively when she tried to use
them. They could not be extended, nor could the patient
make use of the hands. She had been obliged to give up
work on that account. Whenever she talked her face became
painfully drawn and distorted. The mouth would especially
be drawn downward. Under the least excitement she would be
seized with what she called "choking spells." The throat
muscles would contract and interfere seriously with respiration.
She had constant headache, chiefly in the forehead and occiput,
and a per.-istent pain in the neck. No painful points existed,
nor did pressure, movement, or other tests reveal the existence
of organic disease of the spinal cord. Sensibility to touch,
pain, and temperature was normal, Motility was unimpaired.
The muscular sense was perfect. No inco-ordination existed.
I considered the case one of aggravated chorea, complicated by
headache and asthenopia.
Treatment and Results. — The muscular anomalies were
satisfactorily relieved by graduated tenotomies of both internal
recti and the left superior rectus. Applications of static sparks
were made daily for about two months. The patient had by
this time regained the use of both hands, carried her head
erect, had no headaches, and little spinal pain. For a while
she returned to work. The effect of hard labor brought back
her "choking spells" ; hence she was advised to take a year of
absolute rest. She now has some asthenopia remaining and an
occasional headache. Her facial contortions persist to a slight
extent when she is unduly excited. I suspect that some latent
hyperphoria exists still, and that further operative work on
the eye muscles will be demanded before the patient recovers
completely.
Case XVI. Constant Headache for Sixteen Years, associated
with Nervous Prostration that kept her in Bed for Five Months.
— Mrs. A., wife of a physician, aged thirty-three. Has had two
children.
Family History. — Mother has headache. One sister has
headache. Two sisters have poor eyes. One paternal aunt died
of phthisis.
Eye Defects. — At the first examination the patient showed
the following condition : 0. D. + 0-50 s. C + 0*50 c. axis, 90°.
O. S. + 0*50 s. Right hyperphoria, 2°. Exophoria, Ad-
duction, 37°. Abduction, 10°. Right sursumduction, 8°. Left
sursumduction, 4°. Later, under atropine, the refractive condi-
tion was slightly modified — i. e., O. D. + L00 s. 3 + 0'75 c-
axis, 115°. O. S. + 1-50 s.
Glasses were ordered for constant wear as follows : O. D.
+ 0-50 s. C + 0 75 c. axis, 115. O. S. 4- L00 s.
After wearing the glasses for three days there was no appar-
ent muscular defect, the hyperphoria having disappeared. Ad-
duction, 39°. Abduction, 8°. Right sursumduction, 6°. Left
sursumduction, 5°. No hyperphoria. No exophoria.
History of the Case. — The patient began to have headache at
seventeen years of age. About eight years ago she began to
have more severe headache, which now has become constant,
with exacerbations about every two weeks and also during men,
struation. About five years ago she picked out a pair of glasses
(+ 0-50 s.) for herself which helped her somewhat at first. She
had been under the care of a prominent gynaecologist for retro-
version, but without improvement in her headache. The pain
is in the left temporal region, running both backward and for-
ward. For five months she was confined to her bed with head-
ache, and her husband (a physician) thought she had organic
trouble. She has tried all drugs, electricity, etc., without
benefit.
For years she has only been able to walk short distances with
the aid of her husband's arm.
Treatment and Results. — The treatment consisted simply in
ordering the glasses for constant wear to correct her error of
focus.
The result of wearing the glasses was almost magical. Within
a week she reported that she had walked four miles, was up till
2 a. m. at an entertainment, and had had no headache ; that she
felt better than for nine years.
In a letter received from her husband three months later, he
says : " I am very glad to say to you that Mrs. A. has improved
very much physically and mentally since yon fitted her with
glasses. She has not had a particle of the old headache, with
but one exception. The time I speak of was at her menstrual
epoch, and then but%light and only for a short time."
Case XVII. Chronic Chorea followed by a Loss of Power in
both Legs and the Right Arm. — Miss S., female, aged ten. A
large child for her age.
Family History. — Mother is perfectly well. Father has had
some eye trouble. One cousin on maternal side had epilepsy.
One maternal aunt has nervous prostration. Paternal grand-
mother has nervous prostration. Considerable phthisis in the
father's family.
Eye Defects. — Latent hypermetropia, 4- L00 s. Esophoria,
8°. Adduction, 38°. Abduction, 2°. Right sursumduction, 2*.
Left sursumduction, 2°.
History of the Case. — The patient has had several severe
sicknesses from acute diseases.
Eight months ago it was noticed that she could not keep her
hands still and was constantly knocking thiDgs over. This kept
growing worse until, six weeks before she came to me, she lost
June 18, 1892.] RANNEY : "EYE-STRAIN" AND NERVOUS DERANGEMENTS.
681
all use of the right hand. Her ankles, which had been weak for
some time, turned over so badly that she occasionally fell down.
At times her speech was badly affected, and her words often ran
together so as to be almost unintelligible. When she reads, the
letters blur badly and her eyes become very much inflamed. Her
eyes had troubled her for some time before any choreic symp-
toms were noticed. One eminent neurologist of this city had
seen the patient and pronounced the case as one of organic brain
disease.
Treatment and Results. — The treatment consisted in giving
2° of prism, base out, over each eye for constant wear, and later
in graduated tenotomies of both internal recti.
The improvement in the choreic symptoms began almost as
soon as the prisms were put on. At the end of the first week
her mother reported that she could dress herself much better
than formerly; that her right hand rested quietly in her own
when walking, whereas it used to be impossible to hold it on
account of the twitching. She also began to use her right hand
for the first time to denote the position of candles while being
tested.
The patient now, four months after treatment was begun,
writes and sews with her right hand, walks perfectly well,
without turning of the ankles, and has no choreic symptoms
whatever. The power in her right arm has been fully re-
gained. The parents state that " she is as well as she ever
was," and express the greatest gratitude because of her restora-
tion to health.
Case XVIII. Constant Headache, suspected to be a Symp-
tom of Tubercular Meningitis. — Miss B., female, aged ten; a
large child for her age.
Family History. — Father and mother both had headaches
when young. Several cases of phthisis on maternal side. Pa-
tient has three sisters and one brother, all healthy.
Eye Defects. — At the first examination the patient showed a
myopic astigmatism (— 0-75 c. axis 180°) in both eyes. Later,
under atropine, there was found hypermetropia (-f 0-75 s.)
and hypermetropic astigmatism (+ 0-75 c, axis 90°) in both
eyes.
Her muscular condition, with her refraction corrected, was :
Esophoria, 2*; no hyperphoria ; adduction, 36°; abduction, 7°;
right sursumduction, 2° ; left sursumduction, 2°. One eye shows
a decided tendency toward convergent squint.
History of Case. — In August, 1890, this little patient began
to suffer with severe headache, which soon became almost con-
stant. She was treated for malaria and other diseases by drugs,
but with no improvement in her head. She was taken by the
family physician to two prominent oculists in this city for ex-
amination, and both prescribed astigmatic glasses, which gave
slight but temporary relief. As the headache again returned
with great severity, the glasses were taken off* by one of the
oculists, and her mother was told by him " that the child proba-
bly had tubercular meningitis."
When she was brought to me the headache was almost con-
stant, and so severe at times that she could neither eat nor sleep,
and was steadily losing in weight. Three years ago she had a
fall on her head, and had slight evidence of cerebral concussion.
She has suffered with severe nose-bleed, especially when her
headache is severe.
Treatment and Results. — Almost a full correction of her re-
fractive error was given for constant wear — /. e., + 0-50s. 3 +
0-75 c, axis 00° ; and one degree of prism, base out, was added
over each eye to correct the esophoria.
The patient reports that slio has only had one slight head-
ache since she put on the glasses four months ago. Her mother
says that she "has never seen her child so exuberant in spirits,
and she has never been so well since sho was first taken ill in
August, 1890. She has no pain, her appetite is good, and she
is perfectly well."
The clinical history and treatment of the preceding
cases have been given with as full detail as a brochure
will admit of ; yet I have deemed it wise also to tabu-
late the more important points in order that the reader
may be able to contrast them and note the details of each
case.
If by the histories of these cases the fact is not estab-
lished beyond cavil that " eye-strain " was a cause of the
symptoms reported, and that its correction brought about a
marked amelioration of the symptoms (if not a cure), then
I shall lose faith in the value of evidence to medical minds
in a scientific medical inquiry.
Personally, as a neurologist, I meet in my office (as do
others in the same field) two types of cases :
(a) Those who have organic brain or spinal-cord dis-
eases, and to whom little hope of eventual recovery can be
honestly extended. Rest from care, massage, electrical
treatment, diet, exercise, and drugs may prolong life and
decrease suffering in these cases ; but nothing can restore
to them perfect health, because destructive processes in the
nerve-structures have permanently impaired some part of
the nervous mechanism.
(6) The second type of cases encountered comprises
those whose sufferings may be equally acute (if not more
so) as those of the former class ; but in whom no positive
evidence of organic disease can be discovered by any step
known to medical science.
Among the latter class we meet hundreds where we en-
counter one of the former. We are appealed to by the
victims of chronic or periodical headaches, neuralgias,
sleeplessness, nervous prostration (with its endless variety
of symptoms), St. Vitus's dance, some cases of epilepsy,
and many of deranged mental functions, for relief that
drugs, electricity, massage, etc., have failed to give.
It is absurd for any one to argue that in such cases as
those reported in this brochure the recognized therapeutical
agents have probably been injudiciously administered by
physicians in attendance ; or that, on the other hand, the
existence of some organic disease must account for the per-
sistency of the symptoms. It is begging the question for
any medical man to assert that organic disease exists sim-
ply because drugs fail to arrest symptoms.
Case No. I, repoited in this article, demonstrates most
positively, I think, that the most serious prognosis was ap-
parently justified by the symptoms ; yet they were in
this case arrested at once through a simple surgical step.
How many more cases of a similar character may exist
to-day with the exciting cause unrecognized }. How many
may have gone to their graves with the cause undeter-
mined ?
So it is, only perhaps to a somewhat less startling de-
gree, with other cases reported in this paper. They .ill
point with the strongest emphasis to the importance of /«-
vestigating the eyes and eye muscles of every patient with
chronic f unctional nervous affections.
Some of these cases had been examined by oculists who
failed to detect the eye defects that existed ; hence it is fair
682
RANNEY: "EYE-STRAIN" AND NERVOUS DERANGEMENTS.
[ N. Y. Med. Jovb.,
to presume that the latest methods of examination for de- In bringing this broehure to a close, I would advance
fective equilibrium in the eye muscles were not employed the following conclusions as demonstrated by the facts here
by the oculists in question. reported.
Sex.
Male.
Male.
Symptoms
Duration.
Former
treatment.
Previous
diagnoses.
41
Male.
Male.
Male.
Female
Complete mental
and physical
collapse.
Insomnia.
Severe neuralgic
attacks.
19 EpilepB] .
Epileptic niania.
43
Epilepsy.
35| Epilepsy
Epilepsy.
An approach to
mental imbecility
from bromides."
Complete nervous
prostration.
Constant pain
in head.
Inability to walk.
Female. 42
8 Female. 42
10
1 year.
6 months.
SO years.
n years.
2 years.
24 years.
Unknown.
6 years.
Since
bromides
were begun.
Nervous
prostration.
Trembling of
face and limbs.
Neuralgic attacks
of a violent form.
5 years.
5 years.
5 years.
10 years.
8 years.
16 years.
Great
1 year.
despondency.
Confusion of
1 year.
mind and thought.
Loss of
1 year.
emotional control.
Confirmed
1 year.
sleeplessness.
Constant
1 year.
headache.
Male.
Male.
10
Melancholia.
Morbid impulses.
Severe neuralgia
(of bladder and
prostate gland).
Nervous
prostration.
Sleeplessness.
Pain in head.
1 year.
1 year.
8 months.
IS years.
15 years.
15 years.
Medicinal,
massage,
water
treatment,
electricity,
diet, etc.
Enormous
doses of
bromides,
with chloral,
arsenic, und
other drugs,
without
any relief.
Enormous
doses of bro-
mides for
many years
without bene-
fit, cerebral
galvanism,
massage.
Unknown.
Bromides in
very large
doses, causing
serious men-
tal sluggish-
ness and
apathy.
Electricity,
massage,
drugs of all
kinds.
Electricity,
massage,
drugs of all
kinds,
uterine
treatment.
Had consulted
an oculist
who " found
nothing
wrong in the
eyes."' Had
been under
care of a spe-
cialist who
prescribed
drugs, elec-
tricity, and
restricted
diet, with only
partial and
temporary
benefit. Had
never used
glasses, even
for reading
or sewing.
Tliis patient
had been
treated for
months by a
specialist for
prostatic dis-
ease. He had
also taken
drugs of all
kinds for his
mental
condition.
This patient
had been un-
der constant
medical care.
' Drugs gave
no benefits
or relief.
! Organic cere-
bral softening
(by several
,'physicians)
EYE TESTS.
Refractive errors.
Muscular
errors.
Eye
treatment.
Results.
Epileptic
mania (papers
were drawn
to commit the
patient to an
asylum as an
incurable).
Epilepsy
(from early
masturbation
and later
sexual
excesses).
Epilepsy.
Epilepsy.
This patient
had seen
many physi-
cians of emi-
nence and
none had dis-
agreed on the
diagnosis.
Organic
Bpinal and
brain disease
(by several
phyaicans).
Organic dis-
ease had been
strongly sus-
pected. This
patient had
employed
physicians by
the score and
had received
no benefits
from drugs.
Organic
brain disease
had been
suspected.
One physician
' ' feared the
approach of
melancholia."
Undoubted
symptoms of
insanity had
appeared at
times.
U I +0 50 8.
u- +0 75 c, ax. 00*
n „ I +125 s.
s- I +0 50 c, ax. 90'
Hypermetropia.
Astigmatism.
No defect in either eye,
even when under full
effects of atropine.
Hypermetropia.
O. S. f M s-
(Entirely latent, and
therefore unsuspected
by the patient.)
O. D.-
O. S.
4-1-50 s.
-2 75c,ax.l80'
J +l-50s.
i — 2 75 c, ax. 180'
Hypermetropia.
Astigmatism.
O. D. +0-50 a, ax. SO
n a j +4 00c.,ax.lR0'
°" I -100 c, ax. 90'
Hypermetropia.
Astigmatism.
O. D. + l-25s.
O. S. 4-1-25 s.
Hypermetropia.
Emmetropia.
(No defect, even under
atropine.)
Hvpermetropia.
O. D.+0-75S.
O. S. 4-0-75 s.
(Under atropine.)
Presbyopia.
Spherical glasses
(+2-50) tolerated well
for reading, sewing,
etc
Cerebral
congestion.
Organic
brain disease
had been
suspected.
Cerebral
congestion.
Excessive
business
aires.
Left
hyperphoria,
4'.
Esophoria,
Esophoria
(mostly
latent).
Right
hyperphoria
(entirely
latent at
first visit).
Esophoria
(mostly
latent).
Esophoria.
4".
Esophoria,
11°.
Left
hyperphoria,
2'.
Esophoria,
2\
Esophoria,
3\
(A much
higher degree
of latent
esophoria
disclosed
itself laten.
Esophoria.
7".
Right
hyperphoria.
Spherical and
( cylindrical
glasses. Grad-
uated tenoto-
my of left sup.
rectus. Grad-
uated tenoto-
my of right
internal rectus
Wearing of
prismatic
glasses. Grad-
uated tenoto-
| my of right
sup. rectus.
Graduated
tenotomy of
each internus.
Full correc-
tion of the hy-
permetropia
by spherical
glasses. Grad-
uated tenoto-
mies upon
both interni.
Spherical
and
cylindrical
glasses only.
Correction
by spherical
and cylindri-
cal glasses.
Graduated
tenotomies
upon both
interni.
Spherical
glasses. Grad-
uated tenoto-
mies upon
both externi
and left supe-
rior rectus.
Graduated
tenotomies
upon both
interni.
Spherical
glasses for
distance.
Strong read-
ing glasses.
Graduated
tenotomies
upon both
intend and
right superior
rectus
muscle.
Hypermetropia.
O. D. 4-2 50 s.
O. S. 42-50 s.
(Entirely latent and on
suspected by patient.)
Hypermetropic.
O. D. 4-1-00 s.
O. S. 4-1-00 e.
Esophoria,
12V
Esophoria,
18*.
Spherical
glasses for
constant
wear.
Graduated
tenotomies
upon both
inteini.
Graduated
tenotomies
upon both
interni.
A practical cure. Patient still
has some headache, but has
entirely regained his mind and
is able to resume control of
his finances. The insomnia
and neuralgia have ceased.
One attack during past two
years. Patient has taken no
drugs for nearly four years,
and has entirely regained his
mental and physical strength.
Both had been seriously af-
fected by the bromides in the
past.
An apparent cure. Patient
taken no drugs and has had
no seizures for nearly six
years.
An apparent cure. Patient has
not had a fit since April, 18»0.
Patient has not had a fit for
eighteen months. Has taken
no drugs. Has regained his
intellect and gone into busi-
ness pursuits. Travels with-
out an attendant and weighs
eighteen pounds more than
when eye treatment was be-
gun.
Patient is now teaching gym-
nastics in a ladies' school.
This patient had never suspect-
ed any eye trouble ; but made
a perfect recovery within a
month after the last tenotomy
was performed. Five years
have elapsed without a return
of a single symptom. For
over sixteen years she had
been a hopeless invalid.
This patient was enabled to re
sume her profeasion, and was
restored to health without the
use of drugs until within a
week of her death. The full
history of thia case U of spe-
cial interest.
Complete cure. The patient is
restored to mental and physi-
cal health, and has resumed
his profession. AH neuralgic
attacks have ceased for past
five vears.
Complete recovery- During the
past tw o years this patient has
had no return of his former
symptoms.
June 18, 1892.]
BANNEY: "EYE-STRAIN" AND NEB \ 0 US DERANGEMENTS.
683
12
14
16
18
m Symptom*.
\<
Female. 45 Complete nervous
prostration,
Chronic
bladder trouble.
Chronic
sleeplessness.
Male.
Duration.
33
Female. 10
Female.
Female
Female.
1.-)
26
Chronic
neuralgia.
Asthenopia.
Headaches.
Nervous
prostration.
Confirmed
digestive troubles.
Inability to walk
or endure fatigue.
Nervous
prostration.
Abnormally large
pupil in one eye.
Confirmed
sleeplessness.
Chronic chorea.
Aggravated
deformity of
head and limbs.
Headache.
Asthenopia.
3.3
Female
Female
Constant
headache.
Nervous
prostration.
10 Chronic chorea.
Loss of power in
right arm and
both legs.
Constant
headache
(very severe).
Steady decrease
in weight.
1 year.
5 years.
1 year.
10 years.
5 year*,
in years.
6 years.
Most of
her life.
0 vears.
Several
years.
12 years.
1 year.
16 years.
4 years.
16 years.
16 years.
16 years.
5 months.
8 months.
6 weeks.
14 months.
14 months.
Former
treatment.
Patient had
been confined
in bed for
about one
year from
nervous col-
lapse. Drugs
of all kinds
had been
administered
without per-
manent bene-
fit Uterine
treatment had
accomplished
nothing.
Drugs of all
kinds without
beneficial
results.
Patient had
contemplated
suicide.
Uterine
treatment for
years. Drugs
of all kinds.
" Pest cure "
(for 3 consecu-
tive months).
Electricity
for month's.
Massage.
Had taken
drugs of all
kinds. Had
consulted a
prominent
oculist with-
out benefit.
The wife of a
prominent
medical
lecturer and
practitioner.
This patient
had been seen
by many phy-
sicians. Drugs
and electricity
had accom-
plished noth-
ing.
Has been
under uterine
treatment
without relief.
Has taken
drugs, elec-
tricity, mas-
sage, etc.,
withoutben'fit
Drugs of all
kinds.
EYE TESTS.
Previous
diagnoses.
Some
obscure form
of abdominal
disease had
been sus-
pected by the
many phy-
sicians who
had seen her
in consulta-
tion.
Some local
disease was
suspected as
the exciting
cause of the
neuralgic
paroxysms.
The uterine
trouble was
always sup-
posed to be
the chief
cause of the
physical
weakness.
The diag-
nosis in tiiis
case had
been very
obscure to
all that had
been called
to examine
this patient
Organic
spinal
disease had
been
suspected.
Organic
disease had
been
suspected.
Drugs. Rest
from school.
Country air.
Had been ex-
amined by two
noted oculists.
Organic brain
disease (by an
eminent
neurologist
of New York)
One oculist
told the par-
ents that the
"child proba-
bly had
tubercular
meningitis."
Refractive errors.
Muscular
errors.
Hvpermetropia.
O. D. + 1-75.
O. S. + 175.
Presbyopia.
+ 4-50 s. needed for
reading or sewing.
Hypennetropia.
O. S. 1 +~ u" s-
Hypermetropia.
O;^; [+1-50 8.
Hypermetropia.
Astigmatism.
O. D. + 1-50S.O
+ 0-50 c, ax. 75°
O. S. + 1-30 8.C
+0 50 c, ax. 105°
Hvpermetropia.
O. D. ( ^n.„e .
O. S. f +0 75
Hypermetropia.
Astigmatism.
0 D J +1-00 8.
u. u. { +0-75c.,ax.ll5'
O. S. +1-50 8.
Hypermetropia.
O. D.
Right
hyperphoria,
3°.
Esnphoria.
Esophoria.
Esophoria.
4°.
0. S.
+ 1-00 8.
Apparent
orthophoria.
Hypermetropia.
Astigmatism.
O. D:+0-75 s.
O. S.+0 75C, ax. (XT
Esophoria,
20°
(mostly
iatent).
Left
hyperphoria,
3".
Orthophoria.
Esophoria,
8*.
Esophoria.
Eye
treatment.
Results.
Spherical
glasses for
distance, and
stronger ones
for reading
or sewing.
Graduated
tenotomies
upon both
internal recti
and the
right superior
rectus
muscle.
Spherical
glasses for
distance, and
stronger ones
for reading.
Graduated
tenotomies
upon both
internal recti
muscles.
Spherical
glasses for
reading,
sewing, etc.
Graduated
tenotomy
upon the
left internal
rectus
muscle.
Spherical
and
cylindrical
glasses for
constant
wear were
alone
prescribed.
Graduated
tenotomies
upon both
intern! and
left superior
rectus
muscle.
Spherical
and
cylindrical
glasses to
fully correct
all latent
errors of
refraction.
Graduated
tenotomies
upon both
interni. Pris-
matic glasses
for some
months prior
to tenotomies.
Cylindrical
and spherical
glasses, com-
bined with
prisms for the
esophoria.
This patient has been able to
walk for miles and to take full
charge of her house since the
tenotomies were performed
(two years and a half ago).
She has taken no drugs,
sleeps well, and is apparently
restored to perfect health.
Complete cure. (No neuralgia
for past two years.)
Complete cure for past six
years. This patient can walk
for miles, and her digestive
functions are perfect.
A very rapid recovery of
strength, and a return of the
pupils to equal size. Almost
complete relief of the in-
somnia.
Relief of the deformity of the
head and neck, and marked
amelioration of the other
symptoms. The patient- was
enabled to return to her for-
mer position, and has since
been self-supporting.
Rapid and complete cure. The
patient walked four miles in
less than a week. No return
of headache for past two
years.
Complete restoration of power
to the limbs, and disappear-
ance of all choreic move-
ments.
Immediate cessation of all head-
ache, that has not since re-
turned. This patient is now
perfectly well.
Conclusions.
1. " Eye-strain " may be said to exist whenever errors of
refraction or a maladjustment of the tendons that move the
eyeballs in unison with each other can be demonstrated. The
extent and type of the errors found modify in each indi-
vidual the relative amount of this strain and its probable
significance as a factor in influencing the physical state.
2. The determination of refraction without the use of
atropine is unscientific, and usually unreliable as a matter of
record.
3. The variety and extent of errors of adjustment of the
ocular tendons can not be positively determined without a
phorometer and the judicious use of prisms. Neither is one
test, or even a series of tests, necessarily conclusive in some
complex ocular problems.
4. The tests for the detection of maladjustment of
ocular tendons are of little or no value until the errors of re-
fraction are detected and rectified by proper glasses — accu-
rately centered to the pupils.
5. The methods employed in public institutions (to save
time and trouble) of determining refraction by an ophthal-
moscope are unreliable and unscientific. JavaVs instrument
is a better one ; but even this instrument ought to be used
with a pupil widely dilated with atropine, and its results
confirmed by other tests commonly employed to detect
astigmatism.'
684
CRANDALL: MANAGEMENT OF THE NEW-BORN INFANT. [N. Y. Med. Joub.,
6. The condemnation of any method by those who have
not perfected themselves by personal practice with its de-
tails has no bearing upon a scientific inquiry.
7. The conditions that cause eye-strain (see conclusion
l) are usually congenital ; hence they are seldom the result
of any debilitated physical state.
8. " Eye-strain " is a frequent cause and perhaps the most
important of all factors that tend to produce functional
nervous diseases. This is demonstrated, I think, quite
clearly by the cases reported, which embrace examples of
most of the functional nervous affections in an aggravated
form.
9. Statistics drawn from the records of public charita-
ble institutions, where large numbers of patients are ex-
amined, are of little or no value in this particular inquiry.
The tests and records are usually made in such institutions
with haste and without proper regard to the methods that
should be employed to make them more than approximately
reliable. It is almost impossible to do accurate work under
these conditions. Few public institutions possess the neces-
sary apparatus, or use it if they have it.
10. I have yet to encounter a case where typical sick-
headaches occur that is not associated with " eye-strain."
Latent hypermetropia exists to a marked degree in most sub-
jects that are so afflicted, and esophoria is also frequently
present.
11. The table which accompanies this article shows at a
glance (what, in my experience, is the rule) that esophoria,
hyperphoria, and hypermetropia are the most common abnor-
mal eye conditions encountered in cases of neuralgia, head-
ache, epilepsy, chorea, insanity, nervous prostration, and
other severe types of chronic nervous disturbances. Exo-
phoria and myopia are far less frequently encountered among
these subjects.
12. Hypermetropia is much less frequently corrected
among sufferers than myopia, although it is by far the more
important eye defect in nervous diseases. The condition of
hypermetropia may exist to a very high degree and be
totally unsuspected by the patient. It may even be unde-
tected by an oculist until atropine is employed to fully di-
late the pupil and arrest the action of the focusing muscle
(ciliary action).
13. A typical 11 cross-eye," although a deformity, is not,
as a rule, the cause of serious nervous disturbance. These
subjects have habitual " double vision " in consequence of
their eye defect ; hence, since no effort on the part of the
patient can result in the fusion of the images of the two
eyes, the patient learns early to suppress one visual image
and to use only one eye at a time for visual purposes. For
that reason, " eye-strain " is practically absent in extremely
" cross-eyed " subjects.
14. Respecting the relationship of chorea to anomalies of
the visual apparatus, I would draw the following conclu-
sions :
a. Choreic subjects belong to one of two classes: (1)
Those who tend to get well under almost any treatment or
even without treatment, and (2) those who fail to get relief
from any medicinal aid. The latter tend to run a chronic
course, usually one of unfavorable progression."
b. The chronic form of chorea is one of the most seri-
ous and hopeless of nervous maladies. It is not infre-
quently associated with epilepsy or with mental impair-
ment. . •
c. Both forms of chorea are based, as a rule, upon a well-
marked neuropathic or tubercular predisposition.
d. The pathology of chorea is not known. No one has
ever proved that it was a " constitutional disease," in the
sense that an organic lesion was essential to its develop-
ment.
15. The accurate fitting of frames to the face of each pa-
tient is a factor too often overlooked in attempts to relieve
" eye-strain." A glass not accurately centered to the pupil
may cause great distress, and frames that allow the axis of
either glass to be tilted so that they sit at an angle before
one or both eyes cause a strain in themselves, as the glasses
then act like prisms before the eyes.
I have seen many instances where serious nervous dis-
turbances have been modified almost immediately by simply
changing the frames of the glasses that the patient had pre-
viously worn.
156 Madison Avenue.
MANAGEMENT OF THE NEW-BORN INFANT*
By FLOYD M. CRANDALL, M. D.,
NEW YORK.
The subject of this paper, lying as it does on the border-
line between two departments of medicine — obstetrics and
paediatrics — has, as a natural result, received very inadequate
attention. Most works on diseases of children contain no
reference whatever to the management of the healthy new-
born infant, and but slight attention is given to the numer-
ous ailments and disorders of the first two weeks of life.
Works on obstetrics, while they contain numerous scattered
references to the infant, are chiefly concerned with the
mother and rarely give connected instructions upon the im-
portant matters pertaining to the child. It is a frequent
complaint that mothers and nurses follow the physician's
directions regarding medicine, but pay no heed to his in-
structions concerning diet and the details of management.
This is usually the doctor's own fault, for while he gives
definite orders regarding treatment, his instructions regard-
ing management are vague and indefinite, chiefly because
his ideas are vague and indefinite. Clear-cut and definite
directions upon any subject will usually be followed faith-
fully, especially if written.
As my professional experience has been to a consider-
able degree in these two departments, my attention has
been frequently called to the improper treatment which the
infant frequently receives. I bave ventured to present it
to-night, therefore, not because there is anything new or
remarkable to offer, but because it is a subject of interest
to the general practitioner which is seldom discussed in a
connected and compact manner. It has seemed almost im-
possible for writers who have attempted the subject to
* Read before the Society of the Alumni of Bellevue Hospital, Feb-
ruary 3, 1892.
June IS, \H92.\
CR AND ALL: MANAGEMENT OF THE NEW-BORN INFANT
685
confine themselves to their text. In an article upon the
new-born infant, recently published in a series of mono-
graphs, the writer passes from tying the cord to dentition,
both temporary and permanent. This paper is restricted
to conditions arising during the first fifteen or twenty days
of life.
During the progress of labor the interests of the child
are to be considered in various ways. General discussion
on the use of the forceps is not within the province of this
paper. To the child I am convinced that they are less
dangerous than ergot. Ergot babies are blue babies, and
the more the ergot the bluer the baby. A physician, living
in a locality where public opinion is intolerant of instru-
ments, who has had considerable experience with ergot,
recently expressed to me very strongly the same opinion.
From a study of a considerable number of birth-palsies 1
have been led to the belief that forceps are a less potent
factor in their production than prolonged and tedious
labor. There seems to me little room for doubt that in-
struments in the hands of a reasonably judicious man are
less dangerous to the child than the continued compression
of the head attendant upon labor prolonged in the second
stage, or a prolonged first stage, when the waters have
broken.
The vaginal douche before delivery is also a matter of
importance as regards the child. With ordinary precau-
tions it can do no harm, and may save much trouble. A
vaginal discharge, even when apparently simple, may be
the cause of ophthalmia, and is sometimes the source of
serious general septic infection of the child. The douche
should certainly not be omitted when the slightest purulent
discharge is present, and should be repeated at intervals
sufficiently short to insure cleanliness of the parturient
canal.
Asphyxia may be the result of premature separation of
the placenta, certain morbid conditions of the mother,
weakness of the child sufficient to prevent respiratory action
and expansion of the lungs, or obstruction of the respiratory
passages by some foreign substance, but the most common
cause is doubtless long-continued compression of the head.
When not due to actual organic lesion of the brain it ap-
pears under two general forms. In one the head is blue
and turgid, the face puffed and swollen, the lips are livid,
while the body is of a lighter hue. The heart may usually
be heard beating, and sometimes can be felt by the hand,
the rate being usually slow. Under these conditions the
possibility of resuscitation is good. If, on the other hand,
the surface is pale and shrunken, the limbs flaccid, and the
muscles without tone, the prognosis is bad, and whatever is
done must be done quickly. Fortunately, the infant toler-
ates the condition of cyanosis better than the adult, proba-
bly from the comparatively low grade of oxidation to which
the blood has been accustomed. As long as cardiac pulsa-
tions can be detected by auscultation, efforts at resuscitation
should not be abandoned. If the child fails to breathe, the
throat should be cleared of mucus by the finger, when one
or two slaps upon the back or a sprinkling of cold water
are usually sufficient to induce respiratory movements. If
this fails, the application of alcohol or whisky to the chest
may prove efficacious. If the child still fails to breathe, in-
flation of the chest by means of a catheter passed through
the glottis is often effectual, and for this purpose the Mer-
cier catheter, with its peculiar elbow, is admirably adapted.
We are told that attempts to force air into the lungs with-
out elevation of the epiglottis are futile. Practically, I
have had better results by forcibly blowing into the mouth
of the child, a thin handkerchief being spread over the lips
and the nostrils being compressed, than by Sylvester's
method of artificial respiration. Perhaps the air all goes
into the stomach, but I certainly know that I have seen
respiratory movements induced by the procedure. As I
have thrown the head well back, the oesophagus may have
been sufficiently compressed between the vertebrae and
larynx to prevent the entrance of air into the stomach.
The child is apt to be so relaxed and flabby that little or
no expansion of the chest is gained by Sylvester's method.
Marked results sometimes follow the alternate dipping of
the child into hot and cold water, as described by Playfair.
It is a great mistake to allow the child to lie unprotected
from cold. If it is evident that prolonged efforts are to be
required, the child should be placed in a bath of warm water
and not removed until respiration is established. This
maintenance of the vital heat, it seems to me, is a matter
of the utmost importance.
I have recently in a single case had a satisfactory result
by the method of inflation described last year by Dr. For-
rest. The child is placed in hot water and the head is
thrown backward so as to throw the vertebra of the neck
forward. The hands are drawn up and pressed against the
sides. This compresses the oesophagus between the larynx
and vertebra}, and at the same time the mouth opens. The
physician then strongly blows into the mouth of the child.
The head is then thrown forward and the arms are brought
down to the side so as to compress the air from the lungs.
The point of importance is the compression of the oesopha-
gus, preventing the entrance of air into the stomach.
Under normal conditions, when the child is born the eyes
should receive the first attention. They should be carefully
washed with a boric-acid solution before the cord is tied.
I have never abandoned the old Emergency Hospital prac-
tice in this regard, and have never regretted the slight
trouble it costs. It is very easy to order a saturated solu-
tion of boric acid, or to carry a little powder from which a
solution may be quickly made. It is placed in a cup with
a small, soft handkerchief, or a few squares of cloth ready
for use.
I now rarely use nitrate of silver. According to Credo's
method, a drop of a two-per-cent. solution (ten grains to
the ounce) is placed in each eye. The reaction is often
severe and, as a routine practice, seems to me entirely un-
necessary. In case of purulent vaginal discharge it should
invariably be employed, but, as a rule, thorough use of the
boric solution is sufficient. The satisfaction of having no
ophthalmia to deal with would repay much more trouble
than these simple measures cost. The necessity for prompt
action when ophthalmia is present, and the method of treat-
ment by silver, cold, and perfect c leanliness, is too well
known to require comment.
686
CRANDALL : MANAGEMENT OF THE NEW-BORN INFANT. [N. Y. Med. Jock.,
While there is no necessity for undue haste in tying the
cord, it is best to do so as soon as the eyes have been
bathed. I have tried different lengths and have found a
cord of about an inch and a half most satisfactory. I have
also tried various forms of dressing, and have found noth-
ing more satisfactory than the time-honored square of soft
cloth cut in the center. Charred cloth, although recently
commended by a high authority, in this day of antiseptics
is a relic of barbarism. Cotton is better than linen, and
should be rendered antiseptic by being soaked in a subli-
mate solution and dried. As the fluid of the cord exudes
rapidly dining the first few days, the dressing becomes
damp, and should be changed every day. There is no need
whatever of odor about the cord, and there will be none if
it is kept clean and dry with powder, which for tins inn-
pose should contain salicylic acid. It will leave a better
navel surface and will fall quicker, the average time being
about the fifth day. The scar should be healed by the
tenth day. With wet dressings, falling of the cord is usu-
ally later. The same is true with oily dressings, which
some prefer. They are less cleanly and permit more odor.
The scar should be kept clean, and be dressed with the
same powder. If a so-called umbilical polypus forms, it
should be removed by means of a tight ligature. Smaller
masses of granulation should be cut down with nitrate of
silver and dressed antiseptically. The antiseptic care of
the umbilicus can not be too strongly insisted upon. Sim-
ple moist antiseptic dressings or, still better, antiseptic pow-
ders are preferable to ointments.
The various diseases at and about the umbilicus are ex-
tremely rare when proper antiseptic treatment has been
carried out. They require active surgical treatment and are
beyond the scope of this paper. Tetanus neonatorum, now
known to be of microbic origin, is, happily, a rare disease
in this city, and will probably never occur under strict anti-
septic management of the umbilicus and of abrasions upon
the child's body.
The radical changes which take place at birth should
not be forgotten. The child is suddenly transferred from
an unvarying temperature of 100° F., where surface evapo-
ration is impossible, to a varying temperature twenty de-
grees to foity degrees lower, where evaporation from sur-
face and lungs is constant, and where it must rely wholly
upon heat generated within its own body. It is wonderful
that such a change is as well tolerated as it is. We should
certainly do nothing to reduce the vital forces, and should
take every precaution for preserving the vital heat. The
child should be removed from exposure as soon as possible
and wrapped in a warm flannel blanket.
It is best not to put the baby into the bath-tub at first.
The vernix caseosa is soluble in fat, which should be em-
ployed for its removal. An animal oil is best, and every
nurse will tell you that lard removes it more readily than
any other substance. After thoroughly anointing every
portion of the body, especially the folds and creases, the
oil should be wiped away with a soft towel, a sponge, with
a little warm water and soap, being used in places. On the
following day, when the child has become more accustomed
to its new surroundings, a more thorough bath may be
given, but it is best not to use the tub until the cord has
fallen.
Absolute cleanliness throughout the whole period of in-
fancy is of the most vital importance to the well-being of
the child. The daily bath should be omitted only for the
most serious reasons. The use of powder is a necessity,
but is often overdone, the nurse depending upon it rather
than upon care in drying the surface. Some powders are
irritating and cause eruptions. Rice powder does nicely;
starch is often improperly prepared ; lycopodiuin is all that
some skins will bear, and it may be advantageously added
to most powders. If there is excoriation, two per cent, of
salicylic acid or five per cent, of boric acid may be added.
Salicylic acid is especially adapted to such use, and in some
conditions, as for the cord, may be employed in the
strength of twenty per cent, to eighty per cent, of starch.
For ordinary purposes the compound talcum powder has
been the most satisfactory preparation I have used.
The napkins should be changed as soon as soiled, even
if it is every hour, and the child should not only be dried,
but washed with water. Some nurses dry the napkins and
use again without washing. Erythema is almost certain to
follow such practice. In treating this disorder, it is best
to question upon these points, and also as to the method of
washing the napkins. If washed with strong soda or harsh
soaps, without thorough rinsing, they will irritate the skin
when wet and prolong the disorder, which is at best rebel-
lious to treatment.
The parts should be very gently washed with water and
perhaps a little borax, but no soap. If mild, a dusting
powder containing salicylic acid or oxide of zinc may be
used. If there is excoriation or much discharge, the pow-
der may form into little masses and irritate. On the whole,
I have obtained the best results from an oily preparation,
which may not only be curative, but protects from dis-
charges. The following, proposed by Fox, has been very
satisfactory : R, Acidi salicylici, gr. x ; bismuthi subnitra-
tis, 3 ij ; corn starch, 3 jss. ; ung. aq. rosaj, ad § j. M.
In some cases boric acid, or zinc oxide, in ointment with
resorcin, seems to be more efficacious.
Before the child is dressed it should be inspected by
the physician, and any birth mark or abnormity had better
be reported to the father or some friend. Nurses are in-
clined to make capital upon such matters at the expense of
the physician, using a discovery of some abnormity as
proof of their superior knowledge of infants. The average
male child, according to Dr. Smith's observation, weighs
seven pounds eleven ounces ; the average female, seven
pounds four ounces. During the first three days there is
usually a loss of weight, which has been regained before
the end of the week. If the child does well, it should gain
an ounce a day to three months, the original weight being
doubled at six months and trebled at one year. The aver-
age length is nineteen inches, which is doubled at four
years. The temperature at birth is 100°, which soon falls
to 98-6°, and then returns to 99°. The pulse is about 130,
which may be increased twenty or thirty beats by crying,
or decreased ten or fifteen beats during sleep. Even in
perfect health the pulse is often irregular and is practically
THE NEW YORK MEDICAL JOURNAL, JUNE 25, 1892.
DK. STIMSON'S ARTICLE ON
POTT'S FRACTURE AT THE ANKLE.
Fig. 3. — Backward displacement, right foot; recent.
Fig. 9.
June 18, 1892.]
CRANDALL: MANAGEMENT
OF THE NEW-BORN INFANT.
687
of no value *as a symptom. The respirations are about 44,
and fall to 30 at one year. The eyes are almost invariably
of a greenish or bluish-gray color, and no opinion can be
formed at birth as to what their permanent color will be.
The pupils are large and sensitive to light. The auditory
canal, owing to swelling of the mucous membrane, is usu-
ally closed, and there may be a slight discharge which
might mislead the unwary. The abdomen, owing to the
frequency of digestive disorders in infants, is an important
region. The peculiarities in the relations of the abdominal
organs are due chiefly to the great size of the liver, which
displaces the stomach and colon to the left, the caecum be-
ing extremely variable in position. The sigmoid flexure is
long, sometimes reaching well into the right iliac fossa, and is
the cause in some instances of persistent constipation. The
bladder is almost wholly an abdominal organ, and its de-
tection above the pubes does not necessarily mean undue
distention.
While the physician is rarely consulted regarding the
clothing of the infant, it is a subject upon which he should
have some knowledge. Tight bands and waists are fortu-
nately being superseded by more rational methods of dress-
ing, though but slowly. The unfortunate infant is bound
about the chest and waist by layer after layer, while the
arms, legs, and neck have but half the covering. Each
layer has its own array of buttons and safety-pins always
at the back. The baby protests, and a new reef is taken in
his bandages, already too tight, and he is put back in the
cradle to lie on the same buttons, safety-pins, and lumps
he has been complaining of. The Gertrude suit, of which
so much has been said in Babyhood, is a vast improvement
over old methods. The original suit has been considerably
modified and improved, and does away with the bands and
waists and all constriction about the body.
The band for the baby as well as for the mother is a dis-
puted point. I can see no real objection when properly ap-
plied, but several advantages in a light flannel band during
the first few months. It should be four inches wide, with-
out a hem, and long enough to go once and a half about the
body. Pieces of tape fastened to one end make a better
fastening than pins. The shirt should be cut high in the
neck and have long sleeves. Flannel should be used, for it
is a necessity in this climate. The Jaeger flannel is by all
means the best. It is rare that.it can not be worn next the
skin. In hot weather flannel should still be used, the thin-
nest possible being employed. The napkins are usually too
thick and bungling. Soft cotton cloth is the best material.
They should be cut a yard long and half a yard wide and
folded once so as to make two thicknesses, the napkin when
ready for use being eighteen inches square. If thicker and
larger they are uncomfortable and may distort or deform
the child. Rubber napkins and shields are objectionable
from their tendency to overheat the parts. They are only
admissible for short periods or when traveling.
The stockings should be long enough to fasten to the
napkin and should always be kept on the feet. The outer
garments, one of which should be of flannel, should not be
so long and heavy as to obstruct the limbs. All the clothes
should be opened in front.
I need not here urge the importance of breast feeding,
but would urge more careful attention to the numerous de-
tails in the care and management of the breasts, neglect of
which deprives many children of the food to which they are
justly due. The breasts should receive attention at least six
weeks before the birth of the child. Cracking of the nip-
ples is to a large degree a preventable misfortune. The
most efficient preventive measure is the gentle drawing out
and manipulation of the nipple night and morning for sev-
eral weeks before the begfinnino: of lactation. Certain me-
dicinal applications may be made with advantage at the same
time. The usual application of astringents frequently fails
utterly. I have seen a primipara who had faithfully aj>plied
solutions of alum, borax, and alcohol for two months obliged
to stop nursing entirely on the fifth day because of deep As-
suring of the nipples. They were certainly tough — as tough
as sole-leather ; and, like sole-leather, when pinched, bent, and
squeezed, they cracked. They were not pliable ; but plia-
bility is as necessary as toughness. It is to be gained by
frequent manipulation and the use of an oil. The best oil
in my experience is lanolin, with a little cold cream added
(one part to three) to render it less waxy and more readily
applicable. It should be gently and thoroughly applied
after each application of the astringent to counteract its
tendency to stiffen and harden.
Both the nipple and the mouth of the infant should be
washed with plain cool water, to which a few drops of lis-
terine may be added, before and after each nursing. De-
composing milk on the nipple excoriates and favors Assur-
ing ; in the mouth of the child it irritates and forms a cult-
ure medium for bacteria. Without this care germs and
spores which have lodged on the nipple and in the mouth
are carried into the stomach during nursing and may de-
velop serious digestive disorders.
Fissures, when they occur, try the physician's resources
to the utmost. Not to enumerate the scores of drugs that
have been proposed, I would simply say that on the whole
I have had the most satisfactory results from the use of dry
tannic acid. The nipple is cleansed with boric-acid solu-
tion and dried and the tannin dusted well into the fissures.
It should be repeated after each nursing. It forms a coat-
ing that does not readily come off, and relief is usually ex-
perienced at the next nursing. The nipple should be af-
forded all the rest possible, and a shield should be used if
practicable.
Sometimes, in addition to the fissures, or even when no
fissure can be detected, the whole nipple becomes eroded
and extremely sensitive. For this condition balsam of Peru
is very effectual, or a one-per-cent. ointment of resorcin.
In other cases there is a hypersensitiveness far out of pro-
portion to the apparent seriousness of the fissures or ero-
sion. The mother falls into an extreme nervous condition,
and looks ahead with apprehension to everv nursing. I
saw a marked case of this character last year. The mother
was anxious to nurse her child, but would fall into such a
condition of nervous excitement before every nursing that
bottle-feeding seemed inevitable. An application of a four-
per-cent. solution of cocaine on a piece of cotton for five
minutes was finally tried, and relieved the pain. The inter-
688
(J RAND ALL: MANAGEMENT OF THE NEW-BORN INFANT.
[N. Y. Med. Jouh..
vals of nursing were extended as far as possible, and the
cocaine used eacli time. The nipples were washed before
and after each nursing and balsam of Peru applied. The
mother was reassured, the strength of the cocaine was re-
duced, and in a week she was nursing the child without
serious discomfort, and continued to do so during the
summer.
For various reasons, nursing should be discontinued
from a breast in which pus has formed or is forming. In
mastitis, or any condition accompanied by fever, the con-
stitutional disturbance alone often renders nursing im-
possible.
Unless the mother is especially exhausted, the child
may be put to the breast at the end of four or five hours.
During the first two days six hours is a sufficiently short
interval for nursing. The child will get all the breasts con-
tain, and will obtain no more by more frequent attempts. I
can not say that I never give anything but the breast during
the first two or three days. The child gets very little from
the breast during the second day, and the stomach must
become empty. A baby will wail and cry and show every
evidence of hunger, and will drop quietly to sleep upon re-
ceiving a little warm fluid. If it is restless and crying on
the second day, you may be quite sure that the nurse will
give it something before night — it may be milk, broth,
gruel, syrup, or sugar. It is better for the physician to
prescribe what shall be given.
I have seen no bad results from weak oatmeal water.
You thus give water that has been boiled, with sufficient
nourishment to satisfy the scruples of the mother and
nurse. But let the nurse feed indiscriminately with the
score of things that tradition demands, and you will find
about the fourth day that the family has been awake with
a crying child. The bowels are usually loose, the passages
being of bad odor, and perhaps greenish. With a mild
laxative and exclusive breast feeding, the symptoms usually
disappear in a few days, but the baby is subject to attacks
of colic for a much longer time, and may have formed the
pleasant habit of lying awake and crying at night.
Sometimes, I believe quite frequently, the mother's
milk is too rich in fat during the first two or three weeks,
causing colic, indigestion, and irregular bowels. Order
outdoor exercise for the mother, increase the amount of
fluid she takes and decrease the meat, for proteids in the
mother's diet increase the fat in the milk. Give the baby a
teaspoonful or two of Vichy water before each nursing, and
the indigestion will probably disappear.
The most important matter in this whole subject of
breast-feeding is regularity. It is even more important
than in bottle-feeding, for the breast milk changes decidedly
according to the frequency of nursing. If the interval is
too long, it becomes thin and watery ; if too short, con-
centrated and rich and causes indigestion. The first week
is not too early to begin the formation of regular habits.
If the child is asleep, wake it when the time for nursing
arrives. It will soon form the habit of waking at regular
intervals, and will go to sleep as soon as the nursing is fin-
ished. Above all things, warn the mother against con-
tinuous and everlasting: nijdit nursing. It wears on the
mother, impairs the milk, and ruins the digestion of the
child.
A discussion of the subject of artificial feeding would
occupy far more space than this paper will permit. To
state the matter briefly, I would feed a child of average
weight half an ounce of food every four hours during the
first two days, soon increasing to an ounce every two
hours, and an ounce and a half at the end of the second
week. With one feeding between eleven at night and
seven in the morning the child receives ten feedings a day
during the first three months. As to the composition of
the food, let it be cow's milk by all means. Allow the milk
to stand in a bottle or pitcher for two hours and pour off
the upper half. For the first feedings take of this rich
milk four parts, lime water one part, and water seven
parts. After a few days the milk may be increased and
the water decreased. In warm weather the milk should be
sterilized.
Urine is usually passed during the first twelve hours,
and thereafter about an ounce is passed ten or twelve
times a day, ten ounces being the normal average amount
for the new-born infant. It is at first cloudy from the ad-
mixture of epithelial cells and uric acid and of very low
gravity (1*003 to 1*006). Later it becomes clearer and
pale, but the gravity continues low during childhood.
When the urine does not pass, the distended bladder may
be readily felt, as it lies very high. Usually hot applica-
tions over the hypogastrium, a sprinkling of cold water, or
a warm bath are sufficient to start the flow. The catheter
is very rarely required, and should be used only as the last
resort.
The bowels usually act within a few hours after birth,
the passages during the first two days, and sometimes
longer, being greenish-black in color and tarry in consist-
ency. If there is no passage, a teaspoonful of sweet oil is
often sufficient, to which a few drops of castor oil may be
added. In certain cases constipation is obstinate and per-
sistent, and is due to an excessively long sigmoid flexure.
In such cases a daily enema may be required until the
child is several months old. Constipation is occasionally
present from the first, the passages being hard and dry ;
more frequently it is acquired.
The treatment is often discouraging. The attention
must be directed first and chiefly to the milk which the
child receives, whether it is cow's milk or breast milk, and
any error in digestion should be corrected as far as possi-
ble. Give plenty of cool water. This, I believe, is very
important, for the infant usually requires more fluid than it
obtains in the milk. Instruct the nurse to gently massage
the abdomen daily, not by simply rubbing the surface, but
by grasping the abdominal wall with the flattened hand
and causing it to move upon the bowels beneath. If these
measures fail, try a small soap suppository at the same time
every day, or in more extreme cases part of a small-sized
glycerin suppository, or half a teaspoonful of pure glycerin
by syringe. Drugs should be the last resort. Among
these, cascara has, on the whole, served me best, but some-
times fails completely. Two drops of cascara cordial may
be given twice a day as the initial dose, to be increased if
June 18, 1892.]
GRAND ALL : MANAGEMENT OF THE NEW-BORN LNFANT.
689
necessary. When the passages are white or pasty and
the child does not thrive, a few grains of phosphate of
soda, given three times a day, often yield most satisfactory
results. It may he added to the milk if the child is bottle-
fed. "Whatever drug is given, an attempt should he made
to reduce the dose very slowly, relying more on diet and
other measures. Mild measures at first are often sufficient,
but if the bowels are neglected during the first few weeks a
habit of constipation may develop which will be very hard
to break.
Two errors are common in the treatment of chronic
constipation. The first is reliance on a single measure — a
single article of diet, a single mechanical measure, or a
single drug. No one of these is of itself sufficient if the
case is obstinate. The diet must be corrected and the at-
tack must be made from several points at once. The sec-
ond error is the attempt to cure a continuous and persistent
condition by intermittent and spasmodic treatment. No
matter how good the treatment, it is sure to fail unless per-
sistently applied.
Jaundice in the infant, as in the adult, is symptomatic
of numerous conditions. In the vast majority of cases it
appears on the second or third day without assignable
cause, continues about a week, and is unaccompanied by
symptoms. The sclerotic is not discolored, the urine does
not stain, and the stools retain their normal color. In rare
instances acute obstructive jaundice marked by the usual
symptoms occurs during the first week. The cause of the
disorder has not been satisfactorily explained. There may
be truth in the theory of Quincke, which attributes it to
non-closure of the ductus venosus, which permits portal
blood containing bile pigment to pass at once into the gen-
eral circulation. As the condition naturally disappears, it
rarely requires treatment. The clothing should be investi-
gated, but it is extremely doubtful if bands could be so
tight as to cause mechanical congestion of the liver. If the
bowels are not free, gray powder is, perhaps, the most ap-
propriate cathartic.
Thrush is a disease of young infants and marasmic chil-
dren. It is rarely seen in healthy children when proper
cleanliness of the mouth and nipples has been maintained,
for it does not develop on a perfectly healthy membrane.
Digestive disorders, while common in connection with
thrush, are not necessarily a part of that disease, but result
more from the swallowing of acrid secretions than from
actual extension of the thrush. It is best combated by an
alkaline wash. Borax is a time-honored remedy, and a
good one. I have seen better results by adding to the
mixture an equal amount of bicarbonate of sodium. Honey
or syrup should not be used as a vehicle, for their decompo-
sition adds to the disease. A simple solution in water is
best, to which a little glycerin and tincture of myrrh may
be added. Gentle but thorough removal of the exudation
should be practiced three times a day by means of a soft
cloth saturated with the solution, and wrapped on the finger
or a lead-pencil. Unless this is done with extreme gentle-
ness, more harm than good will result. If the disease is
localized, the spots may be touched to advantage with atwo-
per-cent. solution of sulphate of copper.
Colic is most common between the second and fourth
months, but not infrequently appears during the first week,
and may be severe and very troublesome, the attacks being
periodical, with a tendency to recur at the same time each
day. The causes and preventive treatment have already
been considered. It seems sometimes almost impossible to
prevent it, and treatment for its relief is demanded. The
feet will usually be found cold, and should be made warm
at once. This simple precaution is sometimes followed by
relief of the pain. Heat should also be applied to the ab-
domen, the warm hand of the nurse sometimes being suf-
ficient. A little plain warm water may be given, to which
peppermint may advantageously be added. Three or four
drops of rhubarb and soda mixture in a teaspoonful of
warm water is extremely effective. Aniseed cordial (elixir
anisi) is frequently used, and is quite efficient. It contains
twenty-five per cent, of deodorized alcohol. Dalby's car-
minative, so largely used, it should be remembered, as com-
monly dispensed, is an opium mixture of half the strength
of paregoric. Equal parts of lime water and cinnamon
water, or equal parts of camphor water and compound
tincture of cardamom, are effective mixtures. The mother
should never be allowed to suppose that she can use pare-
goric for these attacks. The temptation to overuse it is
altogether too great.
So little is said of snuffles in the text-books, except as a
symptom of syphilis, that many a young practitioner has
been worried by a simple and very common disorder. Cold
in the head is common in infants, and is more serious than
in older children. Frequently it amounts only to snuffling
or rattling, and perhaps sneezing without much closure of
the passages. It can not become very severe, however,
without preventing nursing by obstructing the breathing,
and this is the serious aspect of the disorder.
Syphilitic coryza begins with a watery, somewhat acrid
discharge which soon becomes muco-purulent, is frequently
streaked with blood, and forms excoriations and thick scabs
upon the lip. It persists and becomes steadily worse, and
is rarely present for any length of time without other syphi-
litic manifestations. Simple coryza rarely continues longer
than a week or ten days ; the discharge is not as acrid, but
frequently becomes so thick as to wholly occlude the nasal
passages, which are comparatively small in the infant.
Treatment, when the disease is mild, consists in apply-
ing warm camphorated oil over the bridge of the nose and
introducing a little cold cream into the nostrils with a
camel's-hair brush. In more severe cases the nostrils must
be as thoroughly cleaned as possible with a brush or piece
of cotton wrapped on a probe, or an attempt may be made
to gently syringe the nostrils with Seder's solution, after
which the cold cream may be applied: Gentleness here, as
in treating diseases of the mouth, is of the first importance.
Bronchitis at this early age is an extremely serious dis-
ease, for if marked it virtually means broncho-pneumonia.
The term used by some of the older writers — suffocative
catarrh — expresses very well the clinical aspect which the
disease is inclined to assume. Treatment does not differ
materially from that of the same disease in older children.
Bronchitis is important also from another point of view.
G90
ROBINSON: TWIN EXTRA-UTERINE PREGNANCY.
fN. Y. Mud. Joub.
In a recent study of congenital heart disease, I found that
a large percentage of the cases suffered from bronchitis dur-
ing the first week. The foetal openings of the heart and
vessels do not fully close until the seventh or eighth day,
and it has been suggested that bronchitis, by causing pul-
monary obstruction, may be a factor in causing their con-
tinued patency. Every precaution should certainly be taken
to prevent the disease, and it should be removed with the
greatest possible dispatch.
Cerebral hemorrhage, due to venous congestion and
rupture of the capillaries of the pia mater; the various
forms of obstetrical paralysis ; haemorrhages from the vari-
ous cavities ; trismus neonatorum — are all serious conditions
of great interest, but their consideration is prohibited from
lack of space.
Numerous minor ailments or abnormal conditions occur
which require attention. Cephala?matoma is a collection
of blood commonly subperiosteal. It forms a tense, some-
what elastic tumor, situated, in the great majority of cases,
over the right parietal bone. Unless evidence of suppura-
tion appears, it should be let entirely alone, for it rarely
happens that the blood is not absorbed.
Swelling of the breasts is sometimes marked and causes
considerable discomfort. They should be simply protected
from pressure. Sometimes warm camphorated oil very
gently applied seems to give relief. If suppuration occurs,
which is rarely the case, they should be treated like any
abscess.
If vomiting of blood occurs, the breasts should be ex-
amined, for a surprisingly large amount of blood may flow
from a fissured nipple. Congenital teeth are not, as a rule,
attached to the bone and soon loosen and fall. They should
be at once removed. Vaccination, unless there is some
definite reason for haste, had better be postponed until the
child is at least six months old. It does not " take " well
before that age, and it may be necessary to repeat the
operation several times.
The baby may be wailing and puny, with low vitality
and apparently little hold on life ; the asphyxia may be
deep ; the convulsions long and severe ; the indigestion ob-
stinate, and yet the case may not be necessarily hopeless.
In no condition is the truism that while there is life there
is hope more true than in that of early infancy. Vigorous
and healthy children not infrequently develop from the
most unpromising infants. Many a strong man is to-day
engaged in the active affairs of life whose first days prom-
ised nothing but speedy death. While an infant breathes
it is never wise to wholly abandon hope or to relax one's
efforts.
113 West Ninety-fifth Street.
The Death of Mr. Henry A. Riley occurred in New York ou the 9th
inst, of heart disease, from which he had long been a sufferer. Though
a lawyer, he was well known to the medical profession by his contribu-
tions upon medical jurisprudence to this and other journals. For many
years he had been a contributor to current literature, and for two years,
having been compelled to abandon his professional and business pur-
suits, he had devoted his time largely to writing upon medical law. In
this direction his work was unique, for he developed a field before un-
occupied, being quite different from that of medical jurisprudence as
that term is usually understood.
A CASE OF
TWIN EXTRA-UTERINE PREGNANCY.
ABORTION PER VIAS NATCH ALES AT THE FOURTEENTH WEEK.*
By A. L. ROBINSON, M. D.,
SEATTLE, WASH.
Mks. F. K., aged twenty-seven, multipara, came under my
care about the middle of January, 1892, while suffering with
la grippe. After the acute symptoms had passed, but while
still weak, morning sickness came on. She informed me that
her last menstrual period had commenced on November 4, 1891.
The vomiting soon became almost constant, and was but slightly
modified by any of the numerous remedies employed, which in-
cluded rectal feeding. Extreme prostration, insomnia, and in-
cipient nephritis made abortion advisable, and the patient, her
husband, and other members of the household were so informed.
While this procedure was being discussed, the patient told me
that for several days small blood-clots had been passing, but
that free haemorrhage had not occurred. On the following day,
February 6, 1892, Dr. Montgomery Russell, of this city, was
called in consultation, and the previous treatment and proposed
operation were approved by him. Ether was administered, and,
anaesthesia being obtained, the cervix was exposed and a pro-
truding muco-blood-clot removed. An intense violet color of
the vagina was observed. After dilating the cervical canal a
careful examination of the uterine cavity was made. It meas-
ured five inches and a quarter from external os to fundus, and
its contents were a few small blood-clots only. These were re-
moved. A roughness was noticed at or near the right Fallop-
pian uterine ostium. Dr. Russell's examination confirmed the
results of mine. We concluded that the product of conception
had died in vtero, undergone maceration and partial absorption,
and the remainder passed with the discharges previously men-
tioned, which had probably been greater in amount than the
patient supposed. The uterine cavity was then syringed out
with two quarts of a warm bichloride-of-mercury solution (1 to
3,000), and faradaic electricity applied for fifteen minutes.
That evening it occurred to me that the condition was pos-
sibly extra-uterine pregnancy. At my next visit the patient
was closely questioned, and it was ascertained that for several
weeks dull pains had been emanating from the right iliac fossa
and extending downward on the thigh. An extremely offensive
discharge from the vagina, which she supposed was leucorrhcea,
had continued during this period. At first it was thick and
viscid, but recently had become watery and mixed with small
blood-clots. Since the cessation of menstruation her subjective
symptoms had differed greatly from those of her two former
pregnancies, but in what manner she could not clearly state.
An attempt was then made to make a bimanual examina-
tion of the pelvic viscera, but fear of pain caused so much pro-
testation that it was not persisted in, for she was so weak and
nervous that convulsions were feared. The employment of an
anaesthetic was considered unsafe at that time. External palpa-
tion gave no positive results, as pressure was not tolerated.
The family was informed of my conjectures, and the various
forms of extra-uterine pregnancy with their possible termina-
tions were explained.
The day following the operation the attacks of vomiting de-
creased in frequency. Nausea and occasional vomiting persisted,
consequently but little nourishment could be taken at one time.
Rectal feeding, gastric and nerve sedatives, tonics and stimu-
lants were employed, but the general condition was not greatly
improved. Pains emanating from the right iliac fossa con-
* Read before the Seattle Medical Society and Library Association,
March 16, 1892.
June 18, 1892.]
TUTTLE : RECOVERY AFTER VERATRUM VIRIDE POISONING.
691
tinued ; also a slight discharge of blood from the uterus. The
cavity of the latter was several times explored, the blood-clots
found therein removed, and warm bichloride injections made.
On the evening of February 17, 1892, eleven days after first
examining the uterus, I was sent for in haste. Considerable
pains had been experienced all that afternoon, commencing in
the right iliac fossa, but later extending to the sacrum and assum-
ing the characteristics of labor pains. Previous to my arrival she
had been delivered of an embryo with considerable hemorrhage.
The patient was too much prostrated to permit cleansing the
uterus at that time, the pulse being 120 and weak, temperature
100° F. Haemorrhage was checked by ergotin hypodermically,
and brandy and digitalis were ordered. During my visit the
'following morning a second embryo was passed without pain.
Haemorrhage was inconsiderable. The uterus was at once cu-
retted and a large blood-clot and shreds of membrane removed,
as well as small pieces of placenta, which were scraped with
difficulty from the location of the right Falloppian uterine os-
tium. Its cavity was then syringed out with a warm bichloride
solution and ergot prescribed.
Examination of the embryos showed them to be of about
fourteen weeks' development. They were more than five inches
in length, and had evidently been considerably compressed and
elongated. The heads were shapeless masses. Membranous
nails were forming on fingers and toes. The sexes were not dis-
tinguishable.
Haamorrhage continued daily, at times requiring electricity,
astringent and styptic injections, and the administration of ergot,
but these measures failed to satisfactorily control it. Examina-
tions of the uterine cavity were several times made, and its onlyj
contents, blood-clots, removed.
The patient continued weak, with continual nausea and fre-
quent vomiting. Temperature varied from normal to 99-5° F.,
and pulse from 95 to 105 and weak. Pain was constantly com-
plained of, mainly on right side of the uterus. Morphine, phen-
acetin, salol, and gelsemium were frequently administered to
modify it.
Laparotomy for the removal of the placentae and membranes
was considered, but neither at that time nor at any other was
the patient strong enough to justify such an operation.
On February 23d she had a slight chill followed by rise of
temperature to 102-5° F. The following morning the tempera-
ture was 102° F., pulse 130, respiration 30. The abdomen was
considerably distended and tympanitic, severe pain was com-
plained of, and vomiting was more frequent.
Dr. Russell was again called in consultation, and he con-
curred in my diagnosis of general peritonitis. Turpentine stupes
were applied to the abdomen and the " Alonzo Clark opium
treatment" was agreed upon and commenced, the patient being
closely watched until her tolerance for the drug was ascertained.
Respiration increased to 38 that day. The duration of this
treatment was ninety hours; one hundred and forty-one grains
and a half of pulverized opium were administered, and throe
grains and three eighths of sulphate of morphine given hypo-
dermically to lessen vomiting. The acute symptoms gradually
subsided, and on the evening of February 28th vomiting had
not occurred for six hours, abdominal pain and tympanites had
disappeared, temperature was normal, pulse 105, respiration 14.
Opium was given that night at increasing intervals and then
discontinued. On the morning of February 29th I found the
patient witli temperature of 100° F., pulse 125, respiration 20.
The uterine cavity was explored, an entire placenta removed,
and it was then syringed out with a warm bichloride solution.*
* A large piece of placenta had been removed from the uterus four'
days previously.
An enema of warm water and soap brought away considerable
hardened clay-colored faeces. Fifteen grains of sulphate of qui-
nine and cardiac stimulants were given. A tablespoonful of a
saturated solution of sulphate of magnesium was ordered every
four hours. During the afternoon the temperature fell to 99° F.,
but the pulse increased in rapidity and feebleness. I remained
by the patient's bedside all that night. At 4 a. m., March 1st,
the pulse was 150. At 5.20 a. m., shortly after waking from an
hour's sleep, death resulted from asthenia.
For some years palpitation of the heart and uneasiness in the
cardiac region had at times been complained of. Much prostra-
tion had been caused by la grippe, and the vomiting of pregnancy
following this disease so closely prevented the retention of the
tonics and stimulants ordered. But for debility caused by la
grippe it is believed the patient would have recovered.
Minor details of treatment, etc., have been omitted. It
was undoubtedly an interstitial pregnancy on the right side,
the growth of the embryos enlarging the Falloppian uterine
ostium and permitting their entrance into the uterus. The
shape of the uterine cavity, as disclosed by the several
examinations, negatives the probability that this was a case
of pregnancy in one portion of a uterus bicornis.
A post-mortem examination was not obtained.
Cases of extra-uterine pregnancy with delivery per vias
naturales are extremely rare. Dr. Charles McBurney re-
ported one in the New York Medical Journal, March num-
ber, 1878, page 273, and Dr. Cornelius Williams another in
the same journal, December number, 1878, page 595, but
an examination of the literature at my disposal fails to dis-
close a case of multiple extra-uterine pregnancy with that
termination ; indeed, I find no cases of multiple extra-uter-
ine pregnancy of any variety, though possibly some are of
record.
2506 Jackson Strkkt, March 8, 1892.
RECOVERY AFTER TAKING A
LARGE QUANTITY OF VERATRUM VIRIDE.
By JAMES P. TUTTLE, M. D.
Me, A. was attacked on February 5th with severe epididymi-
tis and orchitis. That night his brother came to me, saying
that his fever was very high and that he was suffering a great
deal of pain. I prescribed for him "tr. verat. virid. (Nor-
wood's), f 3 iv. Sig. : Two drops every half-hour until perspira-
tion is well established." The patient read the directions "two
teaspoonfuls " every half-hour, and took the first dose accord-
ingly at 8.30 p. it. This he retained without any appreciable
effect until 9.05 p. m., when he took the second dose of two
teaspoonfuls. In about half an hour he " began to vomit and
became very weak," as he described himself. On the following
morning I was called to see him, and having heard his story of
how he took the medicine, was more surprised to find him alive
than that he was exceedingly weak and very pale. The heart
was feeble but regular, and the respiration very nearly normal.
A small quantity of whisky and infusion of digitalis were given,
and the patient recovered without any unusual symptoms. The
prescription was compounded by a reputable pharmacist, who
assured me that he had dispensed the stronger tincture. The
interest in the case centers in the remarkable fact of the patient's
having retained so large a quantity of the drug for nearly an
hour without any disastrous effects.
30 Wkst FoETY-rnrTH Street.
692
L EA DING ARTICLES.— MINOR PA RA GRA PUS.— ITEMS.
[N. Y. Med. Jour.,
tub
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by Edited by
D. Appleton & Co. Frank P. Foster, M. D.
NEW YORK, SATURDAY, JUNE 18, 1892.
OPIUM-SMOKING.
Aocoeding to an editorial note in the Journal of the Ameri-
can Medical Association, the vice of opium-smoking, or " opio-
Icapnism" as the writer calls it, has been increasing to a re-
markable extent during the last decade. The statistics of the
custom-house at San Francisco show that the sum of $750,000
was collected last year as the duty on importations of smoking-
opium at that port alone, with the tariff at twelve dollars a
pound. In other words, 62,000 pounds of a drug which has no
good uses and has a bad history in other countries came into a
single port of entry in one year. In addition to the openly im-
ported drug, a very large illicit trade is carried on over the
Canadian border. It is said that a million pounds of the srnok-
ing-drug has come into the country in eleven years through the
port of San Francisco alone.
The term " opiokapnism " is used by the writer in contra-
distinction to ''•opiophagism'''' (or opium-eating), a term which
has been coined to cover the commoner forms of addiction to
opium or its derivatives in which the drug is taken by the
mouth or by subcutaneous injection.
" Opiophagism " may be taken to represent those cases of
the morphine habit which are so common in all parts of this
country, being very frequent among professional and other re-
fined persons, and concerning which the medical profession has
so much of unjust blame laid to its charge as being the occa-
sion of the formation of the habit. " Opiokapnism," on the
other hand, is an Oriental and un-American vice. Introduced
by the Chinese laundry men, opium-smoking has spread some-
what in the depraved purlieus of our Western and Northern
cities. This is the imported vice, the causation of which has
not as yet been laid to the charge of our profession. The thera-
peutic indications of the smoke of opium are not. regarded in
the Orient as of any moment whatsoever, and it is not at all
probable that any good uses will ever be discovered for it. In
the article above cited, it is stated that fifty qualified native
physicians of the city of Bombay have signed a statement
that among their Hindoo patients the habit of smoking opium
is an evil without a redeeming feature, ruinous alike to mind,
body, estate, and family.
MINOR PA RA GRAPHS.
THE CONSERVATIVE TREATMENT OF TUBAL DISEASE.
At the last meeting of the Academy of Medicine, on Thurs-
day evening of week before last, a notable paper on The Con-
servative Treatment of Salpingitis was read by Dr. Paul F. Munde.
The paper was remarkable for the clearness with which it showed
the absence of justification for what the author denominated the
" Birmingham epidemic," meaning the rage for salpingo-oophor-
ectomy. As he justly remarked, it is one of the drawbacks of
the Listerian system that it has to a great extent robbed certain
mutilating and unnecessary surgical procedures of their danger
to life, and consequently led to their indiscriminate and often
utterly uncalled-for execution. We have no hesitation in say-
ing that among the most flagrant of them is laparotomy for dis-
ease of the Falloppian tubes, and we think the profusion ought
to feel thankful that a gynecologist of Dr. Mund6's eminence
has taken the trouble to demonstrate the rarity with which it
is required. Dr. Munde used the word conservative in the
sense of preservative of the essential generative organs in
women, and it is interesting to note that their preservation is
not incompatible with a curative laparotomy, as was strikingly
brought out in the discussion by Dr. Polk, who related briefly
the history of a case in which he had removed the uterine an-
ne.xa on one side for disease, and at the same operation had cut
away about half of the ampulla of the oviduct on the other side,
and yet the patient had since conceived. Surely such a case
ought to rise up against those who lightly declare in cases of
tubal disease that the organs have already been rendered func-
tionally worthless by disease, and therefore that their loss by a
surgical operation is really no loss to the patient.
A WORTHY SANITARY FEAT QUIETLY ACCOMPLISHED.
It is alleged for General Rusk that he has greatly improved
the treatment of cattle exported to Europe for food purposes.
The mortality among them at sea, resulting from cruelty, want
of water, etc., was formerly stated at sixteen per cent., while at
the present time it is one per cent. The value of these exporta-
tions is not far from $25,000,000 annually. If this statement is
only partly true, General Rusk has accomplished a great sani-
tary reform, for he has been the means of indirectly purifying
the flesh food supply of thousands of European consumers.
WOUNDS WITH DYNAMITE.
The action of dynamite seems to be almost as chaotic as
that of lightning, to judge from an occurrence related in La Sci-
ence moderne, an abstract of which is given in a recent number
of V Union medicale. A nickel-miner was fishing with dyna-
mite cartridges, when one of them exploded as he was in the
act of casting it and carried away one of his hands. During
the twelve hours that it took to convey him to a hospital ship,
under a tropical sun, gangrene set in, and he died shortly after
reaching his refuge. His body was riddled with communicat-
ing subcutaneous channels, and at the post-mortem examina-
tion it was found that the nails of the lost hand, having been
detached, had acted as projectiles, and were found near the
spinal column in the thoracic region.
ITEMS, ETC.
The Medical Society of the County of Queens. — The annual meeting
of this society was held on May 31st, at Mineola, Long Island. The
following officers were elected : President, Dr. C. J. G. Finn ; vice-
president, Dr. John Mann; secretary, Dr. James S. Cooley ; censors, Dr.
Meynen, Dr. Heyen, Dr. Ludlam, Dr. Frye, and Dr. Zabriskie. It was
voted to elect delegates to the State society and to re-establish the
broken delegate relations that have been interrupted since 1884. Dr.
Cooley and Dr. Lanchart were elected sucli delegates. Delegates were
also appointed to the American Medical Association. Dr. 0. B. Doug-
las, of New York, and Dr. G. G. Hopkins, of Brooklyn, read papers at
the meeting.
June 18, 1892.]
ITEMS.— PROCEEDINGS OF SOCIETIES.
693
The Medico-chirurgical College of Philadelphia. — The following
appointments nave been made: Dr. W. Frank Haehnlen, professor of
obstetrics ; Dr. W. Easterly Ashton, professor of gynaecology ; Dr.
Charles M. Seltzer, professor of hygiene; Dr. H. H. Boom, adjunct pro-
fessor of chemistry ; and Dr. B. T. Shimwell, adjunct professor of op-
erative surgery.
Bellevue Hospital. — Dr. Robert W. Taylor has been appointed on
the attending staff, on the division of the College of Physicians and
Surgeons, to have a continuous service in genito-urinary diseases.
The Woman's Medical College of the New York Infirmary. — Dr.
William Oliver Moore has resigned from the chair of ophthalmology and
otology.
The New York Polyclinic. — Dr. Robert Safford Newton has been
appointed lecturer on diseases of the mind and nervous system, in the
department of Professor L. C. Gray.
The Death of Professor Meynert. — The Lancet announces the death
of Professor Theodor Meynert, of Vienna.
Change of Address. — Dr. P. A. E. Boetzkes, to No. 861 Lexington
Avenue.
A Large Bequest for Hospital Purposes. — By the will of the late Mr.
Robert A. Barnes, of St. Louis, the sum of nine hundred thousand dol-
lars will become available for the building and endowment of a new hos-
pital in that city. The management of the fund will rest with the Metho-
dist Episcopal Church South, but the institution, when completed, will
be unsectarian in the bestowal of its charities.
The late Dr. Birdsall. — The New York Neurological Society has
passed the following :
Inasmuch as by the death of Dr. William R. Birdsall, the New York
Neurological Society has lost an active member, whose eminent services
in our department of medicine have secured for him our highest re-
spect, and whose many attractions of character and personality have
awakened our warmest attachment ; therefore,
Resolved, That we record upon our minutes the expression of our
great sorrow at his untimely death ; of our appreciation of his eminent
ability, untiring industry, and scientific accuracy and skill ; and of our
tender regard for the many admirable qualities which will endear his
memory to us for many years.
Resolved, That these resolutions be published in the current medical
journals, and that a copy be sent as an expression of our deep sympathy
to the afflicted family of our deceased friend.
M. Allen Starr, M. D.,
[Signed.] Charles L. Dana, M. D.,
Graeme M. Hammond, M. D.,
Committee of the Council.
Society Meetings for the Coming Week :
Monday, June 20th : American Association of Genito-urinary Surgeons
(first day — Richfield Springs, N. Y.) ; American Ophthalmological
Society (first day — New London, Conn.) ; New Hampshire Medical
Society (first day — Concord) ; New York County Medical Associa-
tion; Hartford, Conn., Medical Society; Chicago Medical Society.
Tuesday, June 21st : Colorado State Medical Society (first day — Denver);
American Association of Genito-urinary Surgeons (second day) ;
American Ophthalmological Society (second day ) ; New Hampshire
Medical Society (second day) ; Medical Societies of the Counties of
Kings and Westchester (annual), N. Y. ; Ogdensburgh, N. Y., Medi-
cal Association ; Baltimore Academy of Medicine.
Wednesday, June 22d: Colorado State Medical Society (second day) ;
American Association of Genito-urinary Surgeons (third day) ; New
York Pathological Society ; Medical Society of the County of Al-
bany ; Metropolitan Medical Society (private) ; Philadelphia County
Medical Society.
Thursday, Jane 23d: New York Orthopaedic Society.
Friday, June 24th : New York Society of German Physicians ; Phila-
delphia Clinical Society ; Philadelphia Laryngological Society.
Saturday, June 25th : New York Medical and Surgical Society (pri-
vate).
Answers to Correspondents :
No. 383. — Their formula; are probably of no special value. Ninetj-
five-per-cent. alcohol has been used with good results.
'|)roceebings jof Societies.
AMERICAN" MEDICAL ASSOCIATION.
Forty-third Annual Meeting, held in Detroit on Tuesday,
Wednesday, Thursday, and Friday, June 7, 8, 9, and 10,
1892.
The President, Dr. Henby O. Maeoy, of Boston, in the Chair.
(Concluded from page 664-)
Recommendations of Proprietary Medicines.— A resolu-
tion from the Medical Society of Pennsylvania was read by the
secretary, which disapproved of the common custom among
physicians of giving certificates of the value of patent and pro-
prietary medicines. The Journal of the American Medical
Association was condemned for encouraging such practice in its
advertising columns.
Dr. Thomas, of Pennsylvania, offered a resolution that the
trustees of the Journal be directed to abide by the code of ethics
by declining to make commendatory mention of secret prepara-
tions. This resolution was unanimously adopted.
The Pan-American Medical Congress.— The Peesident
introduced Dr. William Peppee, of Pennsylvania, the president
of the Pan-American Medical Congress. Dr. Pepper referred to
the preparations for the Congress which had been made, and
expressed the belief that the managers would do all in their
power to make the Congress successful and beneficial.
Dr. C. A. L. Reed, of Ohio, offered a resolution thanking
Senator Sherman, of Ohio, for his efforts in securing the passage
of the bill incorporating the Congress through the United States
Senate, and expressing the hope that the bill would speedily be
passed by the House of Representatives. This resolution was
unanimonsly adopted.
The Peesident announced as the Committee for Considera-
tion of the Status of the Members of the Association belonging
to the Medical Society of the State of New York and for Con-
ference with Members of that Organization : Dr. Davis, of
Illinois ; Dr. Rauch, of Illinois ; Dr. Briggs, of Tennessee ; Dr.
Reynolds, of Kentucky ; and Dr. King, of Missouri ; and, as a
Committee on the Revision of the Code of Ethics: Dr. Didama,
of New York; Dr. Lee, of Pennsylvania ; Dr. Connor, of Michi-
gan; Dr. Holton, of Vermont; and Dr. Nelson, of Illinois.
The reports of the treasurer and librarian were then read by
the secretary.
The report of the Committee on the Rush Monument Fund
was read by the chairman, Dr. A. L. Gihon, of the navy. An
urgent appeal was made for contributions. The treasurer had
already received nearly $3,000, of which $2,000 was securely
invested. It was now positively decided that a monument
would be erected in Washington, but whether it should be a
bust or a full-length figure would depend upon the amount of
money obtained.
The Standard of Medical Education.— Dr. Dudlet, <>f
Kentucky, read a preamble and resolution Indorsing the action
of certain American colleges of medicine in raising the standard
of medical education, and urged that the colleges throughout
the entire country be requested to adopt similar requirements,
The preamble and resolution were unanimously adopted.
694
PROCEEDINGS OF SOCIETIES.
[N. Y. Med. Joub.,
Dr. Millard, of Minnesota, moved that a copy of tliem be
transmitted to every medical college iind medical journal in the
United States.
The Report of the Committee on the Celebration of the
Centennial of the Discovery of Vaccination was read by the
secretary. It recommended a celebration in the city of Wash-
ington, if possible, on May 14, 1896, when the centennial anni-
versary of Jenner's conclusive experiment in inoculation would
occur ; also that a committee of five be appointed to arrange
a plan for such a celebration.
Dr. Reynolds, of Kentucky, asked that the nominating
committee be requested to give its report upon the instructions
that had been given to it.
Dr. Watson, of New Jersey, replied that the report was not
ready.
Dr. Reynolds moved that the committee be requested to
render its report at Friday's meeting.
Dr. Tkuax, of New York, did not understand that the
nominating committee had been called upon for a report, and
called for the reading of the motions which were supposed to
apply to the case.
Dr. Quimby, of New Jersey, did not consider that the nomi-
nating committee had any duty to perform in the matter at
issue.
Dr. Davis, of Illinois, took the same view of the matter.
Dr. Tonee, of the District of Columbia, said t he minutes had
been falsified by the introduction of names which had not been
mentioned in the motions as offered upon the floor. This state-
ment was strongly objected to by Dr. Gihon, of the navy.
The president then declared further debate out of order.
Intellectual Progress in Medicine.— This was the title of
the Address in Medicine, by Dr. A. L. Gihon. The reader did
not propose to offer anything original, but would merely give a
digest of the year's progress, which was to be found in the medi-
cal journals of the year — the search-light of medical progress. He
called attention to the improved character of medical editorship,
which, of course, had been required with increasing intelligence
and aspirations on the part, of the profession. It was only the
highest ability that could now expect to reach the proper dis-
tinction in medical editorship. Reform in the system of medi-
cal education was also a most noteworthy fact. The lengthen-
ing of the period of education to three, four, and even six years,
in addition to the required preliminary examination, which had
obtained at numerous medical colleges, especially in the North
and East, should be a stimulus to the colleges in the South and
West which had not already adopted similar progressive meas-
ures. The duty of a physician in the line of education was to
identify himself with educational medical societies, not only the
county societies, but those of the State and nation as well. Thus
would a physician become broader than by simply attending to
his medical duties and his relations to his patients. The physi-
cian should also not forget his civil duties, and should ever seek
to emulate such men as Benjamin Rush, who was not only phy-
sician and teacher, but patriot, statesman, and scientist as well.
The action of medical men in founding and sustaining in recent
years such organizations as the Loyal Legion and the Grand
Army of the Republic was an evidence of the possibilities in this
direction. The revelations of chemistry and bacteriology in re-
cent times had been most interesting and valuable. Especially
was it a comforting fact that, if many deadly microbes were in
the body, processes were also at work within the body by which
those microbes were destroyed. The old idea of the entity of
diseases had long since been exploded and we now looked to
modern science to explain upon a rational basis the morbid con-
ditions with which we were everywhere confronted. The recent
work of Sternberg on bacteriology was alluded to with pride as
a product of American medicine, and extensive quotations from
that author's recent publications were made. He (Sternberg;
believed that we were on the eve of a new era in the treatment
of infectious disease, that the important question now was the
isolation of the toxines and toxalbumins of the body, and that
the inference was justifiable that in the blood and tissue juices
of animals and human beings who had suffered with infectious
disease antitoxines would be found winch, by inoculation in the
healthy, would render them proof against such infectious dis-
eases.
NEW YORK SURGICAL SOCIETY.
Meeting of January 13, 1892.
The President, Dr. Arpad G. Gerster, in the Chair.
Injury of the Ulnar Nerve.— Dr. MoBubney showed a
patient whose hand had been crushed eleven months before
in a pane of glass. The ulnar nerve and artery and all the
tendons on the anterior surface of the wrist were divided.
Sensation on the ulnar side was completely lost. The artery
was tied and the nerve and tendons were sutured. The result
had not been satisfactory, on account of the adhesions of the
tendons to the cicatrix. At a second operation the scar was
freely dissected away from the tendons and nerve which were
attached to it, all cicatricial tissue was removed, and the wound
was sutured. The result was now eminently satisfactory ; sen-
sation was perfect and flexion practically normal.
Nephrectomy. — The President showed a woman, thirty-
one years old, from whom he had removed one kidney while un-
doubted disease of the other was present. The tumor occupied
the entire left side of the abdomen, and was very slightly mova-
ble. The patient's condition was wretched. The tumor con-
tained pus, which was evacuated by the operation of nephroto-
my, on March 3, 1890. Improvement took place, but, as
elevations of the evening temperature still persisted and the dis-
charge was profuse, it was decided to remove the kidney, which
still formed a noticeable tumor. Nephrectomy was, therefore,
done on January 23, 1891. A long oblique incision was em-
ployed between the last rib and the crest of the ilium. Ex-
tensive adhesions had to be torn, and the peritoneal cavity was
freely opened. Several additional pus cavities were evacuated.
The pedicle was secured by an elastic ligature, and the peri-
tonaeum by continuous suture was shut off. The wound was
treated openly. The patient made an excellent recovery. The
ligature came away on the thirteenth day. In four months the
patient's weight had increased from ninety-nine to one hundred
and thirty-five pounds, and she now enjoyed comparatively
good health.
In another case he had done nephrectomy, with a satisfac-
tory result, upon a patient whose other kidney at the time of
operation was undoubtedly diseased.
Dr. Lange remarked that he had operated in several cases
where the second kidney was also diseased. The questions to
be considered in such cases were: First, was the presence of
the diseased kidney of such risk to the patient that its removal
was desirable ; and, secondly, was the kidney of use as a urine-
secreting organ ? In one of the speaker's cases the patient was
still alive at the end of six years, and in another at the expira-
tion of three years. Neither of them was cured, as the remain-
ing kidney was not healthy, but both were living in comparative
comfort.
The President said that an important point in the technique
of such operations was the patient's posture. He used in such
cases the posture suggested by Lange — i. e., the patient lay on
the side to be operated on, with the incision as low as possible,
so that the pus might flow away from the peritoneal cavity.
June 18, 1892.J
BOOK NOTICES.
695
Cuneiform Osteotomy. — The President showed two patients
on whom he had done cuneiform osteotomy for cure of flat-foot.
A semilunar incision was made on the inner side of the foot, an
inch in front of and below the apex of the malleolus, and carried
forward from two to two inches and a half. The wedge of bone
was removed from the most prominent part of the foot without
attention to the anatomical tissues, its base being on the inner
margin of the sole and its apex on the outer side of the dorsum.
He chiseled out the wedge piecemeal, rather than in one mass.
The foot was then broken into shape, a plaster dressing was ap-
plied to the foot in its over-corrected posture, and the limb was
kept elevated for a few hours. The first case was that of a
waiter, aged twenty-two, who was operated upon on January
16, 1891. The result had been excellent. The second case was
that of a man, aged sixty, and the result had been fairly satis-
factory. Out of six cases of operation in this manner he had
obtained a good result in five. No drainage-tubes were used,
but the wound was left open at one angle. The bones removed
were generally the head of the astragalus, the entire scaphoid,
and part of the cuboid. He had found that in the simple
Ogston operation not enough bone was removed.
Diseases of the Nervous System. By Jerome K. Bauddy, M. D.,
LL. D., Professor of Diseases of the Mind and Nervous Sys-
tem and of Medical Jurisprudence, Missouri Medical College,
St. Louis, etc. Second Edition. Philadelphia : J. B. Lippin-
cott Co., 1892. Pp. 352. [Price, $3.]
The author states that the solicitations of his former pupils
have induced him to prepare a second edition of a work that
was published some sixteen years ago ; and the same lack of
proportion that then characterized the work is apparent in this
rewritten edition. The title is misleading, for nervous diseases
include much more than diseases of the brain and its mem-
branes and those of the mind ; and nowhere on the title-page is
there an indication that this is a first volume in a series, as a
sentence in the seventh paragraph of the preface suggests.
Furthermore, if this was to be a comprehensive treatise, how
could anatomical detail and physiological discussion be inad-
missible, as the author states, notwithstanding the practical
aim of the work ? That he has not found this exclusion possible
is shown in his first chapter, on the cerebral circulation. Be-
sides the two cerebral pulsations mentioned on page 14 there
is the third, the vascular wave, that is also a factor in affecting
the intracranial pressure. One half of the nineteen pages in the
first chapter is a quotation from Schroeder van der Kolk. And
this is a feature of the volume, for we recall no book in which
page after page of quotation is so often encountered as it is in
this. And the quotation is not always correctly credited ; for
example, wherever M. Allen Starr's name is mentioned that of
Frederick Peterson should be inserted, as he is the deservedly-
accredited author of the chapter on insanity in Dr. Starr's
opusculum on nervous diseases.
Just as the author very properly objects to acute hydro-
cephalus a9 a nosological term, because it expresses one of the
results of tubercular meningitis, so do we object to the exag-
gerated importance he attaches to cerebral hyperemia and
anaemia, which are merely general terms expressing the results
of a variety of causes. And yet to these symptoms more space
is devoted than to many more important conditions, such, for
instance, as general paralysis.
In the chapter on meningitis, tumors and abscesses of the
brain are not mentioned in connection with the diagnosis of
that condition, and there is nothing in the volume regarding
these not altogether rare diseases of the brain.
An entire lecture is devoted to the consideration of the com-
paratively rare condition of neo-membranes of the dura mater,
while such diseases as chorea, hysteria, and paralysis agitans are
not, or but barely, mentioned.
While, as a rule, the author's therapeutical recommenda-
tions are familiar, yet his prescriptions are examples of poly-
pharmacy that one would not expect to see in a text-book of
the day: one, for instance, calls for three varieties of pepsin.
In the effort to fortify his position by quoting he has too
often obscured or eliminated the results of his own personal
study and experience, thereby rendering the work unservice-
able to the neurologist, while the unsystematic manner in which
the subject is considered makes the volume one of the least use-
ful to the medical student of any of the existing text-books on
nervous diseases.
BOOKS, ETC., RECEIVED.
Traite de medecine. Publie sous la direction de MM. Charcot, Pro-
fesseur de clinique des maladies nerveuses a la Faculte de medecine de
Paris ; Bouchard, Professeur de pathologie generale a la Faculte de
medecine de Paris, et Brissaud, Professeur agrege a la Faculte de
medecine de Paris. Par MM. Babinski, Ballet, Brault, Chantemesse,
Charrin, Chauffard, Courtois-Suffit, Gilbert, Guinon, Legendre, Marfan,
Marie, Mathieu, Netter, Oettinger, Andre Petit, Richardiere, Roger,
Ruault, Thibierge, Thoinot, Fernand Widal. Tome III. Par MM. A.
Ruault, A. Mathieu, Courtois-Suffit, A. Chauffard. Avec figures dans le
teste. Paris: G. Masson, 1892. Pp. 987. [Prix, 20 francs.]
Proceedings of the New York Pathological Society for the Year
1891.
Medical Education and Legislation. By George J. Englemann,
A. M., M. D., St. Louis, Mo. [Reprinted from the Medical Fortnightly.]
The Wills Eye Hospital, Philadelphia. Founded April 2, 1832. Re-
ports for the Years ending December 31, 1890, and December 31, 1891.
Die Accumulatoren im Dienste der Medicin. Von Dr. W. Freuden-
thal, New York. [Separat-Abdruck aus der Monatsschrift fur Ohren-
heilkunde.] •
Transactions of the Southern Surgical and Gynecological Associa-
tion. Volume IV. Fourth Session, held at Richmond, Va., November
10, 11, and 12, 1891.
Proceedings of the Philadelphia County Medical Society. Volume
XII. Session of 1891. T. B. Schneideman, M. D., Editor.
The Purification of Water by Chemical Treatment. By Willis G.
Tucker, M. D., Ph. D., Albany. [Reprinted from the Albany Medical
Annals.]
D. Hayes Agnew, M. D., LL. D. Biographical Sketch by his Pupil,
Friend, and Assistant, De Forest Willard, M. D. (Read by invitation
before the Philadelphia County Medical Society, April 13, 1892.)
A View of Modern Surgery from the Standpoint of a General Prac-
titioner. By James S. Green, M. D., of Elizabeth, N. J. President's
Address, delivered before the New Jersey Medical Society, June, 1891.
The Use of Morphine and other Strong Sedatives in Gynaecological
Practice. By Hunter Robb, M. D., Johns Hopkins Hospital, Baltimore.
[Reprinted from the Maryland Medical Journal.]
The Bacteria in Wounds and Skin-stitches. By Hunter Robb, M. D.,
Baltimore. [Reprinted from the Johns Hopkins Hospital Bulletin.]
Les pericardites experimentales et bacteriques. Rccherches du Dr.
Alfredo Rubino. Resume du Dr. G. Rummo.
Wichtige Gesundheitsregeln nicht bloss den Schulern sondern auch
den Eltern und treuen Pflegern der Jugend in wohlmcinendster Absicht
gewidmet. Von P. B. Sepp, kgl. Gymnasialprofessor. Zwcite Auflage.
Augsburg: Kransfelder'sche Buchhandlung, 1892.
Zwolf Vorlesungen iiber den Ban der nervosen Centralorgane. Fur
Aerzte und Studirende. Von Dr. Ludwig Edinger, Arzt in Frankfurt am
Main. Dritte umgearbeitete Auflage. Mit 139 Abbildungen. Leipzig:
F. C. W. Vogel, 1892. Pp. viii to 196.
696
MISCELLANY.
[N. Y. Med. Jodh.,
HI i s c c 1 1 a a n .
Medical Manhood and Methods of Professional Success. — This was
the title of a valedictory address delivered before the graduating class
of the Marion-Sims College of Medicine, at St. Louis, on April 25th, by
Dr. C. H. Hughes, professor of neurology, psychiatry, and electro-
therapy.
To-night you conclude your curriculum and comraence'vour life's
career as physicians. But only your preparatory study ends to-night,
not your pupilage. That must go on while you live. Thus far you
have done well, and your alma mater, in recognition of your acquire-
ments and appreciating your moral merits, has to-night bestowed upon
you your well-earned laurels. For the past three years (and especially
during the last eight months of your course) you have toiled faithfully,
zealously, nobly ; but if your study stops now, your energy fails, or
your zeal ends here, the life before you will be an ignoble one, your work
up to this hour will have been fruitless, and life a failure — not worth
living.
I congratulate you on your auspicious entrance into the profession.
Tou could not have decided upon a more opportune period in its his-
tory for efficient service to mankind or for satisfactory work to your-
selves. This is the electric and dynamite age of the world — its time
of greatest light and power. You enter the profession at an epoch of
most remarkable advancement — an era of grand discovery and magnifi-
cent achievement for the glory and honor of medicine and the happi-
ness of the race ; a period when the microscope has achieved for medi-
cine what the telescope has accomplished for astronomy, revealing in
that grand cosmos of the infinitely minute beyond the reach of unaided
human vision, myriads of hitherto unknown existences and laws of
physiological and pathological motion ; when chemistry has done her
almost perfect work, and biology makes a pathway plain and clear
through much of the terra incognita of the physiology of the recent
past ; and pathology, clinical medicine, and therapeutics have kept equal
pace with the electric-light illumination that has so lately been thrown
upon all physical science.
A new world of bacteriological and rnicrococcic life has been re-
vealed to the pathologist, a new meaning has been given to the term
microcosm by modern medical research. It means to the physician a
great world of infinitely minute beings — microscopic pygmies in size
and form, but giants in power to destroy, whose name is legion — the
microcosm of the lens. When the history of this world beyond the
ken of normal vision shall have been fully revealed, no fiction of
Jules Verne will equal it in wondrous revelation. Many things, there-
fore, which the profession a generation or two before us saw but dimly
and did imperfectly, we now see clearly and do with precision. The
defective and incomplete methods of research anil therapeutic resource
of the fathers have given place to clearer vision in diagnosis and greater
precision in practice. The endoscope, the test-tube, and the crucible
of the chemist supplement this wondrous illumination of the way over
which our ancestors groped in darkness. Antisepsis and the newer
therapeutics have made dangerous pathways safe to the surgeon and
averted the untoward endings of many formerly fatal diseases. They
have made once painful surgical procedures painless and rendered many
hitherto toxic processes harmless, while preventive medicine puts back
the oncoming pestilence. Medicine, as it never stood before, now stands
between the people and the pestilence, " and the plague is stayed."
The people dwell at home in security and flee no more from many of
the scourges of the past, because our profession has found out methods
to successfully combat them.
To you, gentlemen, belongs the proud honor of falling into line of
battle with the Grand Army of Medicine while it is making this forward
movement toward its grandest achievements. Foes fall before it that
once appalled the profession and baffled its greatest chieftains. Other
foes of human health and life are destined in your day (and perhaps yet in
mine) to surrender to our blows for humanity's cause: The science and
art of medicine all along the line are achieving wonderful victories for
the welfare of mankind again-t the enemies of his health. In the glory
of this conquest of the closing century you are to be sharers — all of you
if you will — and the names of some of you are destined, if you but will
it so and work with a will to that end, to become renowned as tbo-e of
great physicians and immortal human benefactors.
Lives of great men all remind us
We may make our lives sublime,
And departing, leave behind u-
Footprints on the sands of time.
I charge you then to
Be up and doing,
Witli a heart for every fate.
Still achieving, still pursuing,
Learn to labor and to wait.
Yes, to labor and to wait. Labor et patieniia. In this sign you shall
conquer in the battle of life before you. In these and other lines of
Longfellow's Psalm of Life we have the reminder of the example of
the great before us for our emulation and advancement and of the in-
fluence of our own example in turn upon the lives of those who are to
come after us in the profession ; the fruition that follows faith, hope,
courage — the stuff that all true men are made of — and fidelity to duty
and conscience, without which no man can be a true physician.
They wove bright fables in the days of old,
When Reason borrowed Fancy's painted wings,
And Truth's clear river flowed o'er sands of gold
And told in song its high and mystic things.
It is not so now. Though our ancestors in medicine saw many
things as through a glass, darkly, and imagination sufficed and sup-
planted investigation, the modern physician is a student of fact and a
diligent searcher after the unembellished truths of medical science, and
these truths are " stranger than fiction."
Hitzig's and Ferrier's cerebral localizations, Championniere's cranial
topography, Macewen's and Horsley's surgical achievements, the autopsic
verifications of others, and the spinal differentiations of Seguin and his
colleagues, have given remarkable exactness to the topical diagnosis of
brain and spinal-cord disease, so that neurology, with the aid of surgery,
now locates and removes a blood-clot, spicula of bone or morbid growth,
or empties a pus sac embarrassing, irritating, or paralyzing a speech,
arm, leg, or other psycho-motor center in the brain ; and the spinal cord
may be penetrated in the same way for the relief of certain of its focal
lesions, while deep-seated ganglia, like Gasser's, are cut out for the re-
lief of intractable neuralgias.
Indeed, so great have been the recent advances in physio-anatomical
knowledge of not long ago unknown localities and functions, and the
perfection of surgical technique, that the timidity of some and the con-
servatism of others of the older surgeons in regard to operating within
the cavities of the body has been replaced by an operative temerity that
even now demands some repression in the light of clinical experience as
to the sequences of certain surgical procedures. The annals of modern
surgery in general give us records of unprecedented audacity with the
knife. Scarcely any organ of the body escapes its saving or destructive
touch. By a chemical process Senn searches for and sews up a severed
bowel ; Billroth exsects a stomach ; German surgery extirpates a larynx
and mechanical ingenuity replaces it with a pretty fair substitute. The
lung has even been pared away under certain circumstances without
causing the death of the patient, while hysterectomy, splenectomy,
nephrectomy, oophorectomy, intestinal exsection, and the removal of
the pelvic viscera generally are, some of them, common and others are
not so frequent, but no longer impossible operations. So that the
voung graduate with surgical aspirations and eager for speedy fame has
now rather to be cautioned as to when not to operate — cautioned to
proceed with a conservative regard for his patients and to study and
employ the milder means of relief before employing that last resort of
the true physician, the total ablation of an important organ. In regard
to all of these brilliant capital operations which some of you are or will
be skilled and anxious to perform, I enjoin the golden rule, " Whatso-
ever you would that others should do unto you," under similar circum-
stances, " do you even so to them." No less, no more.
June 18, 1892.]
MISCELLANY.
G97
Virchow, Brown-Sequard, Charcot and Weir Mitchell, Hammond,
Meynert, Xothnagel, Fleehsig, Wernicke, Munk, Exner, and others, still
diligently at work, have made, up to the present time, contributions to
pathology, physiology, and neurological and clinical medicine generally!
not before surpassed in the history of the profession's progress, while
Pasteur, Formad, Toinassi-Crudelli, Laveran, Sternberg, Salisbury,
Schmidt, and others have found the light in pathology and bacteriology
for which our fathers hoped, but sought in vain.
Asiatic cholera and yellow fever are held at bay in their native lairs.
The exact nature of that once deadly mystery, malaria, whose name
confesses the ignorances of Watson and others of our not remote pre-
decessors as to its real nature, is now known. Puerperal fever, eclamp-
sia, and the autotoxic diseases generally are being unraveled. The
pathological mysteries of phthisis, tetanus, diphtheria, etc., are solved.
That opprobrium medicorum of the past — epilepsy — is now a manage-
able disease, and rheumatism has become almost as tractable as a com-
mon cold, if it were not for its unfortunate tendency to constantly re-
cur. Skin and bone are now transplanted and made to grow on dermal
sail once too barren for their sustenance, and arteries are ligated and
intestines sutured with animal fiber. The abdominal and thoracic cavi-
ties are no longer forbidden ground to surgical interference. Lapa-
rotomy is triumphant. Penetrating wounds of these regions are no
longer sealed and their unfortunate victims left to the tender mercies
of fate and the vis medicatrix naturce.
You have been taught the nature and differentiation of nervous con-
ditions, but it has not been long since to be nervous was to be simply
indefinitely miserable to the physician, and grave neuropathic conditions
which are now well known had no certain pathology and received no
treatment.
Within comparatively a few years syringomyelia, acromegaly, exoph-
thalmic goitre, poliomyelitis anterior, progressive muscular atrophy and
its antipodal paralytic condition pseudo-hvpertrophic muscular paraly-
sis ; posterior, lateral, anterior and postero-lateral spinal sclerosis, pe-
ripheral neuro-tabes, polyneuritis and the chronic toxic neuritides gen-
erally, athetosis, Landry's paralysis, bulbar paralysis, Friedreich's ataxia,
paramyoclonus multiplex, morbus Thomsenii, paresis, paranoia, dipso-
mania, aphasia, Jacksonian epilepsy, polyneuritis, and too many other
diseases of the nervous system — central and peripheral — to be here
enumerated, have been diligently studied and accurately differentiated,
evidencing astonishing activity in clinical and pathological investiga-
tion.
Cardiac, pulmonary, laryngeal, and cutaneous affections, surgical and
gynaecological diseases and those of the eye, ear, and every other organ,
and many of the fevers are better defined and managed than they were
even a few years ago, and scarcely any region or organ of the body is
mow exempt from surgical resource. Spencer Wells, Lawson Tait, and
.Marion Sims began their eminent careers and became famous for their
work during the last third of this century.
Thus you see the past and the present have bequeathed to you a
Tich legacy of clinical and pathological knowledge, the accumulation of
years of laborious research. What will you add to the scientific heri-
tage ? You certainly owe to your medical ancestry and to the world's
posterity your best efforts to increase the store of fact you have so
freely received.
The knowledge of the physiology of the almost omnipresent nervous
and its attendant vascular system has so far advanced that we now ap-
pear to be fully familiar with the last factor in the phenomena of that
wonderful discovery of the circulation whose initiative was made by
Galen and Harvey — namely, that of the neural mechanisms of arteriole
control through the vaso-motor and vaso-constrictor nerves. This added
to the heart's propulsion, the vis a tergo, and the heart's exhaust, the
vis a f route, with what we know of the impressibility of the intracardiac
ganglia of Ludwig, Remak, and Bidder, and of the regulating vagus and
cardiac inhibitory nerve influence, gives to our knowledge of the circu-
lation of the blood the appearance of the finality of a complete dis-
covery.
New views of the function of the cerebellum in its relation to the
cerebrum, at variance with the views of Flourens long accepted by the
profession, have been advanced even pending your pupilage, notably
those of Luciani, whose studies in the normal and pathological physi-
ology of this important organ I commend to your consideration. In
fact, Luciani, as his accomplished reviewer, Seppilli, asserts, has de-
stroyed Flourens's theory and assigned to the cerebellum trophic func-
tions like those of the ganglia of the great sympathetic. The balancing
power or equilibrating function of this organ seems, according to
Lueiani's exhaustive researches, to be secondary to cerebellar toni-
city.
According to this eminent and most recent Italian investigator,
three classes of phenomena characterize the healthy functioning of the
cerebellum — viz., sthenic, tonic, and static neuro-muscular power —
while damage to the cerebellum, sufficient to destroy its function,
causes asthenic, atonic, and astatic neuro-muscular phenomena, and
besides, his conclusions are in the direction of the functional unity of
action of this organ, contrary to the views of Nothnagel. The theory
of Flourens has been assailed in a different manner by Tolet, he giving
to the cerebellum function of psychical sensibility.
How truly, then, can I cordially congratulate you, gentlemen, on the
present auspicious beginning of your life work !
You have, by diligent industry and zealous endeavor, placed your-
selves abreast of this wonderful progress the profession has been mak-
ing, even some of it since you commenced your studies.
Omens of work already done give hopeful augury of a yet more
victorious future. But you still have work before you, and much of it
in contributing to unfold the yet unraveled mysteries of medicine. The
present epidemic of influenza will claim your study, as it is engaging
professional attention almost throughout the world, as a toxic neurosis,
and the nature of the grippe toxine, as a poison of the nervous system,
whether microbic or otherwise, is being closely investigated and will de-
mand your attention. Even while I write, this subject is being eluci-
dated by Babfes, Pfeffer, and Canon, and some of you may make per-
fectly plain this and other unsolved problems to the final satisfaction
of the scientific world. Why not ? What man has done man may do.
What graduates of other colleges have done the graduates of this
school may do. Any of you may become great if you will, and be bene-
factors of your race and have your names enrolled high on the key-
stone of " Fame's triumphal arch." Mayhap some of you may be
accounted by posterity as among the " few immortal names that were
not born to die." At all events, it will not harm you if you strive
for a place in history with the Turcks, Wallers, Hunters, Harveys,
Ferriers, Jenners, Grosses, or Flints. Aim for the top even though
you may not be able to climb beyond the middle rounds of the ladder
of Fame.
The best calling in life is that which, after contributing sustenance
to the worker, bestows the most good upon mankind. That calling is
Medicine. It cares for the body of man and fits its tenant, the soul,
for all the duties and demands of life. Mens sana in corpwe sano is a
maxim handed down to us from the ancient masters.
Without disparaging other professions or occupations, it can not be
disputed that the practice and teaching of the medical art is the highest
of benefactions. It is the greatest of charities as it is the noblest of
human callings. The ministry of love was the life-work of the Divine
Master, for though he began his mission as a carpenter' and loved to
dispute, as a boy, with the philosophers in the temple, he concluded
his career as a physician of both body and soul, and went about heal-
ing the sick and doing good. He was the Great Physician.
The greatest and mightiest word that ever proceeded from the mouth
of God or his apostles was " charity " — the fatherly love of God and
the fraternal charity of man. St. Paul pronounced charity the highest
of the virtues, and one of the sweetest-minded of the apostles was
Luke, the good physician. The two professions that practice true
charity more than all others are those of Medicine and Divinity, and in
them the physician and the divine go hand in hand. There are no two
of the callings of men so closely allied in their work. That true charity
which considers in every aspect the welfare of our fellows, brings the
doctor of divinity and the doctor of medicine close together. It was
the appreciation of the true charity of our noble profession that caused
Cicero to regard the physician as near the gods.*
* " Homines ad deos nulla re proprias accedunt quani saluteni
hominibus dando."
698
MISCELLANY.
[N. Y. Med. Joue.,
With the highest human sanction and the Divine example, I com-
mend to you the practice of charity. It will do you good all the days
of your life as well as those who may be the recipients of your minis-
trations.
It falleth like the gentle rain
Upon the place beneath,
And is twice blessed ;
It blesseth him that gives
And him that takes.
The study of the physician includes the moral as well as the physi-
cal well-being of man, for the purity of the soul has much to do with
the health of the body. The purity of the heart and the dominance of
the body by principles of rectitude has much to do with the health and
consequent happiness of present and succeeding generations. The direct
and hereditarily entailed diseases which are the offspring of sin, and vice
versa, which have filled and are filling the land with misery and woe,
both physician and divine are alike especially interested in preventing.
The psychology of sin and the pathology of crime are studies alike for
doctor and divine.
The man who is sick in his soul is seldom well in his body, and the
soul's affairs do not prosper well when the body is disordered.
Like the divine, the physician may also aid in healing " the wound-
ed in spirit and the broken-hearted," and in " binding up their wounds."
He may " minister to a mind diseased," and " with sweet oblivion's an-
tidote cleanse the stuffed bosom of that perilous stuff which weighs
upon the heart." He does this effectually through the modern success-
ful management of melancholia.
Besides the bedside treatment of disease, therefore, your calling is
one of the noblest and most indispensable of the vocations of men.
You sustain a most intimate relation to the people in their " hours of
ease " and freedom from the presence of plainly perceptible disease.
The populace is never free from the present or antecedent impress of
disease upon their bodies and minds. Its active potency in preceding
generations impresses itself upon the psychological character and physi-
cal power of nations as well as individuals. They rise or fall in physi-
cal prowess or moral greatness through the sanitary or unsanitary influ-
ences which promote or arrest the development or blast the life of the
primordial cell, and individuals, singly or in aggregate, grow into giant
grandeur or dwarf to pygmy insignificance — psychical or physical — as
their physiological or pathological environment and organic antecedents
permit and ordain.
This is a fact which medicine has established. This is what our
profession has to teach all the people. It is the importance of medical
research to the people's welfare that has led to the demand of the profes-
sion generally for higher medical education and of the American Medical
Association for a National Health Department and a physician in the
Cabinet, and some of you will live to see this much-needed advance ac-
complished. Some among you may even fill that important position.
When this consummation of the people's highest welfare, " so devoutly
to be wished," shall have been accomplished, then will the nation begin
to realize what as yet it appreciates but faintly, that the perfection of
the human species is possible only through the means supplied and ways
pointed out by our profession — a fact long ago indicated by Descartes :
" STil est possible <h perfcctionner Pespioe humaine, c'est dans la medecine
q\Cil faut en ehereker leu moyens"
The problems you will be called on to solve are those of the effects
of alcohol and other drink and drug habits and vicious indulgences, and
the many other devitalizing propensities and passions of our times,
teratological defects, insanity, acquired and transmitted, the psychical
and physical interrelation of mind and organism, the relationship of
organism to mental endowments and imperfections, faulty methods of
education, wrong manners of living, improper modes of travel, and some
of the unsanitary social customs of the times on the generation now
coming on the stage of life's action, and the entail of these neuropathic,
psychical, and social vices, manners, customs, and habits upon posteri-
ty, as well as the more obvious demands of the diseased patients who
will personally seek your ministrations, and of public and personal hy-
giene.
You are to be sanitarians in the broadest sense of the term ; educa-
tors of the people in the chief essentials of their temporal if not spirit-
ual welfare.
The physical and psychical sanitation of the nation is in the hands
of its physicians. They are the prophets whose precepts, wisely ac-
cepted and practiced by the people, will save the nation from that in-
evitable decadence which must attend in the future, as it has in the
past, on failure to follow the true teachings of sanitary science of body
and mind.
Your vocation has in it, as you see, an element of the highest
patriotism.
A wise physician, skilled our wounds to heal,
Is more than armies to the public weal.
Aim high, then, and nobly, and persevere. " Let all the ends thou
aim'st at be thy God's and Truth's." Then if thou fallest, " thou shalt
fall a blessed martyr." But you will not fail. And here let me recall
the inspiring rejoinder of that great cardinal of France to the timid
youth who ventured to suggest the possibility of a misadventure :
In that bright lexicon of youth,
Where Fate holds forth the promise
Of a glorious manhood,
There's no such word as fail.
There should be no such word in your dictionary. Be brave, be
true, and persevere. Train your courage by careful study of your capa-
bilities and defects, your adaptabilities and powers. Though pluck is a
plant whose seed is in the nature, it improves by cultivation. Cultivate
your courage, train your powers. Perseverentia omnia vincit, Labor
omnia vincit, are old and true working maxims for youth and age. In
the conflict of life, as in physical conflict, " the battle is not to the
strong alone, but to the brave, the vigilant, the active," and I am con-
vinced, from a life of observation, that Providence assists the always
courageously true and deserving, and helps to make them strong. This is
my faith. Be true in every trial and falter not and you will not fail. You
may often fall, but, like Antseus of old, you will rise again with renewed
strength for the battle of life before you. Courage is an inspiration.
Buckle on your armor and never say die. If you must fall, fall as the
valiant falls, with face to the foe and defiance on your brow. Such
failures are victories. They are triumphs which true courage always
brings to the unvanquished soul. The bright ideals and high aspira-
tions of this hour may not all be fullv realized. Some of your fondest
hopes may be cruelly crushed as you travel toward that unknown fate
which awaits every mortal. The true soul is purified in fires of adver-
sity and disciplined by its trials to deeds of greater valor. Some of you
may have spent your last dollar and feel depressed and gloomy at the
close of your work. To such I would say, Do not despair. Hope 1
Hope on ! Hope ever !
With manly courage, ceaseless endeavor, and unfaltering faith, push
on and you shall yet see the silver lining to the clouds and the sun
finally burst forth to brighten your pathway through life to a glorious
future, all the more glorious for your trials. After every storm a rain-
bow of hope and promise skirts the sky of the brave. With faith in
steady work and an exalted, honorable ambition as tributary to success,
I enjoin you to apply yourself diligently, steadily, systematically, and
persistently. A moderate amount of work, free from all enervating
vices and interspersed with adequate recreation for recuperation and
the maintenance of your physical vigor, will work a marvel of final suc-
cess for each of you.
Work with your hands, work with your mind,
Just as your nature has fitly designed ;
Build ye a temple, hew out a stone,
Do ye a work just to call it your own.
Write out a thought to brighten the labor
Of that one who reads — it may be your neighbor.
Work as each day hastens away,
Bearing along the grave and the gay ;
Live out a life of excellent work.
Thus you shall weave for yourselves and mankind " garlands of work
to brighten the earth."
And now, before concluding, I must remind you that your general,
June 18, 1892.]
MISCELLANY.
as well as your special, professional education is not yet complete. It
will be your dufy in continuing your education to endeavor to give to
your minds and bodies " all the force, all the beauty, all the perfection
of which they are capable," to cultivate the good, the true, and the
beautiful in yourselves and in your surroundings. This was Plato's idea
of the best education. It has not been improved on since his day. It
includes purity of body and mind, cleanliness of heart and soul, virtue,
temperance, truthfulness, and industry.
I have already advised you to aim high, to work hard, and to perse-
vere. This is a proper ambition, but there should be even a higher
purpose in life. That purpose is to so discharge one's duty as to de-
serve not only the approbation of mankind, but to secure the approval
of God.
In your ambition to rapidly succeed, do not soil your souls with
sordid avarice, " nor bend the pregnant hinges of the knee that thrift
may follow fawning."
(io forth among men .... mailed
In the armor of a pure intent.
Do not natter [the world's]
Rank breath, nor bow
To its idolatries the patient knee,
Nor coin [your] cheeks to smiles, nor cry aloud
In worship of an echo.
While you have a due regard for your personal interests, so practice
your noble calling in the spirit of a generous love for your fellow-man
that you may feel at the end of your lives that you have been true to
the better elements of your nature. Conform to the dictates of your
consciences in everything. Be unfalteringly true to your several con-
victions of duty. Listen always to that still small voice within, which,
if ever faithfully obeyed, will prove your guiding star and compass to a
successful and satisfactory career.
In your study of the human organism in health and disease — its
growth, development, teratological and morbid entailments, and the ef-
fects of habit and environment upon it — you have seen enough to warn
you, had you needed the warning of Holy Writ, that " as a man sows,
that shall he also reap," in his moral as in his physical nature.
As there are " sermons in stones, books in the running brooks," and
for our instruction, " good in everything," so the wise physician, from
his peculiar studies, reads to himself an instructive sermon on rectitude
of conduct and right moral and physical living. He knows well the
physical and psychical recompenses of right and the retributions of
wrong conduct, through the organism's immutable laws of well or ill
being, and it will be your duty to follow the right paths and rightly lead
the people. You know also of the automatisms of the mind which grow
out of mental repetitions and form habits, that " as a man thinketh in
his heart, so is he." That is, the thoughts he habitually cherishes make
his character. This is the law of the interrelated and interdependent
psychical and physical function of brain and mind ; the law of mental
habit.
This no preacher of the gospel of the Immaculate Immanuel could
better prove to the people than the educated physician.
Finally, in the language of one of America's greatest statesmen —
none other than the great Daniel Webster — let me remind you that " pro-
fessional fame fades away and dies with all things earthly. Nothing of
character is really permanent but virtue and personal worth ; these re-
main. Whatever of excellence is wrought in the soul itself belongs to
both worlds. Real goodness doth not attach itself merely to this life.
It points to another world. Political or professional reputation can not
last forever ; but a conscience void of offense toward God and man is
an inheritance for all eternity."
The American Neurological Association will hold its eighteenth an-
nual meeting in New York, at the Academy of Medicine, on June 22d,
23d, and 24th. The preliminary programme includes the following
titles :
The Pathology of Paralysis Agitans, by Dr. Charles L. Dana ; Sepa-
rate Provision for Epileptics, both Public and Private, by Dr. Henry
R. Stedman ; A Study of the Sensory and Sensory-motor Disturbances
associated with Insanity, from a Biological and Physiological Stand-
point, by Dr. H. A. Tomlinson ; Phthisis in its Relation to Insanity and
other Neuroses, by Dr. Thomas J. Mays ; The Successful Management of
Inebriety, by Dr. C. H. Hughes ; The Seat of Absinthe Epilepsy, by
Dr. Isaac Ott ; On the Extent of the Visual Area of the Cortex in Man,
as deduced from the Study of Laura Bridgman's Brain, by Dr. H. H.
Donaldson ; The Criminal Brain, illustrated by the Brain of a Murderer,
by Dr. H. H. Donaldson ; Researches upon the ^Etiology of Idiopathic
Epilepsy, by Dr. C. A. Herter ; Report of Two Cases of Fracture of the
Spine in which Operations were performed for the Relief of Sensory
Symptoms, by Dr. Graeme M. Hammond ; Progressive Muscular Atro-
phy— Presentation of Specimens, with Remarks on the Functions of
Certain Cell Groups in the Anterior Horn, by Dr. Graeme M. Hammond ;
A Case of Brain Tumor, with Presentation of the Specimen, by Dr.
Wharton Sinkler ; Report of a Case of Infantile Cerebral Hemiplegia,
with Autopsy (Microscopical Preparations by Dr. Warren Coleman), by
Dr. E. D. Fisher; Report on One Hundred and Sixty Cases of Epilepsy,
by Dr. S. G. Webber ; Presentation of a Case of Huntington's Chorea,
also one of Congenital Huntington's Chorea, the First on Record, by
Dr. Landon Carter Gray ; A Further Contribution to the Pathology of
Arrested Cerebral Development, by Dr. B. Sachs ; A Case of Cerebral
Tumor illustrating the Difficulties of Diagnosis, by Dr. B. Sachs ;
Traumatic Nervous Affections, by Dr. Philip Coombs Knapp ; A Note
on the Use of Exalgine in Painful Nervous Affections, by Dr. W. C.
Krauss ; Two Cases of Severe Pressure Neuritis, by Dr. W. C. Krauss ;
Westphal and his Neurological Work, by Dr. W. R. Birdsall ; The As-
sociation of Hysterical Trembling and Anorexia Nervosa, with the Re-
port of a Case, by Dr. James H. Lloyd ; Sleep Movements of Epilepsy,
by Dr. J. W. Putnam ; Diabetes in its Complementary Relations to
Certain Forms of Mental Defects, by Dr. E. C. Spitzka ; Imperative
Movements associated with So-called Pseudo-hypertrophic Infantile
Palsy, by Dr. E. C. Spitzka ; A New Symptom indicating Combined
Cerebellar and Spinal Inco-ordination, by Dr. E. C. Spitzka ; The Basis
of the Prognosis in the Traumatic Neuroses, by Dr. J. J. Putnam ; Mi-
croscopic Specimens illustrating: 1. The Nerve Alterations in a Case
of Beri-Beri. 2. The Nerve Alterations in a Case of Scleroderma. 3.
The Alterations in Nerves excised for Neuralgia, by Dr. J. J. Putnam ;
Some Contributions to the Study of the Muscular Sense, by Dr. G. J.
Preston ; Fissural Studies, by Dr. Burt G. Wilder ; Preliminary Report
of the Committee on Neuronymy ; Three Cases of a hitherto Unclassi-
fied Affection resembling, in its Grosser Aspects, Obesity, but asso-
ciated with Special Nervous Symptoms — a Trophoneurosis possibly Re-
lated to Diseases of the Thyreoid Gland, not Myxedema, by Dr. F. X.
Dercum ; Two Cases of Acromegaly, with Remarks on the Pathology
of the Disease, by Dr. F. X. Dercum ; Description of an Additional
Chinese Brain, by Dr. F. X. Dercum ; The Toxic Origin of Insanity, by
Dr. T. H. Kellogg ; Folie a deux, with Remarks on Similar Types of In-
sanity, by Dr. Charles K. Mills ; and Three Cases of Folie communi-
quee, by Dr. J. H. Lloyd.
The American Climatological Association will hold its ninth an-
nual meeting at Richfield Springs, N. Y., on June 23d, 24th, and 25th,
under the presidency of Dr. Willis E. Ford, of Utica, N. Y. The pre-
liminary programme announces the following titles : An address of wel-
come by Dr. C. E. Ransome, of Richfield Springs ; the address of the
president, The Element of Change per se in the Climatic Treatment of
Diseases ; The Shurly-Gibbes Treatment tof Tuberculosis, by Dr. E.
Fletcher Ingals ; Slow Breathing in Phthisis, by Dr. Carl Ruedi ; The
Treatment of Phthisis by the Pneumatic Cabinet, by Dr. C. E. Quimby ;
A Further Report on the Treatment of Phthisis in Colorado, by Dr. S.
E. Solly ; The Results of Tuberculin and its Modifications at the Adi-
rondack Cottage Sanitarium, by Dr. E. L. Trudeau ; Experience with
Guaiacol in the Treatment of Tuberculosis, by Dr. A. Jacobi ; The Use
of Tuberculin a Safe and Important Aid in Selected Cases, by Dr. C.
Denison; The Hygiene of Bathing, by Dr. F. II. Bosworth ; The Classi-
fication of Mineral Waters, by Dr. A. N. Bell ; Heart Failure, by Dr. A.
L. Loomis ; Altitude in Affections of the Heart, by Dr. Frederick I.
Knight ; Cardiac Disease Consequent on Epidemic Influenza, by Dr. R.
(i. Curtin ; The Effect of Change of Posture on Heart Murmurs, by Dr.
V. Y. Bowditch ; a discussion on The Influence of Bacteriological In-
vestigation on Preventive Medicine; Underground Water Currents,
700
MISCELLANY.
[N. Y. Med. Joru.
Causes and Results of Deflection, by Dr. Leroy J. Brooks ; and The
Causes of Death in Lobar Pneumonia, by Dr. G. R. Butler.
The American Laryngological Association will hold its fourteenth
annual congress in Boston, in the hall of the Natural History Society,
on June 20th, 21st, and 22d, under the presidency of Dr. S. W. Lang-
maid, of Boston. Besides the president's address, the programme gives
the following titles :
The Present Status of the Treatment of Hay Fever, by Dr. C. E. Sa-
jous ; The Influence of Certain Diathetic Conditions upon the Prognosis
in Operations upon the Throat, by Dr. D. Bryson Delavan ; Some Patho-
logical Conditions of the Upper Air Passages accompanying La Grippe
Attacks, by Dr. S. Hartwell Chapman ; Pharyngo-mycosis, by Dr. F. I.
Knight ; A Case of Carcinoma at the Base of the Tongue, by Dr. Jona-
than Wright ; A Case of Cancer of the Tonsil treated by Lactic Acid,
by Dr. E. Fletcher Ingals ; Report of Some Cases of Membranous Sore
Throat, by Dr. Beverley Robinson ; Intubation for Chronic Subchordal
Stenosis of the Larynx in a Boy Twelve Years of Age, by Dr. C. H.
Knight ; Rare Forms of Laryngeal Growth, by Dr. Alexander W. Mac-
Coy ; A Case of Tumor of the Larynx, by Dr. H. L. Swain ; Two Cases
of Laryngectomy for Malignant Disease, by Dr. J. Solis-Cohen ; The
Value of Sprays in the Treatment of Catarrhal Affections of the Upper
Air Passages, by Dr. Clarence C. Rice ; Nasal Hydrorrhcea, by Dr. C.
E. Bean ; An Eligible Method of repairing a Broken Nose, by Dr. W.
H. Daly ; The Correction of Deformity resulting from Abscess of the
Nasal Sseptum, by Dr. John 0. Roe ; The After-results of Nasal Cauteri-
zation, by Dr. T. A. DeBlois ; Diseases Incident to the Frontal Sinus, by
Dr. D. N. Rankin ; and A Case of Suppurating Ethmoiditis, by Dr. J.
H. Bryan.
Mortality in Cities in the United States. — The following table
represents the mortality in the cities named, as reported to Dr. Walter
Wyman, Surgeon-General of the Marine-Hospital Service, and pub-
lished in the Abstract of Sanitary Reports for June 10th:
New York, N. Y June 4.
Philadelphia, Pa May 21.
Philadelphia, Pa May 28.
Brooklyn, N. Y May 28.
St. Louis, Mo May 28.
Boston, Maes June 4.
Baltimore, Md June 4.
San Francisco, Cal . . . May 28.
Cincinnati, Ohio June 3.
Cleveland, Ohio May 28.
Cleveland, Ohio June 4.
New Orleans, La May 14.
New Orleans, La May 21.
New Orleans, La May 28.
Pittsburgh, Pa May 28.
Detroit. Mich June 4.
Milwuukee, Wis May 28.
Minneapolis, Minn. . . June 4.
Louisville, Ky June 4.
Rochester, N.Y June 4.
Providence, R. I June 4.
Denver, Col May 21.
Denver, Col j May 28.
June 3.
May 28.
June 4.
June 4.
June 4.
June 4.
May 28.
Toledo, Ohio.
Richmond, Va
Nashville, Tenn . .
Portland. Me
Binghamton, N. Y
Mobile, Ala
Auburn, N. Y
Auburn, N. Y I June 4.
Newton, Mass May 28.
Newton, Mass June 4.
San Diego, Cal May 28.
Pensacola, Fla j May 28.
II
§■3
1,515
1,046
1,046,
800
451
44R
434
298,
206
261,
261
242
242
242
238.
205
204.
164.
161,
133.
132.
106,
106.
81,
81.
76!
36,
35
31,
25,
85,1
24,
24,
16,
11,
DEATHS FROM-
868
432
404
310
146
209
161
119
119
102
103
161
163
162
81
Mil
70
54
49
51
53
28
29
17
37
26
12
9
21
10
8
1
4
2 26
16
18
5
2
4
8
3
1
'S-i 3*
ri
Chairmen of Committees on Anatomical and Biological Nomencla-
ture ; Correction. — In a circular entitled American Reports upon Ana-
tomical Nomenclature issued last winter by Professor Wilder, as secre-
tary of the committee of the Association of American Anatomists, in
the third paragraph of the third page, the chairman of the committee
of the Anatomische Gesellschaft should be Professor A. von Kolliker,
and the chairman of the American division (appointed in 1891 by the
American Association for the Advancement of Science) of the Interna-
tional Committee on Biological Nomenclature should be Professor G. L.
Goodale. Professor Wilder desires to express his regret for the errors,
due in the one case to his own misapprehension and in the other to
a clerical mistake.
The late Dr. William R. Birdsall.— At a meeting of the medical
board of the Manhattan Eye and Ear Hospital, held on June 10th, the
following preamble and resolution were adopted :
Whereas, It has pleased Almighty God to remove from our number
Dr. William R. Birdsall, one of the physicians to this hospital ;
Resolved, That in bowing to his will we desire to express our esteem
and love for Dr. Birdsall as our colleague and friend, and our sense of
the great loss sustained by the hospital in the removal of one of our
most faithful and efficient workers, who has made valuable contribu-
tions to the science of medicine; that the sincere sympathy of this
board be extended to his family in their deep affliction; that the board
in a body attend his funeral ; and that these resolutions be spread on
the minutes of the board and be published in the Medical Record and
the New York Medical Journal.
[Signed.] D. B. St. John Roosa, M. D., Charles H. Knight, M. D.,
President. Secretary.
To Contributors and Correspondent*. — The attention of all who purpose
favoring us with communications is respectfully called to the follow-
ing:
Authors of articles intended for publication under the liead of " original
contributions " are respectfully informed that, in accepting such arti-
cles, we always do so with the understanding that the following condi-
tions are to be observed: (1) when a manuscript is sent to this jour-
nal, a similar manuscript or any abstract thereof must not be or
have been sent to any other periodical, unless we are specially notified
of the fact at the time the article is sent to us ; (2) accepted articles
are subject to the customary rules of editorial revision, and will be
published as promptly as our other engagements will admit of — we
can not engage to publish an article in any specified issue ; (3) any
conditions which an author wishes complied with must be distinctly
staled in a communication accompanying the manuscript, and no
new conditions can be considered after the manuscript has been put
into the type-setters'1 hands. We are often constrained to decline
articles which, although they may be creditable to tlieir authors, are
not suitable for publication in this journal, either because they are
too long, or are loaded with tabular matter or prolix histories of
eases, or deal with subjects of little interest to the medical profession
■ at large. We can not enter into any correspondence concerning our
reasons for declining an article.
All letters, whetlier intended for publication or not, must contain the
writer's name and address, not necessarily for publication. No at-
tention will be paid to anonymous communications. Hereafter, cor-
respondents asking for information that we are capable of giving,
and that can properly be given in this journal, will be answered by
number, a private communication being previously sent to each cor-
respondent informing him under what number the answer to Ms note
is to be looked for. All communications not intended for publication
under the author's name are treated as strictly confidential. We can
not give advice to laymen as to particular cases or recommend indi-
vidual practitioners.
Secretaries of medical societies will confer a favor by keeping us in-
formed of the dates of their societies'1 regular meetings. Brief notifi-
cations of matters that are expected to come up at particular meet-
ings will be inserted when they are received in time.
Newspapers and other pidAications containing matter which the person
sending them desires to bring to our notice should be marked. Mem-
bers »f the profession who send us information of matters of interest
to our readers will be considered as doing them and us a favor, and,
if the space at our command admits of it, we shall take pleasure in
inserting the substance of such communications.
All communications intended for the editor should be addressed to him
in care of the publishers. a
All communications relating to the business of the journal should be ad-
dressed to the publishers.
THE NEW YORK MEDICAL JOURNAL, June 25, 1892.
(iVighml Communications.
POTT'S FRACTURE AT THE ANKLE*
By LEWIS A. STIMSON, M. D.,
SURGEON TO THE NEW YORK AND CHAMBERS STREET HOSPITALS.
At the time when the courteous invitation of your sec-
retary to read before you a paper " on some practical point
connected with fractures or dislocations " reached me I had
under treatment three cases showing unusual varieties of a
common fracture. It is one in which I have long felt an
especial interest as a hospital surgeon and a teacher, be-
cause of what I believe to be the frequency with which
cardinal points in the treatment are overlooked and because
of the occasional great disability that results. The idea
which at once suggested itself — that the injury in question
was an appropriate subject for the desired paper — was con-
firmed on reflection, and I therefore ask your attention to
a consideration of some points connected with the diag-
nosis and treatment of Pott's fracture at the ankle.
Certain variations in the current use of the name and
in the classification of injuries at the ankle make it desira-
ble to define at the outset the injury we have in mind. By
Pott's fracture at the ankle I mean that common injury
produced usually by a forcible twist of the foot outward,
and consisting (typically) of (l) a fracture of the fibula
from one to three inches above the tip of the malleolus,
(2) a fracture of the internal malleolus or a rupture of the
internal lateral ligament, and (3) a diastasis of the lower
tibio-fibular articulation with rupture of its ligaments, or,
possibly with avulsion of the adjoining portion of the
tibia.
Of these lesions, the fracture of the fibula is, clinically,
the most striking and the most easily recognized, and this
fact has a constant and well-marked tendency to fix the at-
tention upon this one of the three lesions to the exclusion,
or at least to the subordination, of the others — a tend-
ency that is full of danger for the patient for reasons that
are apparent on a closer examination. The fracture ap-
pears usually to be oblique, often very markedly so (in a
specimen of my own the line of fracture is more than two
inches long), but the maximum of crepitus and abnor-
mal mobility appears on manipulation to be well above the
malleolus, a feature which is ordinarily sufficient at once to
distinguish this form of fracture from another of much less
importance which is apparently produced by inversion of
the foot, and in which the line of fracture is situated at or
near the base of the malleolus. A few cases have been re-
eorded in which the fracture was in the middle third of the
fibula or even still higher; and in some of my cases the
fibula was unbroken, a point to which I shall return in a
moment.
The lesion that stands second in clinical prominence is
the fracture of the internal malleolus or the equivalent
rupture of the internal lateral ligament. In this the varia-
* Read by invitation before the Massachusetts State Medical Society
June 7, 1H'J2.
tions in the position and extent of the injury are more
striking than in the preceding one. The common form is
rupture of the ligament, the less common one is fracture ;
and the fracture presents two typical forms. One of them
is the equivalent of rupture of the anterior portion of the
ligament, and has the same mode of production ; in it only
a small portion of the malleolus — an anteroinferior frag-
ment— is broken off, the line of fracture being oblique up-
ward and forward. In the other the whole malleolus is
broken square off at its base, and the mode of production
is quite different, as will be subsequently explained ; in my
experience it has always coincided with the extreme out-
ward displacements of the foot.
The third lesion is the rupture of the ligaments of the
lower tibio-fibular articulation. In a few recorded cases,
instead of rupture of the anterior ligament, avulsion of the
portion of the tibia to which it is attached has taken place ;
in only very few of the specimens which I have had an op-
portunity to examine, either post mortem or in the course
of an operation or of an experiment upon the cadaver, have
I found this fracture, and then it has been only an avulsion
of a superficial scale of bone; I believe that even such
superficial fracture is rare.
The effect of this rupture or avulsion of the ligament is
to loosen the mortise within which the astragalus is held
and thus to permit the displacement of this bone (and, of
course, of the foot) outward. The displacement thus made
possible is at once effected by the continued action of the
vulnerant force ; and if the weight of the individual is then
brought upon the foot, the lack of coincidence between the
point of support at the heel and the long axis of the leg
leads instantly to further displacement in the same direc-
tion, and possibly to important additional injuries. An-
other result of this loosening of the mortise — one which is
of much practical importance but which has received only
scanty attention in systematic treatises — is the backward
displacement of the astragalus along the lower surface 'of
the tibia. This may be slight— an eighth, a quarter of an
inch — or so great that the body of the astragalus lies
wholly behind the tibia. It is effected in part by the con-
traction of the sural triceps and in part by gravity when
the limb is supported in the usual horizontal position. I
have never seen the extreme form in cases less than twenty-
four hours old, and I associate it, npt with correspond i no-
severity in the causative violence, but with persistent, unop-
posed action of the sural muscles — in other words, with
absence of treatment or with defective treatment.
If these two displacements, the outward and the back-
ward, remain uncol lected, the resultant disability is great.
The former removes the point of support so far to the outer
side that an excessive strain is brought, in walking, upon
the ligaments on the inner side of the ankle, and the patient
is soon compelled to stop. The backward displacement, if
slight, limits the range of flexion of the joint ; if great, it
abolishes it completely.
Except in the more marked cases, and unless specifically
sought for, this diastasis of the tibio-fibular joint and the
symptoms to which it gives rise can be easily overlooked,
702
STIMSOX: POTT'S FRACTURE AT THE ANKLE.
[N. Y. Med. Jotjb.
and yet it is the essential lesion of the injury — one which
vastly outweighs the fracture of the fibula in importance (as
we have seen, the latter may even be absent), and one with-
out which the lesions on the inner side of the ankle would
probably be impossible. Without correction of this dis-
placement and repair of these torn ligaments, a satisfactory
recovery from the injury can not be had. This, then, is
the feature which characterizes the injury and dominates
the treatment. It is by the recognition of its presence that
the diagnosis is made, and by the completeness of its repair
that the efficiency of the treatment is measured.
This rupture of the tibio-fibular ligaments and the out-
ward displacement of the foot were recognized by Dupuy-
tren and have formed part of most systematic descriptions
since his time, but the current notion of the change in the
relations of the parts has always been, and apparently still
is, that which is indicated in Percival Pott's original illus-
tration, and it seems not unlikely that this illustration is re-
sponsible for it, for it has often been reproduced and is still
doing duty. This notion is that the astragalus and the
lower fragment of the fibula have been rotated ten or twenty
degrees about an antero-posterior axis passing through the
tibio-fibular joint, so that the upper end of the lower frag-
ment is pressed inward against the tibia, the apex of the
malleolus is directed obliquely outward, and the upper sur-
face of the body of the astragalus is separated from the ar-
ticular surface of the tibia by an angular space which is
widest at the inner side. This conception of the change is
erroneous : there is no angular change in the relations of
the astragalus and tibia, but the former has simply slipped
sideways along the latter ; the upper end of the lower frag-
ment of the fibula has not been displaced inward (indeed, a
glance at the skeleton will show that there is no room for
such a displacement), but the lower part of that fragment
has been pushed outward by the displaced astragalus.
The mode of production is, clinically, sometimes quite
clear, as when the foot is fixed and the body is thrown to-
ward the same side, or, the foot being fixed, the lower part
of the leg is pressed forcibly inward ; in either case fibular
flexion (eversion of the sole) is made at the ankle. This
mode of production is relatively infrequent ; to it belong
the square fracture of the malleolus at its base and the ex-
treme displacements of the foot outward that are sometimes
noted. In some of them I have'also found the lower frag-
ment of the fibula smaller and more movable than usual. It
can be copied upon the cadaver with great precision by fix-
ing the os calcis in a vise and pressing the upper part of the
leg outward.
Clinical proof of what I believe to be the other and much
the more common mode of production is exceedingly diffi-
cult to obtain, notwithstanding the frequency of the fract-
ure. Patients can seldom say more than that they slipped
and twisted the foot ; most of the few who can specify the
direction of the twist say that it was outward ; one of my
patients insisted that his foot turned inward, but he added
that when he rose after the fall and tried to walk he felt and
heard something break at the ankle, so that the case can not
serve as evidence that inward rotation can produce the le-
sions. Occasionally the mechanism seems clear, as in two
cases under my care this spring: in one of them, while the
patient was kneeling on one knee, the foot resting on the
hyperextended toes, he was pressed back by another man
so that his buttocks rested on and forced the ankle inward,
causing abduction of the front of the foot. In the other
the patient was lying on his side on the floor, with his foot
project ing beyond the edge of an elevator shaft ; the de-
scending car struck the inner side of his foot ; the man
hastily arose and withdrew his foot, so that it bore the
pressure only for a moment ; he received the second and
third type lesions, as above enumerated — rupture of the in-
ternal lateral and tibio-fibular ligaments — but escaped with-
out the first, fracture of the fibula.
Experimental proof that such abduction of the anterior
portion of the foot as appears to have taken place in these
two cases is competent to produce the fracture, is easily ob-
tained on the cadaver by fixing the leg and forcing the toes
outward while the ankle is held at a right angle. If the limb
is previously prepared by dissection so that the sequence of
events can be followed by the eye in detail, it will be seen
that the first to yield is the anterior tibio fibular ligament,
then the anterior fibers of the internal lateral ligament, and,
almost coincidently, the fibula breaks by the twisting of its
lower endr the line of fracture being very oblique in such a
way as to make the upper fragment terminate in a posterior
point near the level of the ankle joint. If the tibio-fibular
ligament is first divided by the knife it is interesting to
see how7 promptly abduction of the front of the foot makes
the tibio-fibular joint gape. That the same sequence occurs
clinically is shown by the eases in which the fibula remains
unbroken, the action of the force having been arrested be-
*fore the injury was complete. In one unique case I saw an
interesting variation : dislocation of the external malleolus
backward from the tibia while its relations to the astraga-
lus and os calcis were preserved ; it was caused by an out-
ward twist of the foot while wrestling, and could be easily
reduced and reproduced by pressing the front of the foot
inward and outward respectively. Some hesitation must be
felt in generalizing upon these facts and claiming that ab-
duction of the front of the foot is the one cause of the
common form of the fracture, for it is a forced movement
to which we do not seem to be so much exposed in the
common missteps and slippings as the great frequency of
the fracture * would suggest. Possibly, careful questioning
of the more intelligent patients will yet remove the doubt,
or perhaps some fortunate one of us may repeat the experi-
ence of Pott and, in himself suffering the injury, gain the
know ledge that w ill associate his name also with that of the
fracture.
The diagnosis can be made with great ease and certainty
by the recognition of the points of fracture and of ab-
normal lateral mobility in the joint and by the deformity,
which, even when slight, is so characteristic that the diag-
nosis can often be made with considerable assurance by the
eye alone. I have spoken of the diastasis of the lower
* This frequency is shown by the following statistics : During the
six months ending June 1, 1892, the following fractures of the head,
trunk, and lower extremity were brought into my service at the
Chambers Street Hospital by ambulance ; fractures of the upper ex-
June 25, 1892.]
STIMSON: POTT'S FRACTURE AT THE ANKLE.
703
tibio- fibular joint as the essential lesion, and it is upon tins,
therefore, that I think the positive diagnosis should rest.
It is indicated by one subjective symptom — pain on press-
ure with the tip of the finger at the junction of the two
bones in front close above the articular edge of the tibia ;
and demonstrated by one objective sign — abnormal lateral
mobility — which can be shown by grasping the foot with
one hand so that the posterior portion of the sole rests in
the palm, with the thumb close below the external malleo-
lus and the index finger below the internal malleolus, and
moving it bodily inward and outward, while the other hand
grasps the leg well above the ankle and steadies it (Figs.
1 and 2). Sometimes the click of the astragalus against
the internal malleolus in this manipulation is as distinct as
that of the patella against the femoral condyles when it has
been raised by an effusion. The advantage of this manipu-
lation is not found solely in the certainty it gives to the
diagnosis ; it also calls attention in no doubtful terms to
the essential points in treatment, and it impresses him who
makes it, more than any verbal injunctions could do, with
the necessity of actively opposing the tendency to displace-
ment— for he sees the foot slip outward the instant he re-
moves the pressure of his thumb ; he sees the necessity of
holding it in place, not simply of putting it in place.
This immediate reproduction of the displacement ap-
pears to be due in part to the contraction of the peroneal
muscles, and it may be well to add that, when these and the
other muscles of the leg are kept contracted by pain or the
fear of pain, this demonstration of abnormal mobility is
thereby made distinctly more difficult. The difference ap-
pears at once on the administration of an anaesthetic.
I would also call attention to the usual absence at the
bedside of what is a common symptom in the books — ever-
sion of the sole. (See Fig. 1.) In my experience this is
rarely present ; only when the outward displacement is ex-
ceptionally great or the peroneal muscles tense.
tremity, being relatively infrequent in ambulance cases, are not here
included.
Cranium :
Vault. Simple 2
Compound 19
— 21
Base IT
— 38
Spine 3
Femur :
Shaft. Simple 13
Compound 1
— 14
Neck 4
— 18
Patella 4
Tibia. Simple 8
Compound 2
— 10
Fibula 17
Both bones. Simple 2V
Compound 11
— 38
Pott's fracture '. 55
Bones of foot 18
201
In all but the slightest cases there is also a second con-
stant displacement, which can be as readily demonstrated
as the former, and which recurs as readily if measures to
prevent the recurrence are not taken ; it is a displacement
of the foot backward, ordinarily for not more than a quar-
ter of an inch. It is demonstrated by grasping the foot
with both hands so that the fingers rest on the back of the
heel and the thumbs on the front of the lower end of the
tibia, and then, the sole being vertical, lifting the foot with
the fingers while the leg is held back by the thumbs, and
then allowing it to drop back again. This displacement is
effected partly by gravity, partly by the contraction of the
muscles of the calf. It is more easily recognized by the
eye when the foot is in plantar flexion, for then a distinct
notch can be seen in the dorsal outline immediately below
the articular edge of the tibia (Fig. 3); but— the impor-
tance of the point justifies the reiteration — unless the sur-
geon's attention is specifically directed to the detection of
this displacement and also of the outward one, they will
both, as a rule and except in the most marked cases, pass
unrecognized. This statement is justified by the frequency
with which this failure to recognize has been observed ;
and a belief in this frequency and in that of defective treat-
ment due to it is the main reason for bringing the matter
before this society. Some of the photographs already
shown — those of the old unreduced cases (Fig. 5) — prove how
great a displacement can pass unrecognized ; and in three
cases that had been treated in large hospitals and subse-
quently came under my care for the relief of the disability,
the body of the astragalus lay wholly behind the tibia. And
yet in one of these cases the hospital record states that the
patient was " discharged cured." Of course, the failure to
recognize such marked deformity at the end of treatment,
after all swelling had subsided, must have been due to inat-
tention ; but the inattention is proof of a failure to appre-
ciate the possibilities of the injury.* It is, nevertheless, a
fact that such extreme backward displacement can pass un-
recognized in recent cases even by experienced observers
who are aware of the possibility and have specifically
sought for the displacement. They make the usual manipu-
lation, which should effect its reduction if it is present, and,
as the foot does not come forward, they infer that the dis-
placement does not exist. And it must not simply be con-
ceded that the displacement can be overlooked ; we must ap-
preciate that it may be difficult not to overlook it. The mus-
cles are held tense, and the foot does not yield to the sur-
geon's effort to move it forward ; he doubts his observation ;
he again scrutinizes the profile of the foot. An abiding
faith in the significance of certain apparently slight deviations
from the normal is necessary to save the surgeon from a grave
error and the patient from a serious disability. Anaesthesia,
* It is interesting to note, in some of these neglected cases in which
the deformity is very great, that, while there appears to be a great out-
ward displacement (Fig. 4), it is actually, almost solely, a backward dis-
placement, and that the prominence of the internal malleolus is due to
the fact that the displacement is along a line that makes an angle with
the axis of the foot, so that the anterior portions of the foot, as they
are successively brought back to the line of the internal malleolus, He
further and further to the outer side.
704
STIMSOX: POTT'S Fit A <"Tl' HE AT THE ASKLE.
[S. Y. Med. Jocf.,
pushed to complete muscular relaxation, clarities the situa-
tion; the foot comes at once forward and inward for a dis-
tance that is always startling, and which vividly suggests
that charity in judgment is not only a grace which we may
amiably extend to others, but is also one of which we may
at any moment stand urgently in need ourselves.
To summarize it : Pott's fracture may be diagnosticated
by the recognition of three points of localized tenderness
on pressure — one over the front of the lower tibio fibular
articulation, one at the seat of the fracture of the fibula two
or three inches above the apex of the malleolus, the third
at or just below and in front of the internal malleolus.
These having been found, examination should be made by
the methods indicated to detect outward and backward dis-
placements and lateral mobility.
The indications for treatment (reduction and retention)
have long been well understood ; it is only necessary to
emphasize the importance of meeting them thoroughly and
permanently, and to point out the probability of being mis-
led if one trusts to the eye alone to estimate the complete-
ness of the reduction of the displacement. In the cases of
extreme backward displacement, as has been already said,
anaesthesia may be necessary to annul muscular opposition to
reduction, and the same condition of the muscles occasion-
ally makes its aid necessary in the slighter cases, either to
effect reduction or to maintain it until the dressing shall
have been applied. The indication, in the common run of
cases, is simply to bring the external malleolus back to its
place alongside the tibia, to hold it there until the torn
ligaments and the broken bones have reunited, and thus to
re-establish the mortise with the astragalus within it. This
is accomplished by the aid of the ligaments that unite the
malleolus to the astragalus and calcaneum ; if the foot is
brought back into place, the malleolus must go with it.
But it must be remembered that in this re- establishment 'of
the normal position of the foot it is upon its posterior
portion alone that oar efforts and our attention must be
fixed ; it is the astragalus that is to be brought into place,
and the attitude of the front of the foot is not much
more of an indication of the position of the astragalus
than the attitude of the forearm is of the position of the
head of the humerus. The posterior portion of the foot,
the heel, must be pressed forward and inward, and must be
held in place by pressure made against the outer side of the
calcaneum and cuboid ; the first effect of this pressure is to
move the calcaneum and the rest of the tarsus inward along
the lower surface and front of the astragalus — or, in other
words, to invert the sole and adduct the front of the foot —
and only after this movement has reached its limit and the
ligaments have become tense does the pressure take the de-
sired effect upon the astragalus and malleolus. Conse-
quently, the rule should be to press the foot inward as far
as it will go, adding inversion of the sole and adduction of
the front of the foot, as shown in these photographs.
There is no danger that the movement will be carried too
far ; the astragalus can not move a hair's breadth inward
beyond its proper position ; that is prevented by the in-
ternal malleolus or by the arrest of the fibula by the tibia,
and, however distorted the position may seem, the distortion
is wholly in front of and below the ankle, and within the
limits of a normal range of motion. Let me repeat : This
inversion is not a superfluous addition to the treatment ; it
is the most convenient and trustworthy means of preventing
the recurrence of outward displacement.
It is also necessary that the heel should be supported to
prevent backward displacement.
These indications are satisfactorily met by molded splints
of plaster of Paris, applied as shown in the photographs
(Figs. 6 and 7). I prefer them to complete incasement be-
cause they permit inspection of the inner side of the ankle
and immediate detection of recurrence of the displacement,
and I prefer them to single or double lateral wooden splints
because they are less liable to shift or to permit recurrence.
They can be made of any loose-meshed material and plas-
ter cream, or, very conveniently, of the common four-inch
plaster roller. If made of the latter or of any other gauze,
they should have twelve or fifteen thicknesses. The pos-
terior splint should extend from the toes, along the sole,
around the heel, and up the calf nearly to the knee ; the
lateral one should begin just in front of the external malleo-
lus, pass over the dorsum of the foot to the inner side,
under the sole, and upward along the outer side of the leg
to the same height. They are molded and bound to the
leg while wet with an ordinary roller bandage, which should
be removed after the plaster has set, its place being taken
by a few turns of a bandage just above the ankle and at the
upper end of the splint. It is advantageous to have the
splints wide enough to overlap along the side of the leg,
and thus give greater security against shifting.
Such a splint may be put on immediately after the acci-
dent without fear of strangulation, if the supporting circu-
lar bandages are watched and loosened if there should be
need. If put on while the limb is swollen, the subsequent
shrinking can be met by tightening the circular bands; but
it is advisable to apply a new one after a few days.
In the treatment of old fractures with much deformity
the point of capital importance is, of course, the recogni-
tion of the direction and extent of the displacement, the
appreciation of the fact that the astragalus and external
malleolus are dislocated backward, and that the very notice-
able projection of the internal malleolus is to be relieved
by bringing the foot forward, not inward. I have always
used two lateral, or antero -lateral, incisions. One begins
at the front of the fibula, three inches above the ankle
joint, is carried down along the bone, passing in front of
the displaced malleolus, and then curved forward on the
side of the foot ; the seat of fracture is exposed, and the
lower fragment again separated from the upper one. The
second incision begins on the inner side of the tibia at
about the same level as the first, passes down to the front
of the malleolus, and thence forward to or beyond the
tubercle of the scaphoid. Through it the internal malleo-
lus can be detached with a chisel, and the end of the tibia
protruded so that it is easy to liberate and mobilize the
astragalus and to cut away any new growth of bone that
may have formed on the back of the tibia. The foot is
then easily restored to its place, the incisions closed with
out drainage, and a bulky dressing applied and covered
June 25, 1892.]
POORE: TUBERCULAR
GLANDS OF THE NEOK.
705
with plaster of Paris. I change the dressing at the end of
a week or ten days, and then apply a light plaster- of -Paris
dressing. The patient is allowed to begin to bear his
weight upon the foot in the fourth week. The photographs
(Figs. 8 and 9) show the results as regards the restoration
of form. The gain in function has also been very satis-
factory.
Finally, if a few moments more may be allowed me, I
should like to call attention to two complications of this
injury which I have encountered in four cases and which
have not heretofore been noticed. In two of these cases
the internal malleolus was squarely broken off at its base
and had undergone a rotation of 90° on its antero-posterior
axis, so that its fractured surface lay parallel to and just
beneath the skin. When the first patient came under my
observation (in 1888), a few hours after the accident, the
malleolus formed a prominent, freely movable mass; that
it was the malleolus could not be doubted, but I was
quite at a loss to explain its prominence and its mobility,
or rather its unstable equilibrium, for it rolled about freely,
but did not shift its position. I exposed it by an incision,
discovered the condition, and easily turned the fragment
back into place. When the second patient presented him-
self (1892), the diagnosis was easily made with the aid of
what had been learned in the preceding case ; it was treated
in the same manner. Both patients recovered from the
injury and the operation with full restoration of function,
and both were shown to the New York Surgical Society.
It seems probable that if such a displacement were allowed
to remain uncorrected the solidity of the joint would be
seriously impaired.
In the third and fourth cases the complication was also
marked by exceptional prominence and mobility of the
fractured malleolus, and the cause was found, on exposure
of the parts by incision, to be the interposition between the
fragments of a long strip of periosteum that had been torn
from the inner surface of the tibia in one, and of a smaller
strip of periosteum and a portion of the anterior annular
ligament in the other. In both cases recovery followed
without incident and with full restoration of function.
34 East Thirty-third Street.
CONTRIBUTIONS FROM THE SURGICAL SERVICE OF
ST. MARY'S HOSPITAL FOR CHILDREN.
By CHARLES T. POORE, M. D.
II.
TUBERCULAR GLANDS OF THE NECK.
Enlarged glands of the neck in children may be grouped
in two classes : (1) the tubercular; (2) the simply hypertro-
phied gland. The vast majority, in my experience, belong
to the first class, while those belonging to the second have
been but occasionally met with. They are due to some ir-
ritation about the head; they never suppurate, and subside
as soon as their exciting cause has been removed. They
are most frequently secondary to pedicuji or eczema capitis.
On the other hand, a tubercular gland or glands have
been found whose origin seemed to be due to the same
cause, so that the existence of disease of the scalp in connec-
tion with enlarged glands can not be considered as a proof
that the disease of the gland is not of a tubercular nature.
The tendency of a tubercular gland is toward caseation,
calcareous degeneration, or abscess ; they seldom undergo
resolution. The deposit, if small', may become encapsulated,
and, in rare cases, give no further trouble, but, as a rule, an
abscess slowly forms, opens, and continues to. discharge until
all diseased tissue has been eliminated, leaving unsightly
scars and blemishes, so often seen.
From the experience derived from these cases, the infer-
ence has been drawn that one or many tubercular glands of
the neck are not a symptom of general tuberculosis, except in
rare instances ; thus, in sixty-one cases, in only three children
have these glands been known to be accompanied by tuber-
cle in other parts of the body, and in these the enlargement
of the glands of the neck followed, not preceded, tubercular
deposits elsewhere. Most of the cases operated upon have
been seen or heard from at various times since the patients
left the hospital, and, with but two exceptions, not a single
one is known to have died from tuberculosis. From the
above it would seem that tubercular adenitis is a local, not
a general, affection, and that the danger from general infec-
tion is not great. This deduction, it must be .understood, is
personal from a hospital experience.
Clinically, tubercular glands of the neck have been met
with under two conditions : (l) The large, isolated gland or
glands ; and (2) a number of small or moderately enlarged
glands blended together by inflammatory products.
Of the first class, the number of glands involved has va-
ried; in some cases only one, in others two or more glands
have been diseased — if there has been more than one on a
side. They are separated by more or less normal tissue, un-
less there has been a periglandular abscess with its second-
ary inflammatory changes ; but they have never been found
matted together, as in the second class. The contents of
these glands have always been of a tubercular nature, the
amount found depending upon the size the gland has at-
tained. The larger the tumor, the more has the glandular
been replaced by tubercular tissue, so that in many examples
the contents of the capsule were formed entirely of caseous
and semi-liquid material. These glands vary much in size ;
some are but little enlarged, while others attain considerable
size. The largest removed measured three inches in their
largest diameter. In older glands the more fluid portions
of these contents may be absorbed and calcareous material
found.
The course pursued by these glands varies. In a few
cases, after attaining a large size, there has been ho further
increase, but a gradual diminution in size, their more liquid
contents being absorbed and replaced by calcareous matter,
the capsule shriveling up, and no further trouble is ever ex-
perienced. This course is not always followed, however,
even in glands whose contents have undergone absorption.
Often, iii opening an abscess of the neck, nothing is found
to account for its presence but calcareous material which
has escaped from an old atrophied gland and has set up a
tubercular abscess.
In those glands whose contents do not follow the course
706
POORE: TUBEL'C 1' LA II GLANDS OF THE NECK.
[N. Y. Med. Jodk
mentioned above, after a time the capsule gives way at some
point and allows the escape of infected material into I ln-
surrounding tissue and a tubercular abscess is slowly formed,
which often attain considerable size, perforating the skin ;
finally a sinus remains with undermined and unhealthy skin ;
this sinus may discharge for years, leaving behind it de-
formities and unsightly cicatrices.
The second class consists of small or moderately enlarged
glands, often consisting of a chain of glands blended to-
gether in a mass by inflammatory products. These masses
form large swellings in the neck. On examination, these
tumefactions are found to consist of a chain of glands of
different sizes and in various degrees of tubercular degen-
eration. They have not been met with as frequently as
the isolated gland. They are often deeply seated behind
the deep fascia of the neck, and they are difficult to deal
with.
It may be laid down as an almost universal rule that a
chronic abscess in the neck of a child, if not connected
with bone disease, has its origin in a tubercular inland.
Sometimes these abscesses are rapid in their formation, are
accompanied by marked constitutional symptoms, the tis-
sues of the neck are brawny, and much pain is complained
of. This, however, is not the rule. Tubercular abscesses
generally are slow in their formation and unaccompanied by
any marked symptom but swelling.
These abscesses may form behind the deep fascia of
the neck as a firm, well-defined swelling, and one in which
no fluctuation can be detected. One side of the neck
looks fuller than the other. The true nature of this may
not be known until the deep fascia has been perforated
and the abscess cavity entered. In other cases a large
superficial abscess may be opened and no diseased gland
found. If, however, careful search be made with a director
on the floor of such an abscess, a small opening will be
found in the fascia leading to a tubercular gland. The
history of such a condition is as follows : An abscess has
formed connected with a tubercular gland behind the deep
fascia. After attaining considerable size a small opening
is formed in the fascia, and the contents of the post-facial
abscess slowly empties itself through this channel into the
subcutaneous tissue of the neck ; finally, all the fluid con-
tents of the deep collection of pus finds its way into the
superficial abscess, the tubercular gland and abscess being
connected by a sinus.
The importance of searching for such an opening is
evident, for no cure can be accomplished until the contents
of the deep-seated, diseased gland have been removed.
Treatment. — The medical management of tubercular
glands is far from satisfactory. The general routine treat-
ment with tincture of iodine is worse than useless. The
indications are for soothing, not stimulating, applications.
It is safe to say that painting with tincture of iodine tends
to increase the tumefaction rather than diminish it. Poul-
tices should have no place in the management of these
cases ; they make the skin sodden, and increase rather than
retard suppuration. If an abscess has opened, they are worse
than useless. Moist heat encourages bacterial growth, low-
ers the vitality of the skin, and favors undermining.
Rest to the neck, tonic treatment, change of air, if pos-
sible, the removal of any nose, throat, or ear trouhle, and
maintaining the scalp in a healthy condition, are the means
best calculated to be rewarded by success in cases in which
much tumefaction has not taken place. Tubercular deposits
in the gland differ in no respect from that in other portions
of the body. They follow precisely the same course, and
should be viewed from the same standpoint.
It is perfectly useless to attempt to treat a tubercular
gland that has attained any size by medication with the ex-
pectation of its cure. It will always remain a diseased
gland, and, in the vast majority of cases, will eventually sup-
purate.
The best treatment for a tubercular gland is its enuclea-
tion. If removed before its contents have infected the
surrounding tissue, it prevents the formation of an ab-
scess ; and if suppuration has taken place, an operation
shortens its amount and duration by months, or even years,
obviates unsightly scars, and prevents the infection of
other glands. For these reasons the surgical management
of this affection is to be advocated.
As to the question when an operation should be done,
it is always better to anticipate the formation of a peri-
glandular abscess, and, in order to do this, all chronically en-
larged glands of a tubercular nature, if of any size, should
be removed, as by so doing time will be saved, and the
scar resulting from the incision will only be linear and in
time will be scarcely noticeable.
In regard to abscesses about the neck, the rule should be
that they be opened, their cavity thoroughly curetted, to-
gether with any diseased glands, as soon as possible, and,
above all, in no case should a poultice be applied.
The method of operating that in my hands has been
proved satisfactory is as follows :
In Cases Unaccompanied by an Abscess. — After disinfect-
ing the skin, an incision is made over the enlarged gland, if
there is only one, or over the most prominent, if more than
one is involved, down to its capsule, the incision being, as
a rule, not more than an inch or an inch and a half long.
Into this cut the gland is made to protrude as much as pos-
sible by grasping it behind. If it is non-adherent, it can be
separated from its loose connection by means of a director,
or, what is better, an artery needle used very much as stra-
bismus hooks are used in enucleating an eye, working
around the gland with the hook and a pair of blunt, curved
scissors until the hilus is reached. If it has been thorough-
ly freed from all its other attachments, the gland can now
be forced entirely out of the wound, its only attachment
being at the point where the vessels enter. A catgut liga-
ture is then applied around these and the gland cut away.
Unless some vessel has been divided in the soft parts, there
will be little, if any, haemorrhage. If there are other dis-
eased glands near the one removed, they can usually be
reached through the incision already made. If, however,
this can not be done, the incision can be enlarged or a new-
one made. It is often astonishing how much can be done
through one opening.
If a gland is adherent, its removal is tedious and not
safe ; for such, the better plan is to open the capsule and
June 25, 1892.J
POORE: TUBERCULAR GLANDS OF THE NECK.
707
thoroughly remove its contents with a Volkmann's spoon,
leaving the capsule behind. If the capsule has been opened
during the operation, or its contents bave perforated it be-
fore the date of operation, infecting the surrounding tissue,
the same plan can be adopted, only the spoon must be used
freely over the whole extent of the abscess cavity ; all dis-
eased tissue must be removed.
In those cases where a number of small or moderately
enlarged glands are matted together, and when from their
situation there is danger of injury to important vessels or
nerves, it has always seemed better to remove such as can
be safely and easily done, thoroughly curetting the cavity
of any abscess that may exist, dividing the capsule and re-
moving the contents of as many diseased glands as possible
without making large incisions and tedious dissections. In
some of these cases the glands are so situated that their
thorough removal is easily accomplished without any danger
to other structures, while in others a formidable operation
will be required to remove them. A good result has fol-
lowed in all cases where this plan has been adopted, al-
though a second and sometimes a third operation of curet-
ting has been called for.
In old cases where abscesses have been allowed to pur-
sue their natural course and sinuses exist, there is often
found much tubercular tissue within their cavity. In such
cases a thorough curetting will effectually remove all in-
fected tissue and a rapid closing of the cavity will result.
Where the diseased gland is deeply seated and where there
exists a superficial abscess connected with the gland by
a small sinus through the fascia, the diseased gland can
be easily removed by passing a small or moderately sized
Volkmann's spoon through the sinus and curetting the
o-land. Unless this is done, the opening in the skin will
not close until all infected tissue has been eliminated. After
clearing out these cavities and glands as thoroughly as pos-
sible with a Volkmann's spoon, a moderate-sized sponge,
dampened with mercury solution, is caught in a locked for-
ceps and forced into the cavity and then turned around sev-
eral times. This will remove and bring away any diseased
tissue that may have been left by the spoon.
If the skin is thin, undermined, and unhealthy in appear-
ance about a sinus, it is freely removed.
After the clearing process has been finished, the wound
is well washed with mercuric solution (1 to 1,000), then
dried with a sponge and iodoform dusted in, and the parts
brought together as thoroughly as possible with deep and
superficial suture so as to leave as few "dead spaces" as
possible. It will sometimes be found, however, that the
parts can not be sutured so as to close entirely the deeper
portions of the wound. In such cases the wound has been
stuffed with iodoform gauze.
In regard to the skin wound, one of two methods has
been adopted — either to close it with a subcutaneous catgut
suture, or, if the abscess has been subcutaneous or the
gland large and its removal has left a considerable sub-
cutaneous cavity, the needle, armed with the suture, is
passed from without inward some distance from the edge
of the incision through the whole thickness of the skin
into the cavity ; then, on the opposite side of the cavi-
ty, from within outward to a corresponding point upon
the other side, then back again, and repeated until a suffi-
cient number of continuous sutures have been passed, the
last ending on the side first perforated. The two ends are
then tied tightly together, bringing the inner walls of the
cavity in apposition and causing a prominent ridge on the
neck. The advantage of this is that it helps to obliterate
the cavity, and, when the catgut is absorbed, the skin
assumes its normal position. It has been found to be no
small gain.
In regard to drainage, for some time rubber drainage-
tubes were used, but of late they have been abandoned.
Their points of entrance were always slow in closing, and
seemed to increase the amount of cicatricial tissue. In
their place horse-hair has been substituted, a bunch being
held in place by the skin suture, its ends protruding from
either extremity of the wound ; it affords ample drainage.
It is easily removed, and does not leave the cavity always
seen when rubber tubing has been used.
It is not to be supposed that in all cases of operation
upon tubercular glands of the neck the wound closes up at
once. In many, owing either to imperfect eradication of
the diseased tissue, error in after-treatment, or new points
of disease showing themselves, suppuration follows. Some-
times after the wound has closed it will break down again
and discharge, or a sinus will persist, the edges of the
wound assuming an unhealthy appearance. In such cases
the wound must be reopened. It will then be found that
the old cavity has refilled with tubercular matter and pus,
a neglected gland having reinfected the parts ; or, if no
gland be found, it is due to diseased tissue that had not
been removed ; but, whatever its cause, unless the cavity is
again cleaned out, no permanent benefit will be derived
from the operation, and a sinus may continue to discharge
for months.
In other cases, although the old point of disease may
never give any trouble, new glands may become enlarged
and call for another operation. Thus in one child I have
operated ten times for the last four years. She has had no
return, and is a perfectly healthy-looking girl.
The ultimate result after the surgical treatment of tu-
bercular glands is that, if the gland is removed before a
periglandular abscess has formed, the resulting scar will be
linear and scarcely visible. If, however, an abscess has
formed and the skin is much undermined and unhealthy, the
amount of cicatricial tissue will he in direcl proportion to
the amount of diseased skin. In other cases, even in the
presence of an abscess, a linear scar may be formed.
The following are the statistics of all cases operated
upon :
Number of cases, 58. Of these, 25 occurred in males and
33 in females.
Abscesses are mentioned in 20 cases ; none existed in 28 ;
not mentioned in 23. Age : Eleven patients were two years old ;
11 were three years old; 3 were four years old; 5 were five
years old ; 2 were six years old ; f> were seven years old ; 0 were
eight years old ; 1 was nino years old; fi were ten years old ;
4 were eleven years old; 1 was twelve years old ; 1 was thir-
teen years old ; 1 was fourteen years old.
708
.U/'L'L'AY: MUSCULOSPINAL PARALYSIS AND Fit A < "IT I; LI OF HUMERUS. [N. Y. Med. Jouh.,
The shortest time thai the patient was under treatment
w as "ine days ; the longest, three years.
The duration of treatment was as follows: Fourteen
patients were in the hospital less than three weeks; twenty
were discharged at the end of a month, twelve at the end
of two months, five at the end of three months, two at the
end of four months, two at the end of five months, one at
the end of six months, and one at the end of seven months ;
and two were under treatment for three years.
In the two patients who were under treatment for three
years, in one ten operations and in the other eight were per-
formed; some of them were for simple curetting, while on
other occasions recently infected glands were removed.
In two cases only has there been any troublesome haem-
orrhage, and this was in connection with masses of glands;
during an attempt to enucleate them a vein of considera-
ble size was torn, and for a short time there was quite a
sharp haemorrhage until the vessel was secured by a liga-
ture. Care must be taken not to drag much on these
matted-together glands.
After an operation the neck is well packed with bichlo-
ride gauze, secured by a firmly applied bandage. The horse-
hair drainage is removed at the first dressing.
With glandular abscesses of the neck, simply opening
the abscess and allowing the pus to escape is temporizing
treatment ; the cavity should always be curetted.
MUSCULO-SPIRAL PARALYSIS
COMPLICATING FRACTUEE OF THE HUMERUS.*
By FRANCIS W. MURRAY, M. D.,
VISITING SURGEON TO ST. LUKE'S HOSPITAL.
The uncommon occurrence of the above complication,
and also the desire to relate an interesting and successful
case, are my reasons for bringing this subject to your atten-
tion. From the fact that fracture of the humerus occurs
most frequently at the shaft, and from the intimate relation
of the nerve to the bone in the musculo-spiral groove, it
seems rather remarkable that the nerve so often escapes
injury.
Bischoff,f in examinations on the cadaver, finds that
the " dangerous place " (when the nerve lies on the bone)
" begins about eleven centimetres above the external epi-
condyle of the humerus, and ends about six centimetres and
a half above and behind." Thus the nerve is exposed to
insult for only a proportionately short distance, and at this
point it is also very linn and capable of resistance, all of
which circumstances may explain its immunity from injury
In cases of simple fracture of the shaft. In 562 cases of
simple fracture of the humerus treated during the past
twelve years at the Chambers Street Hospital, in New York,
but three cases of musculo-spiral paralysis are to be found.
Billroth, during a period of sixteen years in his clinic at
Vienna, saw only three cases. From these individual ex-
perienees one naturally concludes that lesions of this par-
* Read before the New York Surgical Society, February '.24, 1892.
+ Ctrlbl.f. Chin, 1877, S. 164.
ticular nerve with fracture are rare, but it is only by col-
lecting together all the material that a correct estimate of
its frequency can be formed. Bruns,* however, was the first
to accomplish the collection and classification of the mate-
rial, which had been accumulating for years, and his results
are most interesting. He shows that while injury and com-
pression of nerves in connection with fracture is of uncom-
mon occurrence, still the complication is decidedly more
frequent than has generally been supposed. He has col-
lected the large number of 189 cases of nerve injuries with
fractures, and all but 21 cases are simple fractures. Of the
189 cases, over two thirds (135 cases) were connected with
nerves of the upper extremity, and of these 135 cases, 77
concerned the musculo-spiral nerve alone, and 2 cases in-
volved the ulnar and median in addition. He found that
the humerus was the bone most frequently complicated with
nerve lesions, and the musculo-spiral the nerve most often
concerned. Thus, in 101 cases of fracture of this bone at-
tended with paralysis, there were 73 examples involving the
musculo-spiral nerve. As to the seat of fracture, the lower
and middle thirds were the most dangerous for this nerve,
as shown by 4 times in the upper, 25 times in the middle,
and 19 times in the lower third. Certainly these results
show that the complication in question is not a rare one.
Primary paralysis was more than twice as frequent (62
cases) as the secondary variety (25 cases), and of the
former class the great majority (44 cases) were caused by
contusion of the nerve, while in the secondary variety al-
most all cases were due to compression by callus and cica-
tricial tissue. Bruns's collection of cases ends with the
year 1885, and in examining the literature since that year I
have found the histories of only five cases. It is likely that
I have failed to find some histories, but this is the result of
a fairly faithful search with the assistance of the Index
Medicus. The cases are briefly as follows :
Middeldorpf.f Man, aged thirty-two; caught in a
thrashing machine, injuring his shoulder ; paralysis set in
immediately ; seen seven weeks after accident. Complete
musculo-spiral paralysis ; also paresis of fibers of part of
ulnar nerve and paralysis of deltoid muscle. Operation
nine weeks after injury revealed fracture of surgical neck
close to head of bone, lower fragment dislocated inward and
backward and pressing on musculo-spiral nerve ; fragment
replaced ; primary union of wound. Slight improvement
began in a month, and paralysis cured at end of seven
months.
Puzey. \ Man, aged fifty ; fracture in lower half of
humerus ; paralysis first noticed when splints were re-
moved; excessive amount of callus. Operation three
months after injury ; nerve exposed over thickened bone ;
was pale, hard, and smaller than normal. It was dissected
out of a groove for three or four inches, until free above
and below. Some tingling at end of a week ; improvement
slow, but was cured at end of nine months.
Stimson.* Young man ; fracture of humerus about its
* P. Bruns. Deutsche Chirwrgie, Lief. 27, II. Halite,
f Munch, med. Wbchensehrift, 1888, No. 14.
X British Med. Jour., 1889, ii, 309.
* N. Y. Med. Jom:, 1890, r>57.
Juno 25. 1892.] MURRAY: MUSCULO-SPIRAL PARALYSIS AND FRACTURE OF HUMERUS.
709
middle ; treated usual way ; did well, and was discharged
with fracture cured. Afterward he returned with musculo-
spiral paralysis ; nerve exposed and found imhedded in
callus, occupying a canal an inch long ; above and below, it
was free. Nerve liberated; wound healed kindly. Five
weeks after operation slight movement of fingers, and at
time of presentation before this society the restoration was
complete.
Nicolson * reports two cases. The first, a boy, aged
ten ; simple fracture at lower third of humerus ; treated in
right-angled splint ; swelling of hand set in soon ; six weeks
after injury sloughing of ring and little fingers; paralysis
discovered when splints were removed. Seen by Dr. Nicol-
son eighteen months after injury ; wrist-drop well marked ;
flexor tendons contracted, and under ether inability to ex-
tend them ; whole hand blue and cold ; hyperesthesia of
palm of hand. Tenotomy to straighten wrist ; electricity ;
some improvement. The second case was a girl, aged
seven, fracture lower half of humerus ; seen some months
after injury ; appearances same as in last case, excepting
sloughing and hyperesthesia of palm. Case had been
treated by plaster splint, and there had been a superficial
sloughing "at center of forearm. In reporting these cases
Dr. Nicolson mentioned a case occurring in the practice of
Dr. Howell, of the same city. In a letter from Dr. Nicol-
son he states that his two cases disappeared and the ulti-
mate results are unknown, and that Dr. Howell's case was
one of immediate paralysis following fracture, and recovered
without operation. He adds a third case lately seen in the
practice of another physician, where the paralysis was com-
plete, and attended with atrophy of extensors and supina-
tors. The patient had lost the usefulness of the hand and
forearm, as well as a large part of the hand by sloughing.
Plaster splint was used in this case.
To these cases already briefly mentioned I should like
to add the history of one lately under my care :
R. S., seven years of age, on March 25, 1891, was run over
by a wagon and sustained a simple fracture of the humerus
about the middle third. An ambulance surgeon reduced the
fracture, applied a right-angled splint, and removed the boy to a
hospital. That night the boy developed measles, and on the
following day was removed to another institution. Here he re-
mained about six weeks for treatment of the measles, and the
fracture apparently received but little attention. On returning
home, the splint was removed and the arm was found to be
crooked, also loss of power in forearm and hand. On June 10th
the boy came under my care at St. Luke's Hospital. Examina-
tion revealed well-marked deformity at the middle of right arm,
a bowing outward and backward; and at this point was felt a
prominence, evidently the upper extremity of lower fragment.
Very little evidence of callus, no pain or crepitus, and a sus-
picion of false point of motion. Measuring both arms from
acromion to olecranon shows a shortening of an inch and a
quarter of right arm. Power of extension of forearm remains,
but supination of forearm, extension of wrist, and radial flexion
lost, "wrist-drop" marked, also impaired extension and abduc-
tion of thumb. Fingers flexed, hut, on passive extension of
proximal phalanges, extension of terminal phalanges is normal.
Borne atrophy of supinators and extensors, but they respond to
* Cfaitiard's Med. Jour., 1890, i, 20-24.
faradism ; sensory disturbances slight. On June 13th incision
two inches long on outer side of arm carried down to site of
fracture, as nerve was not seen ; the incision was carried down-
ward and nerve exposed in its course between brachialis anticus
and supinator longus muscles. On following the nerve up from
this point, it was found firmly adherent to and tightly stretched
over the edge of the lower fragment, which was dislocated up-
ward and outward. At the point of compression the nerve wras
smaller, completely flattened out, and of a dark-red color, which
extended a short distance above and below. Incision through
periosteum, chisel inserted, and the edge of fragment removed;
the nerve released and held to one side. On examination of
fracture, the lower fragment was seen dislocated as mentioned,
rotated strongly inward, and united to the upper fragment at an
angle of 150°. I then/efractured the arm by cutting through the
callus with a chisel and straightening the member with my hands.
Ends of fragments smoothed off with rongeur forceps and ap-
proximated with a strand of silkworm gut passing through
hobs drilled through the bone. Periosteum united by catgut,
wound disinfected and united by a few deep and superficial cat-
gut sutures. Sterilized dressing, plaster splint from wrist to
axilla with few spica turns; forearm flexed on arm. Beyond
slight suppuration in one or two superficial sutures, the wound
healed kindly; splints removed in six weeks. Four weeks after
operation there was some power of extension of fingers, and from
that time his history is of steady improvement. Eight weeks
after operation there was good use of arm, but not complete
restoration. Late in September he returned t'o hospital with a
small, fluctuating swelling over site of wound ; incision let out
a small amount of pus in which was found the silkworm gut.
Wound soon healed, and he left with perfect and complete
restoration of the right arm. On questioning the boy closely, I
find that he was aide to extend the hand and fingers immedi-
ately after the accident, and that the movements were not abol-
ished until some time after his admission to the institution
where he was treated for the measles. Four or five weeks
elapsed before the fracture was examined, so it is fair to pre-
sume that the dislocation took place some time after the original
application of splints. The case, therefore, is of some signifi-
cance, as it is an example of compression of the nerve through
secondary dislocation of a fragment, of which only few cases
are on record. The refracture of the bone 1 think was proper
under the circumstances, and without it the operation would
have been incomplete. To have merely cut away the project-
ing end of the lower fragment- would have relieved the pressure
on the nerve, but the boy would have had a crooked and
shortened arm. and, as he is right-handed, its usefulness
would have been impaired. There are other points of interest
in the case, but I will not detain you by referring to them.
Through the kindness of Dr. L. A. Stimson 1 am able to add
three other unrecorded cases, the cases mentioned above as
occurring at the Chambers Street Hospital. They are briefly
as follows :
Case I. Ajiril 188~>. — G. T., aged forty-four years, sim-
ple fracture middle third of humerus. Shoulder cap and out-
side coaptation splints applied, but replaced in two day- with
plaster splint from wrist to axilla ; spica at shoulder.
July 17th. — Paralysis noticed; wrist- drop marked; loss of
sensation in fingers not absolute. Ordered electricity. Very
slight improvement.
Case II. March 5, 1888. — A. (1., aged fifty years, simple
oblique fracture middle third of humerus. Shoulder cap, appo-
sition splints, elbow splint. Three days later, plaster splint
wrist to shoulder.
April 20th. — Paralysis noticed. Faradism ordered. Result,
improvement in extension at wrist and* of lingers.
71<>
I',. I EKER : < •ERK llli. I A Tl rM0R8.
[N. Y. Med. Jock.,
Case III. August 30, 1890. — R. K., aged forty-four years,
simple fracture middle third of humerus. Plaster splint from
wrist to shoulder and spica.
October 9th. — Paralysis discovered, and, three days later,
Dr. Stimson exposed nerve for three or four inches. It showed
no signs of injury, and was not imhedded in callus or cicatrix.
Union of fracture absolutely without deformity.
November 13th. — Wound healed, but no use in hand as yet.
Result, last seen in September, 1891. Electricity and massage
had been kept up in the moan time. The patient could raise
wrist to level and was slowly improving. As to the ultimate
results in the first two cases nothing is known, as they disap-
peared after the fractures were united.
The last case is unique in that the conditions revealed
by exposure of nerve were not sufficient to account for the
well-marked paralysis. The addition of the eleven cases
collected in this paper to the number collected by Bruns
makes ninety cases in all — certainly not a small number.
Of this number, thirty-eight (forty-two per cent.) were
treated by operation, and in almost all the nerve function
was restored. While in thirty-four cases neurolysis was
performed, in only three cases was the nerve sutured, show-
ing the rarity of complete division of the nerve. Of the
cases treated by neurolysis, the great majority (twenty-two
cases) were examples of compression due to callus or cica-
tricial tissue ; only seven were due to compression by a
dislocated fragment. It is interesting to know that a large
percentage were treated by operation, and that the results
were mostly successful. Where paralysis is due to com-
pression by callus, cicatricial tissue, or dislocated fragments,
already consolidated, in my opinion the earlier the nerve is
liberated the sooner will the patient be cured. Some au-
thors advocate, however, waiting for months to see whether
Nature will not effect a cure. Where the paralysis is due
to the contusion of the nerve, and if no improvement ap-
pears in four to five months after the injury, I think ex-
posure of the nerve is indicated. In such cases the nerve
substance may be destroyed and replaced by fibrous tissue,
which can be removed and nerve suture applied, or com-
pression by a small fragment of callus or a fine band of
cicatricial tissue may be found. A point worthy of men-
tion in the performance of neurolysis is to expose the nerve,
not at the point of compression, but rather at some dis-
tance above or below, and then follow it up to the desired
spot. By so doing, one lessens the risk of injuring or cut-
ting the nerve in our attempt to find it when enveloped in
a mass of callus or cicatricial tissue. Finally, in the exami-
nation of every case of fracture of the humerus, it is wiser
to look for any injury of the musculo-spiral nerve before
applying the splints ; otherwise the injury may be over-
looked and not discovered until the appliances are removed,
and it will then be impossible to say whether the paralysis
was due to the injury or not. From a medico-legal stand-
point it is also important in these days, when unscrupulous
lawyers and ungrateful patients abound.
In conclusion, I would state that this paper has been
prepared to show that musculo-spiral paralysis is not so in-
frequent in connection with simple fracture of the humerus,
and also to place on record the ease which came under my
care.
*
A CONTRIBUTION TO
THE STUDY OF CEREBRAL TUMORS.
By P. 0. BARKER, M. I).,
MORRISTOWN, N. J.
A. W. B., a banker, aged sixty; always had good health,
with the exception of two attacks of typhoid fever— one in early
manhood, and the second while in the army in 186:5. No spe-
cific history. In May, 1891, while asleep on a reclining chair
one Sunday afternoon, he was observed to be breathing with dif-
ficulty— eyes opened and raised, arms and legs being drawn up
and extended again. The seizure lasted but a few minutes, and
he soon regained consciousness, assuring those around him that
lie felt perfectly well. It was not observed wdiether he was
flushed or pale; nor were any other observations made than
those mentioned. In July be fell while walking on the street.
A physician chanced to be just behind him, saw him reel, and
seized hold of him, but not soon enough to prevent a heavy
fall to the pavement. It was not noticed which way he turned
as he began to reel. He bad an epileptoid convulsion, with
the usual manifestations; was carried home and placed in bed.
Some hours afterward, while lying quietly in bed, he had
another convulsion — longer and more severe than that of the
morning. I was summoned by telegraph, started at once for
central New York, where he lived, and arrived there early the
following morning. With the exception of some rather severe
bruises about the face received by falling on the street the day
before, he seemed to be as well as usual. In searching after
any facts that might throw light upon the probable cause of
these seizures, only the following were gleaned : In January,
1890, the patient lost his footing on an icy pavement and fell,
striking on the back of his head. The pain was so severe that
he was unable to get up for some time; and a persistent head-
ache followed for several days. This accident was recalled by
his daughter, and referred to after the investigation had con-
tinued for some time. The patient had entirely forgotten it, as
he had had no symptoms remaining, beyond the few days men-
tioned, that suggested any connection with the fall. It also
transpired that he had been unable to read evenings, as his
habit formerly was, and that some member of the family had
read to him for " a long time." He had consulted an oculist,
and his trouble had been ascribed to the severe use his eyes had
been subjected to during banking hours.
There were no more epileptoid attacks, and the patient
attended to his usual duties until September without having
special symptoms of any kind except an occasional feeling of
weakness in his legs (as he said) and some unsteadiness in walk-
ing. At my request, his eyes were again examined, and, with
the exception of slight astigmatism, pronounced normal. There
was no optic neuritis. Late in September there was an attack
of diarrhoea that lasted several days, together with anorexia
increased weakness, and unsteadiness. The urine became re-
duced in quantity one half, while the specific gravity fell from
1-023 to 1 006, where it remained for some days, and then
gradually ran np to 1016. Repeated tests failed to show the
presence of albumin. The pulse was slow, temperature sub-
normal every morning, and some days it remained all day a
little below normal. The bowels were constipated, and he was
troubled at times with dysuria and rectal tenesmus. Upon
awaking in the morning, he was quite likely to have a little
headache, which soon passed off.
These symptoms, as reported to me from day to day by the
attending physician and the family, were very perplexing; and
so, on October 23d, I visited him again. I got there before day-
light and found the patient asleep. I soon noticed that the left
June 25, 1892.]
LOOKWOOD: CHRONIC ASCENDING POLIOMYELITIS ANTERIOR.
Tit
arm was never at rest for any length of time. The forearm
would be extended upon the bed, and soon flexed again at inter-
vals of a minute, more or less. Now and then he would rub his
forehead and the top of his head with the right hand. After
about an hour he awakened. The same restless motion of the
left arm continued, but less often, and he occasionally passed
his right hand over the head, as when asleep. Upon being
asked why he rubbed his head, he replied that it felt bad when
he first awakened after prolonged sleep: but it was hardly a
pain. (Later on he did have some pain over the frontal region
and vertex; but it was never severe.) He was not aware that
he moved the left arm, and could give no reason for it. The
tendon reflexes were practically normal. Sensation diminished
in both arm and leg. Dynamometer showed a loss of one half
in left hand. Left leg evidently weaker than the right. Per-
cussion over the scalp was complained of when I finally came to
the right parietal bone and over the anterior central region of
the brain. Previous to this visit it had not been observed by the
patient or any one else that his occasional shambling gait was
unilateral ; nor whether one hand rather than the other or both
failed him in attempts at buttoning his collar; or other details
in dressing. With these new facts it was at once manifest to
me that the patient was suffering from a tumor (probably super-
ficial) of the right anterior central region of the brain. The ac-
companying diagram was made at the time to indicate the
probable location of the tumor, and was shown to the attending
physician and to the family of the patient. Soon after this visit
the symptoms became more pronounced. The arm and leg be-
came more paretic, sensation more disturbed. At times both
arm and leg would be almost devoid of sensation ; at other
times hyperaasthesia was complained of. At times, too, he
would have mild transient delirium ; or his face would be
flushed, his nose cold and pinched, his pulse feeble, his respira-
tion labored. One moment he would feel chilly and the next
too warm. These varying symptoms were usually of short
duration ; and he would now and then have an entire day or
entire night of continuous comfort. Then followed a more
rapid progress, the leg and arm becoming entirely paralyzed,
pulse and respiration greatly increased in frequency, increas-
ing hebetude, coma, and death— six months after the first con-
vulsion.
Post-mortem. — Body somewhat emaciated, rigor mortis well
marked. Superficial sinuses congested. Dura mater rather
opaque, but otherwise of normal appearance. Brain and mem-
branes removed intact. Upon section of the dura mater, a tu-
mor two inches and a half in diameter was found in the exact
spot indicated in the diagram. The dura mater was firmly ad-
herent to the center of the growth, involving an area of a little
less than an inch. There was a nucleus of corresponding size
that was readily lifted out from the rest of the neoplasm, which
presented an entirely different appearance from the latter in
color and general appearance, being whiter and of closer, firmer
texture. Next to this nucleus, upon all sides and beneath it to
a depth also of nearly two inches and a half, was, first, a highly
vascular area, with many small extravasated blood clots, while
beyond this was an area of yellowish, semi-softened tissue that
gradually changed into healthy-looking white matter. Upon
the vertex of both hemispheres the arachnoid was opalescent,
and there was also an effusion beneath it. Only a hasty exami-
nation of the deeper structures was made, as none of the ob-
served symptoms remained unexplained, and nothing else ab-
normal was noticed. Professor Prudden examined the nucleus
mentioned and reported that it was a spindle-celled sarcoma.
It is extremely probable that the fall was responsible
for this growth. I was unable to determine whether the
original growth started from the dura or from the gray
matter beneath it. The bond of union between the dura
and the nucleus was certainly very firm, but it was sepa-
rated with the handle of the scalpel, although with some
difficulty.
The period that elapsed between the fall and the first
epileptoid seizure — about sixteen months — not only sufficed
for the growth of the nucleus, but for the second stage as
well, the period characterized by the epileptoid convulsions
and due to the multiple haemorrhages. During the first
period no impairment of health — no symptoms of any kind
save possibly one— were experienced by the patient. His.
inability to use his eyes as he had been accustomed to use
them may have been due to the growth, by involvement of
communicating fibers between this region and the inferior
anterior frontal region. The third stage, that of softening,
was prolific in symptoms and disturbances.
REPORT OF A PECULIAR CASE OF
CHRONIC ASCENDING POLIOMYELITIS ANTERIOB*
By CHARLES E. LOCKWOOD, M. D.,
NEW YORK,
ATTENDING PHYSICIAN, DISEASES OF THE NERVES,
OUTDOOR POOR DEPARTMENT, BELLEVUE HOSPITAL.
Mrs. A., wThite, aged forty-six, born in Ireland.
Fannily History. — Father died of old age; mother died of
cancer of the breast, aged sixty-six years; three sisters and one
brother living and well; one sister died of consumption, aged
twenty-two years.
Personal History. — Never seriously ill ; has suffered some-
what at times from malaria. In the spring of 1889 she bad a
sharp, shooting, burning pain in the right foot, but did not con-
sult a physician in regard to it. She spent the summer of 1880
in Saratoga, and thinks the place where she lived was damp.
No history of gout, rheumatism, or syphilis On September 1,
1889, she stumbled over a chain, bruising her right shin slight-
ly, and a few days afterward noticed that she was unable to
walk as well as formerly. The trouble persisting, she consulted
me, February 6, 1890, complaining of a peculiar heaviness and
weakness of the right leg and foot in walking, and of a diminu-
tion of the temperature in these parts. On examination, I dis-
covered marked weakness of the flexors of the foot and the ex-
* Read before the Medical Society of the State of New York at it-
eighty-sixth annual meeting.
«
712
LOCKWOOD: CHRONIC ASCENDING POLIOMYELITIS ANTERIOR. [N. Y. Med. Joint.
tensors of tlie toes. The right leg and foot felt colder to the
touch than the left ; atrophy of the anterior tibial muscles was
not marked. There was no pain ; no sensory, rectal, or bladder
disturbances. Tendon reflex at the right knee was present.
There was diminished electro-muscular excitability to the in-
duced current, and the normal formula was practically un-
changed so far as galvanism was concerned. Here, then, was a
case characterized by a marked loss of power in the group of
muscles supplied by the anterior tibial nerve, coming on in-
sidiously and gradually, with no premonitory symptom, except
the shooting, burning pain in the right foot, noticed during the
preceding spring. No appreciable atrophy; no sensory, blad-
der, or rectal disturbance. Tendon reflex at the knee intact ;
reaction to the faradaic current diminished, and to the galvanic
unaltered. The temperature of the affected limb lower sub-
jectively and objectively, and this condition connected in its
apparent commencement with a local injury in the mind of the
patient, who otherwise appeared to be in a good state of health.
"Was the affection central or peripheral ? I was unable to de-
cide, and asked Dr. Allan McLane Hamilton to see the case.
He expressed the opinion that the trouble was not central, and
advised the application of the actual cautery over the peroneal
nerve near the outer tendon of the biceps muscle, the hypo-
dermic injection of the paralyzed muscles with one sixtieth of
a grain of strychnine daily, massage, and the daily application
■of the faradaic current. In the way of medication, tilteen
grains of salicylate of sodium three times a day, and two tea-
spoonfuls of Fellows's hypophosphites with meals. Prognosis
was that the patient would eventually recover, but convalescence
would be tedious. Such was the treatment pursued without
improvement until March 31, 1890, when, while going into
church, the patient's right leg gave way, and she fell, bruising
her face severely.
On April 1, 1890, my patient was seen by Dr. M. Allen Starr,
who found paralysis of the anterior tibial group of muscles of
the right leg, atrophy, and the reaction of degeneration ; loss of
faradaic reaction and change in the galvanic reaction, with the
knee-jerk still preserved.
Diagnosis was degeneration of the nerve, with impaired
sensation and motion; said it would take a year to recover, and
recommended the use of the continued and interrupted galvanic
currents — one pole over the sciatic nerve and the other over
the anterior tibial muscles two or three times a week— massage,
and the wearing of a shoe with a piece of iron in the sole con-
nected with an upright piece fastened to the leg by a leather
band to prevent foot-drop. About the middle of April the pa-
tient complained of a sharp, shooting pain in the lett foot, the
same in character as that felt in the right foot a year before, and
further treatment was prevented by her departure to the coun-
try for the summer. On her return in October, 1890, examina-
tion by Dr. M. Allen Starr and myself showed complete paraly-
sis of the entire right leg, with reaction of degeneration. loss of
power and electrical contractility of the anterior tibial muscles
of the left leg, and atrophy and loss of power of the thenar and
hypolhenar muscles of the right hand, with fibrillary twitchings
and diminished faradaic excitability. A diagnosis was now
made of chronic amending poliomyelitis anterior, lesion having
given effects first in the peroneal muscles of the right leg.
The treatment decided upon was ten drops of Thompson's
solution of phosphorus after meals for two weeks, and then one
sixtieth of a grain of strychnine and one fortieth of a grain of
arsenious acid, three times a day for two weeks ; and their use
afterward alternately for two weeks. The application of the
faradaic current to the affected muscles half an hour daily, mas-
sage, and dry cups to the spine weekly.
The above treatment was followed for about a month, when
patient showing no improvement, but gradually growing worse,
her friends were anxions to have another opinion on the case,
and Dr. G. M. Hammond saw her and concurred in the diag-
nosis of chronic anterior poliomyelitis. He was able at that
Diagram of section of the cord through the lower part of the cervical enlarge-
ment (Ranney). A, uncrossed pyramidal tract or column of Tflrck ; B, an-
terior columns : C, lateral columns ; D, direct tract from lateral cotnnm to
cerebellum ; E, crossed pyramidal tracts of lateral column ; F, columns of
Burdaeh or posterior root-zone of Charcot : G. column of Goll : site of
lesion, B, C, E. and portions of gray matter.
time, over one year from the commencement of the disease, to
obtain slight tendon reflex on the right knee, better and fair on
the left knee ; found sensation good ; atrophy of muscles on
inner sides of lower parts of thighs; atrophy of legs not
marked; gastrocnemii contracted. Dr. Hammond gave a favor-
able prognosis; he thought the patient could be cured, but it
would take a long time. He advised the use of the flnid extract
of ergot, one teaspoonful three times a day after meals, to pre-
vent congestion of the cord, and iodide of potassium, commenc-
ing with ten grains well diluted, three times a day after eating,
and increasing the dose daily by one grain until the dose of sixty
grains three times a day was reached, to prevent the formation
of connective tissue, and the use of the galvanic current on the
affected muscles daily.
The patient at this time was placed under the care of Dr.
Hammond, and he very kindly informs me that " she subse-
quently died at the Post-graduate Hospital, about two years after
the commencement of the disease, from the extension of the
degeneration upward until the mednlla was reached and the
cardiac and respiratory centers were implicated. About a week
before she died she began to complain of shortness of breath ;
there was also a slight degree of cardiac irregularity. These
symptoms were intermittent. At the end of the week she sud-
denly had an attack of cardiac and respiratory paralysis ; she
was treated by hypodermic injections of strophanthus, digitalis,
and whisky, and rallied. In about two hours she had another
attack ; remedies were unavailing, and she died."
A post-mortem examination was made by Dr. G. M. Ham-
mond, and sections of the spinal cord from the dorsal and upper
lumbar regions were made for microscopical examination by Dr.
Edward K. Dunham, of the Carnegie Laboratory, who describes
the conditions found as follows: " In sections of the spinal cord
which you submitted to me for microscopic examination the
posterior columns of the white matter appear normal.
•• In the crossed pyramidal tracts on both sides the number
of nerve fibers is decreased and the amount of interstitial tissue
increased — descending degeneration. The number of nerve
fibers in the rest of the antero-lateral columns of the white sub-
stance also appears to be diminished with an increase of inter-
June 25, 18U2.J
PETERSON: AN ANCIENT SPA.
713
stitial tissue, but the amount of the change is not as great as in
the crossed pyramidal tracts.
" In the gray matter the walls of the blood-vessels are con-
siderably thickened, and I have thought that some of the nerve
cells in the anterior cornua were atrophied, but there are so few
normally present in this portion of the cord (dorsal and upper
lumbar) that I have not been able to satisfy myself upon this
point. The examination of other portions of the cord would be
of interest as showing whether the changes in the antero-lateral
columns of the white matter were a part of a disseminated
sclerosis, and also the cause of the descending degeneration in
the crossed pyramidal tracts."
March 1, 1892. — Dr. G. M. Hammond, having made sections
and microscopic examinations of other portions of the spinal
cord, has kindly furnished the following description of condi-
tions found: "Sections of the lower medulla show the hypo-
glossal nucleus to he normal. The motor cells of the pneumo-
gastric nucleus are atrophied, also the spinal accessory cells.
Respiratory bundle, just beneath the pneumogastric center,
shows slight evidence of sclerosis. Anterior pyramids show
slight sclerosis; all else seems normal. The cervical cord shows
same lesions as those found in the dorsal and upper lumbar
portions heretofore described."
The points of special interest in this case seem to me
to be :
1. The rarity of this form of the disease, Erb having
stated, in 1876, that only two reports of post-mortems were
then on record.
2. That the apparent commencement of the disease
seemed to be associated with a local injury, thus suggest-
ing a peripheral cause for the paralysis.
The difficulty experienced in making an early diag-
nosis, owing to the fact that those muscles only of the right
leg were primarily affected which were supplied by the an-
terior tibial nerve, thus seeming to point to a peripheral
lesion.
4. The slow progress of the disease upward, its effects
for six months being confined to the anterior tibial group
of muscles, and its entire progress occupying two years.
5. The advisability of taking into consideration the pos-
sibility of the existence of chronic anterior poliomyelitis in
a slowly progressing motor paralysis of a group of muscles
supplied by a single nerve with no sensory disturbances.
6. The impossibility of distinguishing between a central
and a peripheral cause, while the effects of the disease were
manifested in the peroneal muscles only, by means of the
electrical reactions, as the reaction of degeneration might
be present in both instances.
7. The possibility that the trouble may have been pri-
marily peripheral and secondarily central.
8. The persistence of the cathode closure contraction to
the last, as observed by Dr. Hammond.
!). The identity of this case with those described by
Charcot, Marie, and Tooth as the peroneal type of pro-
gressive muscular atrophies, concerning which Dr. Putzel,
in Wood's Reference Hand-book of the Medical Sciences,
says: " Hardly anything is known concerning the patho-
logical anatomy of the peroneal type of progressive muscu-
lar atrophies. Charcot and Marie suggest that it is the re-
sult of peripheral neuritis, and in three cases interstitial
neuritis was found on autopsy. It must be admitted, how-
ever, that our knowledge of this affection is too imperfect
to warrant us for the present in drawing any conclusions
with regard to its pathology and pathological anatomy,"'
and under the heading of Pathology he remarks : " The
nature of the lesion in the peroneal type of muscular atro-
phy must be left for future investigations ; we may say,,
however, that the strong hereditary element and the clinical
history seem to indicate a peripheral rather than a central
origin."
AN ANCIENT SPA.
By FREDERICK PETERSON, M. D.
The Baths of Helwan, in Egypt, perhaps merit the dis-
tinction of being the oldest health resort of the world, and
while their situation in so remote a country as Egypt may
not make a reference to them so valuable to American phy-
sicians as it otherwise might be, still it may have a historical
interest to many of your readers, and a few may find some
practical use in the following notes of a recent visit, for the
travel of American invalids in this direction is becoming-
greater year by year.
While I have spoken of the Helwan springs as the most
ancient spa of the world, their early history is somewhat
obscure. It seems reasonably certain, however, that during
the eighteenth dynasty, or something over thirty-five hun-
dred years ago, King Amenhotep sent persons afflicted with
leprosy and other incurable diseases to these springs for treat-
ment. There are perfectly authentic records of their being
a health resort twelve hundred years ago, but from that
time until a very recent period they had a very precarious
existence, as the various layers of bricks, granite, marble,
pottery, and the like found as ruins of ancient villages
would seem to indicate. Somewhere about 1871 the Egyp-
tian Government inaugurated a new era for these springs
by reconstructing the baths, building a hotel, planting trees
and the like, so that now a pleasant, well-built town, with
palm groves and villas, and a good railway from Cairo,
stands where not long ago was but a waste of yellow
sand.
Helwan is said by some to derive its name from the
Arabic word helwa, meaning sweet; but this would hardly
be suggested by the waters, which are particularly generous
of their exhalations of sulphureted hydrogen. The modern
spa lies fifteen miles south of Cairo in the desert, about three
miles from the Nile, and with about two miles of sand in-
tervening between it and the river. Back of it lie the bar-
ren, fantastic, and precipitous cliffs of Mokattam. It may
be classed with the desert health resorts, and as such is the
most accessible of all, while it partakes of that remarkable
dryness and purity of air common to such situations. Its
elevation is some 112 feet above the level of the Nile.
Thus far about a dozen springs have been rediscovered.
They are all thermal, varying in temperature from 77° to
80° V., but they differ in their chemical constitution, for
some are sulphurous and others chalybeate and saline. The
analyses made of most of them are as follows :
Three Sulphur Springs. — Temperature, 80° K. ; sp. gr.,
1-0025.
7U
PETERSON: AN ANCIENT SI' A.
[N. Y. Med. Joor.,
Analysis of One Litre.
Gases.
1
tree sulphureted hyd
rogen . .
47 c.
c, -0731 gramme.
carbonic acid
61
" -1200 "
*' nitrogen
10
lt -0126 "
u
118
" -2057 "
Solids.
Sodium chloride
3-2000 grammes.
Magnesium chloride
1-8105 "
Calcium bicarhonate,
•8050 gramme.
" sulphate ....
•2100 "
'•1880 "
•0150 "
Organic matter
•0015 "
6-2300 grammes.
• .i
? wo Iron Springs.
— Temperature, 77° F. ; sp. gr.
"0445.
Gas.
m l'pp r>Q VIM mil' n i * 1 1 1
26 c.
c, '0511 gramme.
Solids.
37-2671 grammes.
Magnesium chloride.
10-6020 "
Calcium bicarbonate
5-9422 "
Magnesium sulphate
2-3507 "
Calcium chloride ....
1-5250
" sulphate ....
1-0820 "
Alumina " ....
•5861 gramme.
Sodium bicarbonate
•2255 "
F errum , ,
•0555 "
Organic matter
•0300 "
Silica
•0180 "
59-6841 grammes.
till/'1 JJf ^ iii'y uri
\s Hv OCfcif/tC kJlJlllKf.
— Temperature, 7 7 ° F. ; sp. gr
•Q J 52.
Gas.
Free carbonic acid
6 c.
c, -01179 gramme.
Solids.
4-0171 grammes.
Magnesium chloride
3-1158 "
Calcium bicarbonate.
1-2569
Magnesium sulphate
1-0798 "
Sodium "
•4468 gramme.
Alumina "
•4257 "
Calcium chloride
•1610 "
Organic matter
•0330 "
Calcium sulphate
•0210 "
Silica.-
•0100 "
10-567l grammes.
The chalybeate water is chiefly used for its aperient,
and the saline for its purgative effects. Both are odorless
and colorless. The hot sulphur springs are those which en-
joy the greatest repute and are most valuable. As soon as
one enters the town their odor becomes apparent. The sul-
phur in the air turns silver ornaments black. The water of
-the springs is at first quite clear, but upon exposure to the
air becomes covered with a film of sulphur and lime salts,
and a greenish cryptogam, called baregine (from the
Bareges waters of the Pyrenees), develops in it.
The bath-houses are commodious and luxurious, kept in
good order, and are indeed up to the usual standard of
similar institutions in the better-known health resorts. The
water is artificially heated to higher temperatures when re-
quired. A European physician is in charge of the estab-
lishment, and European physicians are numerous in Cairo,
near at hand. The two hotels and furnished and unfurnished
villas to let afford excellent accommodations for invalids.
The diseases for which these baths are indicated are pre-
eminently rheumatism and certain skin disorders, and, in
conjunction with the natural advantages of such springs the
world over, the incomparable winter climate of Egypt is to
be considered. There is almost never rain or cloud or fo<r,
and the mean annual humidity is certainly less than that of
Cairo, which is 58-4 (Greenwich 87, Algiers and New York
70). The isothermal line runs between Florida and Canton
and Algiers and Santa Cruz.
Dr. Sandwith, of Cairo, summarized the monthly bulle-
tins of the Khedivial Observatory for five years, finding the
average annual rainfall to be 1*22 inches.
While we in America make comparatively little use of
foreign thermal springs, still, many of our patients go to
Aix-les-Bains, the springs of which are about the same in
character as those of Hehvan, and Aix, as well as our own
Hot Springs, is in a much colder latitude than these Egyp-
tian waters — a matter of a great deal of importance, even if
the distance be great.
It is needless to say, too, that the mind has more to oc-
cupy it here than in most health resorts, for, in addition to
the pleasures common to all such places — such as social
diversions, riding, driving, and reading — there lie in plain
view across the river the Pyramids and the monnds of an-
cient Memphis. The modern Egyptians are interesting in
their manners and customs. The great quarries of Toura
and Maaserah, from which the stones of the Pyramids were
taken, are near at hand. The desert is spread all around,
and, even if one be not a geologist with an eve to the in-
numerable fossils of the nummulitic hills, or a naturalist
zealous for novel additions to his collections, or an amateur
astronomer eager to gaze upon a wide and brilliant expanse
of starry heaven, the desert, like the sea, possesses a fas-
cination of its own which it is difficult to define, or impress
upon another with empty words.
Hki.wan, Egypt, January 20, 1892.
Spontaneous Cure of a Severe Abdominal Wound. — " Dr. Schildt
mentions in Duoi/ecim, a Finnish medical journal, a case, showing that,
occasionally at least, a large wound into a serous cavity which looks
hopeless enough may heal without treatment. He was called some years
ago to a poor man supported by charity, who, in consequence of inflam-
mation of the groin, had a large gaping wound of the abdominal wall,
through which some six inches of the small intestine protruded, all cov-
ered with blood, added to which there was a discharge of fetid matter.
The man was sent to the hospital, where, however, he could not be ad-
mitted, as all the beds were full. He was therefore taken home again,
and received no treatment whatever. Nevertheless, Dr. Schildt a short
time ago happened to see him alive and well, the wound having healed
spontaneously." — Lancet.
June 25, 1892.]
HARTLEY: TYPHLITIC ULCER.
715
TYPHLITIC ULCER.
PERFORATION ; OPERATION ; RECOVERY*
By FRANK HARTLEY, M. D.
When one considers that in 324 cases of the so-called
perityphlitis collected from various authors, 282 times the
appendix was found to be the seat of the disease, the im-
portance of the appendix as a starting-point for disease and
the frequency of its involvement can not be disputed.
Other conditions exist in the right iliac fossa, however,
which, though not so frequent, demand quite as much inter-
est both in a diagnostic and curative sense.
My interest in these conditions has been largely due to
two autopsies upon cases operated upon for appendicitis.
In one case the symptoms — such as the exact spot for
the pain, the tympanites, tumefaction, resistance, tempera-
ture, and respiration, without a distinct history of previous
troubles — pointed to appendicitis. The autopsy revealed
an ulcer of the sigmoid flexure, progressive peritonitis oc-
cupying the lower half of the abdomen, with a single local-
ized interintestinal abscess below and upon the inner side
of the caecum.
The appendix was normal, about four inches in length,
and lay upon the inner side of the caecum and ascending colon.
In the second case, in which there existed a suppurative
salpingitis, with circumscribed suppurative peritonitis and
with adhesion of the vermiform process to the abscess, the
lateral laparotomy was performed for a suppurative ap-
pendicitis. The imperfect history given by the patient and
the failure to make a vaginal examination apparently mis-
led the operator.
Such cases as the above must impress us all with the
importance of a careful physical examination and distinct
anamnesis. While appendicitis, suppurative or gangrenous,
is often the cause of a localized or diffuse peritonitis, ul-
ceration in the ca3cum in the neighborhood of the appendix
may give rise to a condition quite similar in its local mani-
festation. Such a case was reported by Dr. W. Ela, of Cam-
bridge, Mass., in December, 1889, in which recovery fol-
lowed the operation.
The patient I show to-night is one on whom I operated
for typhlo-enteric ulceration with success.
The history is as follows :
J. B., aged forty-seven, Switzerland, painter, was admitted
to the Roosevelt Hospital August 2, 1891. Family history is
good.
Personal LListory.—\l\\t\\ twenty-two years of age he was
perfectly healthy. At the age of twenty-two he had an attack
of gonorrhoea. At twenty -six he had rheumatism. At thirty
years of age a second attack of gonorrhoea. From thirty to
thirty-six he had two attacks of gonorrhoea, with one of which
he acquired chancroids upon the glans penis, with inguinal
adenitis. From the twenty-second to the forty-second year of
age he had about five diarrhceal movements daily. During the
summer these movements became less, and increased in number
during the winter. Since the forty-second year of age he has
had but one movement daily. This had been always of a
watery character.
The present trouble existed for two weeks. At the begin-
* Head before the New York Surgical Society, February 10, lsu-j.
ning of this trouble he suffered from general abdominal pain
which he could not localize in any particular region of the ab-
domen, and which supervened upon a hearty meal. It finally
involved the whole abdomen until, after taking a dose of castor
oil, on the second day, the pain over the abdomen wras relieved.
This pain disappeared completely during the next twenty-four
hours, except for a distinctly localized spot in the right iliac
fossa. He has never vomited and has had daily movements.
Examination. — Patient is a weak, ill-nourished man ; pulse,
120; temperature, 102°. His face shows a marked sepsis.
Respiration : thoracic, superficial, and about thirty per minute.
Lungs and heart normal. Urine, U020, no casts, few pus cells,
albumin a trace, otherwise normal. There is a swelling in the
right iliac fossa ; it can be indistinctly defined. There is slight
general tympanites present. The situation of the greatest re-
sistance and tumefaction is just below a line drawn from the
umbilicus to the anterior superior spine of the ilium. The ab-
domen at this point is tender, and the point of greatest tender-
ness is a finger's breadth below the aforesaid line, and at the
outer border of the rectus muscle. Rectal examination reveals
nothing, and the examination of abdominal viscera is also
negative.
Diagnosis. — Ulcer of the intestine with abscess, so far en-
capsulated, probably typhlo-enteric.
Operation. — Antisepsis; ether; incision; as for the appen-
dix (lateral laparotomy), on approaching the peritonaeum the
tissues were found very oedematous. The peritonaeum was in-
cised and the tumor was entered. It contained pus in large
quantity. The odor was feculent. The walls of the abscess
cavity within the peritoneal cavity were very thick, composed of
successive layers of fibrin and lined throughout with granulation
tissue. The wall of this cavity was formed by the lymph cover-
ing the caput coli, small intestines, and the peritonaeum over
the iliac fossa. The vermiform appendix was found uninvolved
and forming a part of the wall of this cavity. On the caput coli
to the inner side of the base of the vermiform appendix was
found a perforation large enough to admit the forefinger. Its
edges were ragged, irregular, and seemed somewhat indurated.
The vermiform appendix was ligated and taken away. An ex-
amination of it revealed its normal condition. The perforation
in the caecum, through which faeces escaped, was excised. The
edges were inverted and sutured with fine silk (Czerny-Lem-
bert). Disinfection of the cavity. Iodoform gauze tampon.
Abdominal wall sutured in the upper two thirds of its extent.
Lower third was left open.
Temperature, 99° ; pulse, 100, on third day.
Dressed on the fifth day, and packing of iodoform removed.
Gauze replaced.
The patient continued to improve and was discharged five
weeks later, completely cured.
Sources of Syphilitic Infection. — " Dr. Rassler, in his essay for the
M. D. of the University of Kiel, makes a valuable contribution to the
literature of syphilitic disease. The Archiv fiir /tt riimto/ot/ic mul Si//thi-
lis states that Dr. Rassler undertook the labor of analyzing six hundred
and thirty cases of syphilis treated in the medical clinic with the object
of ascertaining the number arising from extra-genital infection. He
found thirty-four such eases, comprising twenty-three of the lips, one of
the tongue, tw o of the mucous membrane of the mouth, and three of the
mamma. In three instances the primary sore occurred on the genital
organs without connection having taken place, and in the remaining two
it was impossible to indicate the locality. The result of these investi-
gations shows that five percent, of all cases of syphilis are due to extra-
genital infection. According to other authorities, the proportion varies
between one and ten per cent., except in certain parts of Russia, where
the proportion is said to reach as high as eighty or ninety per cent." —
710
HINKSON: MULTIPLE FRACTURE OF THE STERNUM.
[N. Y. Med. Joue.,
MULTIPLE FRACTURE OF THE STERNUM,
FOLLOWED BY NECROSIS AND ABSCESS.
REMOVAL OF THE FRAGMENT, WITH RECOVERY.
By JOHN R. HINKSON, M. I).,
BLISSVILLE, LONG ISLAND CITT, N. T.
Miss D., aged fourteen, was seen by the writer on September
7, 1891. She was then suffering great pain, had a hectic flush,
and a temperature of 101 -5° F. ; she also had a pulsating tumor,
about the size of a goose's egg, situated in front of the sternum
on a level with the third, fourth, and fifth ribs, in which fluc-
tuation could be plainly detected, the skin covering the tumor
being normal in appearance. The left breast was considerably
swollen and excessively tender.
It was at first thought that the case was one of empyema
which had ruptured beneath the skin ; but, on examination of
the posterior aspect of the chest, there were no abnormal physi-
cal signs discovered, nor was there any bruit to be heard in the
tumor, and the pulsation was not expansile.
The diagnosis of an abscess was made, and was confirmed by
an exploratory puncture with a hypodermic needle.
The following is the history of the case given by the girl's
mother : Some [time in the latter part of March, 1891, a boy,
aged fourteen, struck her a violent blow in the chest : she was
able to walk to her home, which was but a very short distance
away, but was subsequently troubled with frequent attacks of
syncope and constant " pain in her heart." A physician was
called in, and he attributed her symptoms to the advent of
menstruation, she never having menstruated up to this time.
Menstruation occurred, but brought no relief, and another phy-
sician was consulted, who stated at first that the patient'was
suffering from remittent fever, but when the tumor in front of
the sternum became more prominent, he said it was an aneu-
ryism, and that recovery was hopeless.
The latter "physician was in attendance on 'the patient for
eight days before she was seen by the writer.
On September 8, 1891, the patient having been anaesthetized,
an incision was first made in the tumor over' the sternum, fallow-
ing a large quantity of pus to escape; a uterine dressing forceps
was next introduced as a director, when the abscess cavity was
found to extend as far to the left as the posterior axillary line,
and as low down as the sixth rib, being limited above by the
clavicle ; it was also superficial to the pectoral muscles.
An incision two inches long was made about the junction of
the third rib with the posterior axillary line, parallel with the
long thoracic artery, and the cavity was washed out with a
l-to-10,000 solution of mercuric chloride. A pocket was also
found extending from the middle of the second piece of the
sternum upward and to the right for a distance of three inches;
into this a finger was inserted and an incision an inch long was
made at its upper extremity.
On further examination, the sternum was found to be fract-
ured transversely at the level of the fourth rib, and it was de-
termined to wire the fragments. With this intention the first
incision was enlarged and a plain retractor inserted between
the pericardium and the upper fragment, in which two holes
were drilled and wires passed through. The lower fragment
was about to be treated in like manner, but, on raising it
with the retractor, it was found to be quite movable; the in-
cision was prolonged downward, and a second transverse fract-
ure was discovered at the junction of the sternum with the rib
below.
As there was no'attachment of periosteum to the interven-
ing piece of bone, it was removed, the abscess cavity was again
washed out with a solution of mercuric chloride (1 to 5,000)
and a large drainage-tube passed from the opening on the right
side through the abscess cavity to the opening on the left side.
The incision in front of the sternum, which was four inches long,
was closed with sutures of wire, leaving an opening an inch and
a half in extent opposite the place where the loose fragment was
removed. Into this opening iodoform gauze was packed in order
that healing should take place by granulation from the bottom.
The severe oozing which occurred at this situation was checked
by the application of pure carbolic acid.
The patient did not bear'the operation at all well, atid great
difficulty was experienced in resuscitating her from the ether
narcosis. At the close of the operation the radial pulse was
found to be extinct and the facial barely perceptible ; the respi-
rations had also become very infrequent. Hypodermic injec-
tions of whisky and atropine were administered, but without ef-
fect. Nitroglycerin, one one-hundredth of a grain, hypoder-
micaJly, was then tried, and in less than five minutes the pulse
was felt at the wrist, the patient becoming'conscious a few min-
utes later.
The dressing was composed of iodoform and corrosive sub-
limate gauze,Jover which'wafl placed a thick layer of absorbent
cotton.
September 11th. — The dressing, which had become quite moist
and had an offensive odor, was changed. The sutures in the up-
per portion of the wound were found to have cut through, and
were therefore removed. The abscess cavity was irrigated with
a solution of mercuric chloride (1 to- 5,000) and the patient
dressed as on the former occasion. Pulse and temperature ap-
proximately normal, the patient having complained of little pain
since the operation.
15th. — The sutures in the lower part of the wound, which
was now completely healed, were removed. The drainage-tube
was also removed and the abscess cavity irrigated with a solu-
tion of mercuric chloride (1 to 5,000). Dressing as before.
After this date the dressing was changed twice a week. The
wounds healed very slowly, the incision on the left side of the
chest not having cicatrized till one month, and that on the right
side not till two months after the operation. The wound in the
median line was not found to be completely healed till January
3, 1892.
The patient is now in excellent physical condition, and ex-
periences no pain or inconvenience whatever on account of the
absence of the portion of the sternum removed.
The Prevention of Rabies. — " Were it not that experience has fully
proved, both in England and on the Continent, the efficiency of the
muzzle as a preventive of the spread of hydrophobia, we mipht excuse
the delusion that the disease lately so prevalent in this country has
died a natural death. The facts mentioned in the Lancet of April 5,
1890, however, show too close a connection between the prophylactic
method and its effect to admit of any real doubt upon the subject.
The past year has been a period of probation. The immunity conferred
by the muzzling order has not, perhaps, unnaturally been taken as
justifying its discontinuance in favor of the less irksome system of
collar registration, and so far, there is every reason to believe, with
fairly satisfactory results. In this way such cases of rabies, at least,
as arise among stray dogs, and they comprise the greater number,
should, if the regulations are stringently enforced, be held in check.
Of the efficiency of the muzzling system and the justice of its applica-
tion two years ago, we can not entertain a doubt. In its absence regis-
tration is and must remain for some time to come Quite indispensable.
It is difficult indeed to see how, without some such preventive arrange-
ment, security against the disease can be relied upon. We trust,
moreover, that on the least sign of a recrudescence of the disease, in
the interest of our faithful friends, the dogs, as well as of the human
race, muzzling may again he strictly enforced." — Lancet.
June 26, 1892.]
CLAIBORNE:
THE AXIS OF ASTIGMATIC CLASSES.
717
THE AXIS OF ASTIGMATIC GLASSES*
By JOHN HERBERT CLAIBORNE, M. D.,
NEW YORK.
In presenting this paper I have little hope of adding
new facts to your knowledge, but I do hope to make its
purpose and its contents clear. The initial proposition
which I w-ish to make is that astigmatism does not occur at
hap hazard, that there is a regularity in its occurrence in a
given eye, and that there is a certain definite relationship
between the axes of the astigmatism in the two eyes when
both happen to be astigmatic. In order that I may plunge
into the midst of my subject, permit me, without more ado,
to take up the consideration of the axis of astigmatic glasses
in the various forms of astigmatism seriatim. In using the
expression axis of astigmatism, I use it synonymously with
the axis of the cylindrical glass that corrects the error.
1. Simple Hyperopic Astigmatism in a Single Eye. — In
the majority of cases the axis of this form of astigmatism
is vertical — that is, 90°. If a deviation from this position
takes place, it must be in the direction of the horizontal axis
on either of the two sides of the vertical axis, and the first
position assumed by such a deviation is the axis 75° or the
axis 105°, which is a deviation of 15° from the vertical posi-
tion. The next axis of preference is either 135° on the
one side or 45° on the other side of the vertical. It is
certainly comparatively rare that the axis of simple hyper-
opic astigmatism is horizontal, nevertheless it does occur.
Now, the point which I wish to emphasize is that these five
positions— -viz., 90°, 105°, 135°, 75°, 45°— are the posi-
tions of preference for hyperopic astigmatism. It may not
be altogether wise at this date to state it as my opinion that
any of the axes lying between these points are not selected
by hyperopic astigmatism, but I feel compelled to do so
from a sense of profound conviction. I believe that when
any other axes than those mentioned are found, the axes
have been the exceptions that prove the rule or have been
incorrectly diagnosticated. The following are the possible
individual positions of the axes in simple hyperopic astig-
matism in a single eye :
•0°
Fig. 1.
The realm proper of hyperopic astigmatism may then
be said to extend 45° on either side of the vertical. In
* Read before the Section in Ophthalmology of the New York
Academy of Medicine, February 15, 1892.
other words, it may be said to include 90°, or one quarter
of the circle ; and of the axes included within this realm,
the five axes— 90°, 105°, 135°, 75°, 45°— are the axes of
preference. The axis 0 occurs as stated by exception.
II. Simple Myopic Astigmatism in a Single Eye. — The
axis of simple myopic astigmatism is in the large majority
of cases horizontal. If, now, the eye select a deviation from
this axis, it selects the axis that is 15° from the horizontal
on the one side or the other; in other words, the axis 165°
or the axis 15° is chosen. I have not had a case in which
the axis of simple myopic astigmatism has not been one of
these three positions, unless it were vertical. I have found
this latter erratic axis quite frequently in myopic astigma-
tism ; it is more frequent to find this than it is to find the
axis of hyperopic astigmatism in the horizontal position.
The following are the possible individual positions of the
axes in simple myopic astigmatism in a single eye :
90'
Fig. 2.
Its realm proper may then be said to include 30°, or
one third of a quarter of the circle, and the axes included
within this realm — 180°, 15°, 165° — are the axes of prefer-
ence. The axis 90° occurs as stated by exception.
III. Compound Hyperopic Astigmatism in a Single Eye.
— Statements which have been made with regard to the axis
in simple hyperopic astigmatism I hold to obtain in com-
pound hyperopic astigmatism, for compound hyperopic
astigmatism is simple hyperopic astigmatism coupled with
spherical hyperopia.
IY. Compound Myopic Astigmatism in a Single Eye. —
The axes of compound myopic astigmatism are the axes of
simple myopic astigmatism.
V. The Axes of Mixed Astigmatism in a Single Eye. —
It may be broadly said in the beginning that the above
rules in regard to hyperopic astigmatism and myopic astig-
matism hold when these two conditions occur in the same
eye. The axis of the hyperopic astigmatism is restricted,
as a rule, to the realm marked out for this error and to the
axes of preference in this realm — viz., 90°, 75°, 45°, 105°,
135°. The axis of the myopic astigmatism is restricted to
its realm proper and to tin- axes of preference contained
therein, as long as that is permitted by the axis of the hy-
peropic astigmatism. For example, if the hyperopic axis
be vertical, the myopic axis will be horizontal. If the hy-
peropic axis be 105°, the myopic axis will be 15°, or at a
right angle. If the hyperopic axis conversely be 75°, the
718
LEADING
ARTICLES.
[N. Y. Med. Jour.,
myopic axis will be 165°. If, however, the hyperopic axis
be cast as far from the vertical as 45° or 135°, the myopic
axis will be forced from its realm proper and will be com-
pelled to invade the realm of the hyperopic axis. For ex-
ample, if the hyperopic axis be found to lie at 45°, the
myopic axis will be found to lie at a right angle — viz., 135°,
or vice versa. It occurs sometimes, though rarely, that mixed
astigmatism is found in an eye with each axis in a position
the reverse of the most usual one ; for example, with the
hyperopic axis horizontal and the myopic axis vertical. I
have seen this in one eye, but never in both.
The following are the possible individual positions of
the axes in mixed astigmatism in a single eye :
Fig. 3.
{To be concluded.)
Infant Mortality in France. — " At a recent meeting of the Society
for the Protection of Children in France Dr. Rochard (chairman) stated
that France loses every year 250,000 infants, and that out of this num-
ber there are at least 100,000 whose lives could be saved with intelli-
gent care. These lives were the more precious in the present period, for
France could no longer afford to lose them. When he stated, in 1884,
that the population of France would stop increasing toward the begin-
ning of the twentieth century, he was pooh-poohed. His prophecy has
been justified sooner than he wished. The number of deaths in 1890
outnumbered the births by 38,446. It was not easy, said Dr. Rochard,
to add to the births, but it was possible to diminish the death-rate among
infants. The 100,000 babes that ought to be saved every year would
repopulate France. lie then distributed medals and prizes awarded by
the society to doctors and nurses who had given their services to the
society."— British Medical Journal.
xnE
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by Edited by
D. Appleton & Co. Frank P. Foster, M. D.
NEW YORK, SATURDAY, JUNE 25, 1892.
THE "RAILROAD KIDNEY."
De. Cyrus Edson has a thoughtful paper on the hygienic
relations of railway travel in the. May issue of the Dietetic Ga-
zette. The paper is a long one, and takes up a variety of rail-
way situations interesting to medical men, who, as a rule, are
poor travelers; it is altogether worthy of being reproduced for
sale as a sanitary tract. One point — the renal consequences of
an excess of railroading — interests us just now. The great evil
of such excess, from the medical point of view, is not that
caused by jolting, jarring, and straining the nervous apparatus,
but it is dirt. The dirty condition of the cheaper trains is a
manifest abomination to all tidy persons. On the better trains
efforts are made to keep the travelers as free from the grimy
nuisance as possible, but the dirt will force its way in. If any
person who has been traveling a few hours will examine the
skin of his hands, he will find it quite soiled, especially if the
weather has been hot enough to cause perspiration. If, then,
he will examine still more closely, he will see the fine grime in
the orifices of the perspiratory ducts, in a position to sink into
and close up the pores whenever the flow of perspiration
ceases. How deep these little plugs or corks work their way
into the integument may be inferred from the repeated wash-
ings that are necessary to thoroughly clean one's exposed sur-
faces after a railroad trip. This stoppage of cutaneous action
throws back upon the kidneys a heavy load of impeded excre-
tory work, and this, repeated often enough, will result in the
" railroad kidney," in much the same way that serious renal
disease is caused by an extensive burn on the surface of the
body. The morbid consequences are alike, or parallel, chiefly
for the reason that in both cases thousands, if not millions, of
cutaneous outlets are completely blocked up, and renal compen-
sation's demanded by the system.
The chief sufferers, of course, from the fouling of the skin
with grime are members of that class in the community which
is included under the term "railroad men"; and the cases of
engineers, conductors, and brakemen are the most numerous
and striking. The occasional traveler in ordinary health has
not much to fear from this condition after any trip lasting a
few days, but where a person is already the subject of renal
disability, it is quite possible that a week or more of constant
railway travel would appreciably aggravate the existing trouble.
For this reason, if for no other, the commercial traveler, or
"drummer," is not an infrequent sufferer from renal overwork.
And it is an important item in the hygiene of this extra-hazard-
ous vocation that habitual traveling should be given up or
greatly reduced if the kidneys become impaired. This "drum-
mer " class is largely made up of young men of good physique,
June 25, 1892.)
MINOR PARAGRAPHS.— ITEMS.
719
keen intelligence, and a great partiality for the external appli-
cation of water. It i.s not to be sanguinely expected, therefore,
that cases of railroad kidney will be observed frequently in the
commercial traveling class. At the same time, its members
may, as occasion offers, be made to understand the value of and
reasons for a systematic cutaneous hygiene to persons in their
way of living.
MINOR PA RA GRAPHS.
THE OBJECTIONS TO THE INSERTION OF DRAINAGE-TUBES
INTO WOUNDS.
In the Maryland Medical Journal for November 14, 1891,
Professor William U. Welch summed up the objections to the
insertion of drainage-tubes into wounds as follows: First, they
tend to remove bacteria, which may get into a wound, from the
bactericidal influence of the tissues and animal juices. Second,
bacteria may travel by continuous growth or in other ways
down the sides of a drainage-tube and so penetrate into a
wound which they otherwise would not enter. He has re-
peatedly been able to demonstrate this mode of entrance of the
white staphylococcus found so commonly in the epidermis.
The danger of leaving any part of a drainage-tube exposed to
the air is too evident to require mention. Third, the changing
of dressing necessitated by the presence of drainage-tubes in-
creases in proportion to its frequency the chances of accidental
infection. Fourth, the drainage tube keeps asunder tissues
which might otherwise immediately unite. Fifth, its presence
as a foreign body is an irritant and increases exudation. Sixth,
the withdrawal of tubes left any considerable time in wounds
breaks up forming granulations and thus both prolongs the
process of repair and opens the way for infection. Granulation
tissue is an obstacle to the invasion of pathogenic hacteria from
the surface, as has been proved by experiment. Seventh, after
removal of the tube there is left a tract prone to suppurate and
often slow in healing. To these Dr. Halsted adds an eighth:
Tissues which have been exposed to the drainage tube are
suffering from an insult which more or less impairs their vital-
ity and hence their ability to destroy or inhibit micro-organ-
isms.
THE ^ETIOLOGY OF SUPPURATIVE HEPATITIS.
Surgeon-Captain Patrick IIehir, of Hyderabad, has re-
cently publifhed a brochure on The Pathological and yEtiologi-
cal Relations of Tropical Suppurative Hepatitis, and concludes
from his experience in India that hepatic abscess is most com-
monly a sequel of dysentery, arising from a secondary infective
process affecting the liver through the portal circulation. Gases
may arise from the action of septic organisms — such as the
streptococci, staphylococci, or micrococci ; or from the irritation
of the products (ptomaines) of such septic organisms conveyed
to the liver from the ulcerated bowels and acting primarily on
the liver, which plays the part of a filter upon the blood con-
veyed to it by the portal vein, or from the irritation of the Amaba
coli, or the Gercomonas intestinalis, or both together. Some
cases may be due to malarial poisoning, the blocking up of the
radicles of the portal vein by the hasmatozoa of Laveran, these
organisms acting as irritants and lighting up the suppurative
process. In another class of cases the abscess may be the result
of acute sthenic parenchymatous inflammation resulting from
climatic causes, overcrowding, alcoholic excesses, excessive heat,
or chill, acting upon a liver already in a partial state of disor-
ganization. The author makes a third class of idiopathic cases
in which no assignable cause can be traced. While a known or
unknown cause may produce hepatic abscess, a statement made
earlier in the paper, that micrococci are invariably found in pus
removed by aspiration, seems to us to indicate a certain definite
agent producing suppuration in a locus minoris resistentios.
EMIN PASHA.
TnE death of Emin Pasha is announced again. This time
the report seems to be credited at Berlin. The alleged cause of
bis death was small-pox. The real name of Emin Pasha is Ed-
ward Schnitzler, and he is in some sense the most eminent phy-
sician of his generation. He studied medicine at Breslau and
Berlin, and was graduated at the latter city's university in 1864,
at which time he was twenty-four years old. A strong predi-
lection for botany and other branches of natural history, a long-
ing for travel, and an aptitude for languages led him to go down
to Constantinople in pursuit of practice, study, and adventure.
His services were in almost constant requisition in semi-official
positions in Turkey, Armenia, Arabia, and Syria for ten years.
In 1876 he went down into Egypt, and entered the medical
service of the Khedive as Dr. Emin Effendi. From that time
forward his advance was rapid and picturesque, his name be-
came a household word in three continents, and the country
doctor ended by occupying the throne of a barbaric principality
and introducing a semi-civilized government into the Soudan.
THE LATE DR. D. HAYES AGNEW.
At the request of Mrs. Agnew, Dr. J. Howe Adams, of Phila-
delphia, is preparing a biography of her late distinguished hus-
band; in consequence, he is looking for data on this subject, and
is desirous of obtaining from all of Dr. Agnew's former friends,
colleagues, associates, students, and acquaintances all such au-
thentic data as relate in any way to his career or character. Dr.
Agnew's acquaintance was so vast, says Dr. Adam--, and his life
was so actively spent among his friends, while his own modesty
was so marked, that undoubtedly a great many incidents, anec-
dotes, characteristic stories, etc., are unknown to his family.
All material, however insignificant or small, will be welcomed
by Dr. Adams, and credit will be given for all such data as are
used.
THE NEW YORK PHYSICIANS' MUTUAL AID ASSOCIATION.
On several occasions we have commended this association
and the results of its work have gone on increasing in impor-
tance until now the amount paid on each death is $1,000, being
the full sum allowed by the by-laws. The present number of
members is 1,106.
ITEMS, ETC.
The American Chemical Society will bold its fifth general meeting
in Rochester, N. Y., on August 16th. The chairman of the committee
of arrangements, Mr. A. A. Breneman, of No. 9*7 Water Street, New
York, requests that members send him early notice of papers to be
presented.
The University of Pennsylvania. — Under the will of the late Pro-
fessor D. Hayes Agnew, the University is to possess the copyright of
his surgical text-book, also many specimens and tuition-drawings, and
the sum of fifty thousand dollars will go to the hospital on the death of
his widow. The Maternity and Kensington Hospitals also will then be
the recipients of $1,000 each, and the College of Physicians will receive
a like bequest.
Changes of Address. — Dr. W. Evelyn Porter, to No. 50 WestThirtp
third Street; Dr. .John Ridlon, from New York to No. 34 Washington
Street, Chicago.
720
ITEMS.— LETT Kits
TO THE EDITOR,
[N. Y. Mel». Jouk.,
The American Gynaecological Society will hold its seventeenth an-
nual meeting in Brooklyn on the 20th, 21st, and 22d of September.
The Honorary Degree of LL. D. 1ms been conferred on Dr. Reynold
W. Wilcox, of New York, by Maryville College, of Maryville, Tenn.
The Death of Dr. T. G. Richardson, of New Orleans, occurred in the
last week in May. He was* for more than thirty years a professor of
surgery and other branches in Tulane University Medical School. About
three years ago he retired from active college work, but remained an
earnest and liberal supporter of medical educational interests in New
Orleans and elsewhere. He was for twenty years dean of the Tulane
Medical Faculty. He was an editor or co-editor of two or more medical
journals that are now extinct. He was regarded by his older pupils as
a model teacher of anatomy.
The Death of Dr. Henry F. Formad, of Philadelphia, took place on
the 8th inst. He was a Russian by birth and was in his forty-sixth
year. An exile for political reasons while yet a youth, he studied very
diligently at Berlin and at Heidelberg.
Army Intelligence. — Official List of Changes hi the Stations and
Duties of Officers serving in the Medical Department, United States
Army, from June 5 to June 18, 1892 :
Davis, William B., Captain and Assistant Surgeon, is relieved from
duty at Fort Clark, Texas, to take effect upon the return of Major
Skinner to that post, and will report in person to the commanding
officer, Fort Sam Houston, Texas, for duty.
Moseley, Edward B., Major and Surgeon, is relieved from duty at Fort
Sam Houston, Texas, to take effect upon the arrival at that post of
Captain Davis, and will report in person to the attending surgeon,
Washington, D. C, for duty in his office.
Dunlop, Samuel R., First Lieutenant and Assistant Surgeon, is relieved
from duty at Fort Supply, Indian Territory, and will report in per-
son to the commanding officer, Camp Pena Colorado, Texas, for duty
at that station, relieving Skinner, John 0., Major and Surgeon.
Major Skinner, upon being relieved by First Lieutenant Dunlop, will
rejoin his proper station, Fort Clark, Texas.
The following assignments to duty of Assistant Surgeons, recently
appointed, are ordered :
McCulloch, Champe C, Jr., First Lieutenant, will proceed from Char-
lottesville, Va., to Fort Sam Houston, Texas, and report in person
to the commanding officer of that post for duty.
Reynolds, Frederick P., First Lieutenant, will proceed from Elmira,
N. Y., to Fort Monroe, Va., and report in person to the commanding
officer of that post for duty.
Ware, Isaac P., First Lieutenant, will proceed from North Anson, Me.,
to Fort Douglas, Utah Territory, and report in person to the com-
manding officer of that post for duty.
Woodson, Robert S., First Lieutenant, now at Fort McPherson, Geor-
gia, will report in person to the commanding officer of that post for
duty.
Brewer, Madison M., First Lieutenant, is relieved from temporary duty
in the Surgeon-General's Office, Washington, D. C, and will proceed
to David's Island, N. Y., and report in person to the commanding
officer of that post for duty.
Deshon, George D., First Lieutenant, now at Columbus Barracks, Ohio,
will report in person to the commanding officer of that post for
duty.
Heger, Anthony, Colonel and Surgeon, is granted leave of absence for
four months, to take effect after June 30, 1892.
Gorgas, William C, Captain and Assistant Surgeon. The leave of ab-
sence granted is extended one month.
Harris, Henry S. T., Captain and Assistant Surgeon. The leave of
absence granted for seven days is extended twenty-three days.
Ireland, Merritte W., First Lieutenant and Assistant Surgeon, is re-
lieved from temporary duty at Fort Yates, N. D., and will rejoin his
proper station, Fort Riley, Kansas.
Fisher, Henry C, First Lieutenant and Assistant Surgeon, is relieved
from duty at Fort Riley, Kansas, and will report in person to the
commanding officer, Fort YateS, N. D., for duty at that station.
Appointment.
To be Chief of the Record and Pension Office of the War Depart-
ment, with the rank of Colonel, in accordance with the act of May 9,
1892 :
Ainsworth, Fred C, Major and Surgeon, May 27, 1892, to fill an origi-
nal vacancy.
Commission vacated by New Appointment.
Ainsworth, Fred C, Colonel and Chief of the Record and Pension
Office. His commission as Surgeon, with the rank of Major, June
1, 1892.
Naval Intelligence. — Official Lint of Changes in the Medical Corps
of the United States Navy for the two weeks ending June 18, 1892 :
Stitt, E. R., Assistant Surgeon. Detached from the Naval Hospital,
Philadelphia, and ordered to examination for promotion, and then
to Bureau of Medicine and Surgery.
Bailey, T. B., Assistant Surgeon. Detached from the Receiving-ship
Minnesota, and ordered to examination for pr omotion, and then to
Hospital, Philadelphia, Pa.
Byrnes, J. C, Passed Assistant Surgeon. Ordered to special duty at
Norfolk and Portsmouth, Va.
Wilson, H. D., Assistant Surgeon. Ordered to the Receiving-ship Min-
nesota.
Wilson, G. B., Passed Assistant Surgeon. Ordered to temporary duty
at the Naval Hospital, Chelsea, Mass.
Arnold, W. F., Passed Assistant Surgeon. Detached from U. S. Train-
ing-ship Richmond, and placed on waiting orders.
Barnlm, M. W., Assistant Surgeon. Detached from Naval Hospital,
Washington, D. C, and ordered to the U- S. Training-ship Rich-
mond.
Percy, H. T., Passed Assistant Surgeon. Ordered to the Naval Hos-
pital, Washington, D. C.
Pickrell, George M. C, Passed Assistant Surgeon. Detached from the
Naval Hospital, Norfolk, Virginia, and ordered to the U. S. Steamer
Newark.
Society Meetings for the Coming Week :
Monday, June 27th : Medical Society of the County of New York ;
Boston Society for Medical Improvement ; Cambridge, Mass., Society
for Medical Improvement ; Baltimore Medical Association.
Tuesday, June 28th : Medical Society of New Jersey (first day — Atlan-
tic City) ; Buffalo Obstetrical Society.
Wednesday, June 29th : Medical Society of New Jersey (second day) ;
Auburn, N. Y., City Medical Association ; Berkshire, Mass., District
Medical Society (Pittsfield).
fetters to tbc <£ottor.
BANDAGE-CUTTING.
Decatur, III., May 7, 1892.
To the Editor of the New York Medical Journal:
Sir: In the Journal of March 26th is a short article by Dr.
Southgate Leigh, describing a number ef new and improved
instruments. The last thing described is a bandage-cutter, and
I infer that he, like the majority of practitioners, finds the
ready-rolled bandages of the shops too expensive. 1 think I
have hit on a scheme for bandage-cutting that will be of great
practical utility to the surgeon who desires to roll his own band-
ages. I purchase a bolt (or less quantity) of muslin and take it
to a printing-office where they have a paper-cutter, and id five
minutes the entire bolt can he cut into bandages of different
widths, and afterward rolled in lengths to suit. This gives a
nice even bandage, and is in every way superior to those toru or
cut with scissors. M. H. Fahmek, M. D.
June 25, 18!)2.J
PROCEEDINGS OF SOCIETIES.
721
procecbings of Societies.
AMERICAN MEDICAL ASSOCIATION.
Forty-third Annual Meeting, held in Detroit on Tuesday,
Wednesday, 'Thursday, and Friday, June 7, 8, 9, and 10,
1892.
The President, Dr. Henry 0. Marcy, of Boston, in the Chair.
{Concluded from page 694-)
Proposed Amendments to the Constitution. — An amend-
ment was proposed by Dr. C. A. L. Reed, of Ohio, providing
that the association admit to membership physicians from the
Dominion of Canada, Newfoundland, and Labrador. The mat-
ter was to be referred to a committee of the association, which
should confer with proper committees from the countries men-
tioned.
The President appointed as the committee for the associa-
tion Dr. C. A. L. Reed, Dr. N. S. Davis, Dr. H. O. Walker,
Dr. C. A. Lindsley, and Dr. C. G. Conn. The constitution re-
quired that such an amendment should lie over for a year be-
fore adoption.
An amendment to the constitution was also offered that no
physician should be admitted to membership in the association
who had not been four years in practice. Action on this was
also deferred for a year.
A recommendation was received from the Section in Physiolo-
gy and Dietetics that the Haddock Pure Food Bill, now before
Congress, he endorsed, but, as the exact terms of the bill
were not known to the meeting, the recommendation was
tabled.
The Committee on Incorporation recommended that incor-
poration be deferred for the present, as the association might
thereby be more or less involved in litigation.
Dr. Qttimby, of New Jersey, offered as an amendment to the
constitution that Thursday of each annual meeting be devoted
exclusively to section work. This was tabled.
A committee was appointed by the president to audit the
report of the treasurer of the Rush Monument Fund.
The committee on the matter of railroad surgeons reported
that two complaints were before it. One was that railroad sur-
geons were supposed to care for injured passengers and em-
ployees without due regard to their ethical relations to other
professional brethren ; the other, that they took inadequate
compensation for their work, and so tended to lower the stand-
ard and dignity of the profession. The committee denounced
the custom of underbidding in order to get practice, and. dis-
cussed at length the contract system as applicable to surgeons.
It was thought that this system was too extensive and involved
too large a portion of the medical profession who were under
contract, wholly or in part, to be crushed by adverse resolutions
or criticism. The contract system, on the whole, was not to be
encouraged. The report was adopted.
Officers for tne Ensuing Year.— The Committee on Nomi-
nations reported as follows : For president, Dr. Hunter McGuire,
of Virginia; for vice-president, Dr. II. O. Walker, of Michigan;
for treasurer, Dr. R. J. Dnnglison, of Pennsylvania; and
for secretary, Dr. W. B. Atkinson, of Pennsylvania. It
recommended that the next meeting be held at Milwaukee,
and also that the code of ethics of the association he made
broader.
The Address on State Medicine was delivered by Dr. J.
Berrian Lindsley, of Tennessee. His attention had first been
called to the importance of his subject by reading, while a
medical student, in 1843, a book entitled An Inquiry into the
Sanitary Condition of the Laboring Population of Great Brit-
ain, and this had influenced the thoughts, studies, and pursuits
of his life as few other books had done. The influence of the
book in Great Britain had been enormous. Since the time that
it was written the great feature of British history had been the
constant, steady elevation of the masses, and the leading topic
under that head had been the public health. In 1853 the city
of New Orleans was ravaged by yellow fever, which called
forth the report by Dr. E. H. Barton upon the sanitary condi-
tion of New Orleans, and also a voluminous report by the New
Orleans Board of Health. If the teachings of these volumes
had been sufficiently followed, the conditions, commercial as
well as physical, of that city would have greatly improved.
Another notable report in the literature of state medicine was
that which was issued in 1865, entitled Report of the Council of
Hygiene and Public Health of the Citizens'1 Association of New
York upon the Sanitary Condition of the City. Sanitary reform
in Massachusetts was much influenced by Sliattuck's report in
1850 on the sanitary condition of Massachusetts. The first State
board of health was established in that State.
Sanitary reform, then, was inaugurated not so much by the
medical profession as by the general public, looking at first to
its protection from disastrous epidemics, and next to relief from
preventable diseases and improvement in daily health.
Medical men were naturally called to assist in a reform of
this character, and they soon assumed a leading part. But their
influence should not be predominant, for it was law and not
medicine that was chiefly concerned. Medical science could
dictate the kind of laws that should be made for the promotion
of the public health, but it was powerless to enforce those laws.
A powerful auxiliary to sanitary science was found in the arti-
cles upon public and private hygiene which were constantly
appearing in the periodical literature. The advances which had
been made in chemistry, physics, and biology had been notably
useful in that direction. Though the governments of most
civilized nations realized the vital importance of sanitary science,
and fostered or controlled institutions for its furtherance, the
American Government was most backward in this particular;
Here, then, was a fine opportunity for completion by the gen-
eral Government of the work which had been so admirably de-
veloped by local and State boards of health. This was espe-
cially indicated, in view of the great extent of our country, with
its varieties of climate and disease. The untimely end of the
National Board of Health, which was established in 1879 and
expired after a few years of existence, was much to be regret-
ted, notwithstanding the fact that its decline was concurrent
with a noteworthy expansion of the Marine-Hospital Service,
which in some respects represented the Government in the
field of preventive medicine. The evolution of governmental
supervision of the public health would not be complete until a
Department of Public Health was established, suitable dignity
being conferred upon its presiding officer. This would neces-
sarily include the vast interests of the Marine-Hospital Service;
a great bureau of vital statistics, which would supersede the
Census Office and be in operation continually ; a bureau lor the
minute topographical survey of the entice country, with the
mapping of its results on an extensive scab' ; and possibly other
departments which were now under the control of other
branches of the Government.
The Museum of Hygiene, now under the control of the Navy
Department, and the Library of the Surgeon-General's Offioe
were illustrious examples of what the (Jovernuient could do in
the way of State medicine, for, if a separate bureau for this sub-
ject were established, these two institutions would necessarily
be incorporated in it.
722
PRO<'EEDIX<;s
OF SOCIETIES.
[N. Y. Med. Jour.,
Until recent years the American Medical Association had been
too indifferent to the part that should be played by the Gov-
erninent in caring for the public health, but, happily, that bad
been changed ; tbe addresses in state medicine from year to
year bad been stimulating to the work, and tbe same was true
of tbe addresses from the presidential chair. It was recom-
mended that a committee of the association be appointed to co-
operate with other national organizations in which state medi-
cine was a matter of investigation, including the American
Public Health Association, the American Association for the
Advancement of Science, and the Congress of Physicians and
Surgeons.
The President suggested that before tbe adjournment some
expression of appreciation of the courtesies and hospitalities
which the association had received should be made. Dr. N. S.
Davis, of Illinois, and Dr. H. D. Didama, of New York State,
responded to this suggestion in complimetary remarks, and reso-
lutions expressing gratitude and appreciation were also offered
by a committee appointed for the purpose, and adopted.
The president for the ensuing year, Dr. Hunter McGuire,
was then introduced, and the meeting was adjourned.
NEW YORK SURGICAL SOCIETY.
Meeting of February 10, 1892.
Tbe President, Dr. Arpad G. Gerster, in the Chair.
Compression Myelitis in Connection with Pott's Disease.
— Dr. V. P. Gibney read a paper on this subject and referred to
a previous paper read in 1879, in which he had reported tbe his-
tories of fifty-eight cases. Those cases he had carefully followed
up, and, so far as be had been able to ascertain, they had shown
a mortality of 105 per cent, from the disease. With many of
them the paralysis or paraplegia had lasted from four to ten
years, and then recovery had taken place.
The author's present table included a series of thirty-two
cases in which the paralysis had continued from two months to
two years and ten months, the average being eight months. He
described the method by which these cases were usually treated,
which consisted in the fro e administration of iodide of potassium
and Fleming's method of extension. Several typical cases from
his table were narrated. Frequently as much as one hundred
grains of iodide of potassium, in solution, were given to children
not more than eight years of age. The progress of patients who
were cared for at home was frequently interfered with by the
carelessness of parents in attending to their dressings and their
failure to bring them sufficiently often to tbe physician for in-
spection. The supporting apparatus which was applied in these
cases should be immovable and should be worn for a long time.
Relapses frequently occurred in consequence of changes made
in the apparatus. By some surgeons a hopeless view was taken
of such cases. It must be admitted that the prognosis was diffi-
cult. The hopeless cases were those in which the disease in-
volved the ganglion cells of the spinal cord, distortions and de-
formities of the limbs resulting.
Dr. Robert Abbe thought that operations in cases of the
disease under discussion were simple and apt to be successful.
There was no great risk to the patient in the operation, which
he believed was called for only in very bad cases.' He had op-
erated in two cases successfully.
Dr. J. 1). Bryant had seen no occasion for operation in the
cases which had come under bis notice. The patients he bad
seen bad recovered without operation, and he thought that in-
terference by operation sometimes made matters worse.
Dr. Gkoroic R. Fowler's experience with operative proced-
ures bad been unsatisfactory. He had operated in two cases,
both of which had resulted fatally.
Dr. Charles MoBitrney had not operated for this disease.
He was in favor of conservative methods of treatment during
tbe early stages, while those cases which were far advanced or
had come to a standstill might be suitable for operation. The
indications for operation were similar to those that obtained in
cases of fracture of the spine, in which, partial repair having
taken place, and so some support having been supplied, opera-
tions were better borne and more successful. One should gen-
erally try the effect of supporting apparatus first.
The President bad operated successfully in two very bad
cases in which tbe symptoms of compression had increased in
urgency very rapidly. In both of them the compression symp-
toms had been due to a subdural effusion of pus, and when this
was removed the paralysis disappeared rapidly.
Dr. Gibney had found that the opinions of neurologists in
regard to the propriety of operating differed decidedly. It was
difficult to determine this point by electrical tests.
Thiersch's Method of Skin-grafting —Dr. McBurney pre-
sented two cases in which ulcers of the leg had been treated by
Thiersch's method of skin-grafting. In the first case there had
been a large ulcer of the heel and of the inner aspect of the
ankle, which bad followed a severe injury and had existed for
thirty-two years. Tbe tissues of the ulcer had been excised and
four grafts from tbe thigh applied. AH of these bad united and
tbe result bad been complete healing. In the second case there
bad been large ulcers upon the anterior aspect of both legs. In
this case also complete healing had been obtained at once. In
performing tbe operation tbe wound was frequently irrigated
with a salt solution, rubber tissue, moistened with the same so-
lution, was applied, and over this were placed compresses, also
moistened, tbe salt solution being renewed upon the compresses
at proper intervals. Both syphilitic and tuberculous ulcers had
been operated upon by this method with good results.
A Neglected Method of modifying General Anaesthesia.
— Dr. McBurney read a paper thus entitled. The question had
frequently occurred to him whether we did not anaesthetize too
extensively in operative procedures. While it was desirable to
anaesthetize only the nerve centers, by the methods which were
in common use, the brain, the nerve centers, the blood, and all
tbe tissues were saturated with tbe anaesthetic, and all the
agencies of elimination were taxed to the utmost in trying to
dispose of it. It therefore seemed to him desirable to exclude
as large a portion of the circulating fluid as possible from the
action of tbe anaesthetic, and this was done by confining blood
in the limbs by bands securely fastened around them. This
method was not a new one, but had been used in previous years
by Corning, Sweatnam and Aiken, of Toronto, and A. C. Post.
Corning had advised compression of the limbs with sufficient
firmness to exclude all communication of the circulating fluid in
them from the trunk and head. The author had practiced this
method in ten cases, including a variety of operations. An or-
dinary ether cone had been used, with from an ounce to three
ounces of ether. There was usually no struggling, quiet anaes-
thesia resulted in from two to five minutes, and there was no
congestion of the face. There was very little vomiting or dis-
cbarge of mucus or saliva. When the operation was completed
tbe limbs were raised, tbe bandages were removed, and con-
sciousness quickly returned. There might be dangers in the
method, but they were not as yet apparent. It was thought
that the method might obviate shock to a certain extent, also
disturbance of the kidneys and bronchitis. The method was
then practically demonstrated upon a man, about twenty years
of age, in apparently good physical condition. There was very
little struggling. Three ounces of ether were used and com-
June 25, 1892.]
PROCEEDINGS
OF SOCIETIES.
723
plete anesthesia was induced in from eight to nine minutes.
The bandages were then removed and consciousness returned in
two minutes. The subject answered questions intelligently, and
was able to get off the table and put on bis clothes.
Dr. Abbe had observed that the patient's breathing bad been
somewhat shallow during the anaesthesia, and diaphragmatic in
character. He was surprised at the rapidity with which con-
sciousness returned, and also that the face did not become either
pallid or blue, but of a natural red.
Dr. Bryant was much pleased with the demonstration, and
believed the method worthy of further investigation.
Dr. J. D. Rushmore could not accept the statement that pure
blood was thrown into the circulation as the bandages were re-
moved. Having been confined in the tissues, it was quite im-
pure, but it was quickly oxygenated as it passed into the lungs
and was certainly not saturated with the anaesthetic. He did
not think it desirable to anaesthetize a patient with great ra-
pidity.
Dr. McB-urney thought it important that the constriction
should be sufficient, not only to prevent the return of venous
blood, but also to shut off the supply from the arteries. Of
course the method should not be used upon persons with dis-
eased arteries, and if the compressing bands were too narrow in-
jury might be done to the nerves. The brain and trunk were
to a certain extent anaemic during anaesthesia by this method,
and this might have a bearing upon the operation to be per-
formed. The shallow breathing might be due to the possible
anaemia of the lungs. There was a possibility that haemorrhage
might occur in the wound after the circulation was restored ;
hence it was well to defer putting in the final stitches until
safety from this accident was assured. If morphine was in-
jected hypodermically between the bandages and the heart the
quantity should be much smaller than if it was allowed to per-
meate the entire circulation.
Sleeting of February 24, 1892.
The President, Dr. Aepad G. Gerstek, in the Chair.
Deformity of the Lower Extremity following Excision
of the Hip Joint.— Dr. V. P. Gibney presented a patient in
whom disease of the right ankle joint had commenced in his
fourteenth month. The affected bone was excised by Dr. Lange.
Three months later hip trouble had commenced and the head of
the femur had been excised at the German Hospital. Sinuses
had resulted that had been scraped several times since, and at
present there was one over the great trochanter. The foot was
now in the position of equino-varus. The thigh could be flexed
to 90°, but there was limited motion of the limb with atrophy.
The femur, tibia, and fibula were of two thirds of the length of
those bones on the unaffected side.
The speaker presented a second case, that of a patient aged
eight years and a half, in whom the head of the femur had been
excised by a surgeon in one of the general hospitals, and at pres-
ent extension could be made to about 155°. There was limited
adduction, also decided shortening. The question in such cases
was whether it was better to open the old wound, scrape out
the diseased bone, and divide the femur, or to continue tempor-
izing ; and in the first case presented was it better to correct the
ankle deformity or amputate the foot?
Dr. F. Lange stated that he had operated on the ankle of the
first patient shown when the boy was three years old, and Dr.
W. Meyer, in later years, had operated upon the same child for
tubercular disease of the hip joint. The future treatment would
depend upon the possibility of healing the sinuses. Amputation
might be performed below the knee j..int and an artificial leg
employed.
Dr. J. A. W yetit believed it would be better to apply in that
case some apparatus that would fit on the foot, rather than use
prothetic apparatus after amputation.
Dr. Gibney stated that he thought in Ins first case he would
attempt to heal the sinus by an operation, divide the femur
subcutaneously, keep the foot in a plaster-of-Paris dressing,
and then apply such an apparatus as Dr. Wyeth had referred
to. In the second case he proposed doing a subcutaneous oste-
otomy.
Intestinal Obstruction. — Dr. Frank Hartley presented a
patient on whom an operation had been performed two years
ago for suppurative appendicitis with acute suppurative perito-
nitis. In November, 1891, he presented symptoms of intestinal
obstruction. An incision was made in the median line and a
slender constricting band was found and removed. It was the
second case of the kind that he had operated on.
Dr. L. A. Stimson thought, that such cases as this exhibited .
the ultimate, as well as the immediate, risks attending late op-
erations for appendicitis, an operation that could be considered
neither simple nor safe.
Dr. R. H. M. Dawbarn wished to call attention to a point
that he believed to be new in reference to laparotomy for ap-
pendicitis, and that was, the way in which to find the appendix.
Where agglutination had not occurred, the small intestines were
continually falling into the field of operation and annoying the
surgeon. In a dozen instances he had found it a simple expe-
dient to change the patient from his back to the left side and to
pull the abdomen forward (away from the spine), thus forming
a space into which the small intestines would fall, the caecum
being, however, held in position by its short mesentery.
Pyloroplasty for Stenosis after the Heineke-Mikulicz
Method. — Dr. Lange presented a man, twenty nine years old,
whose family history was good. He had been in good health
until about six years ago, when he commenced to suffer from
dyspeptic trouble. He was treated for a long time for nervous
dyspepsia and gastric catarrh, but never for supposed ulcer of
the stomach. Though he often vomited, be never vomited
blood, and no blood was observed in his stools except what was
readily explained by the presence of moderate piles. Within
the last year he had often vomited large masses containing par-
ticles of food that had been swallowed from a day to three days
previously. The degree of acidity had often been examined
and found to be abnormally great, as stated by Dr. Alfred Mey-
er, his attending physician. He had often very severe cramp-
like pain in the region of the stomach, radiating toward the
back and the space between the shoulders. His bowels were
regular.
The speaker saw the patient, in consultation with Dr. Alfred
Meyer, on January 4th. An examination by inflation proved
the stomach to be considerably dilated. An indistinct hardness
could be felt in the region of the pylorus, also some pain on
deep pressure. The patient was emaciated but did not present
a cachectic appearance. On the 8th of January laparotomy was
done. The pylorus was covered by the gall-bladder, omentum,
and large intestine, which had to be separated with the thermo-
cautery, scissors, and blunt manipulations t<> gel access to the
pylorus. The separation of the gall-bladder was especially
tedious, and in this attempt the lumen of the stomach, close to
the stricture, was burned into. The pylorus was greatly nar-
rowed and felt like a hard ring; a longitudinal incision an inch
long into the stomach and a like incision into the duodenum
proved its lumen as narrow as a lead-pencil. The longitudinal
wound was closed by two rows of suture, an internal catgut
and an external silk suture. The application of a loose iodo-
form-gauze tampon and union of the laparotomy wound finished
the operation. The wound through the abdominal wall was a
724
PROCEEDINGS
OF SOCIETIES.
|N. Y. Med. Jocn.r
longitudinal incision in the linea alba, with a shorter transverse
one to the right, about three or four inches in length. The op-
ration was very tedious, requiring over two hours. The patiente
made an uninterrupted recovery and was discharged alter four
weeks. His pain had not returned since the date of the opera-
tion, and he was in fair health and gaining.
From a paper by Dr. Senn, who reported two of his cases
with favorable result in November, 1891, it appeared that this
was the eleventh case on record, and that the operation yielded
safe and good results. The speaker desired to state that Dr.
Prudden's examination of a specimen from the case of gastric
ulcer presented at a December meeting had shown it to be car-
cinomatous.
Dr. Wyeth asked whether he considered this operation
preferable.
Dr. Lange replied that he thought the functional results
were better in Mikulicz's.
Musculo- spiral Paralysis complicating Fracture of the
Humerus. — Dr. F. W. Murray read a paper having this title.
(See page 708.)
Dr. Wyeth said that in a case of fracture of the humerus
symptoms of musculo-spiral paralysis appeared, and two weeks
after the injury he operated and successfully released the nerve.
An analogous condition was sometimes caused by the plaster
dressing on a fractured patella compressing the external pop-
liteal nerve and producing talipes.
Dr. Stimson said that in one of his own cases, referred to by
Dr. Murray, there was no apparent injury to the nerve, and in
another there was a bony [canal within which the nerve was
noticeably smaller, but not tightly held; whether the nerve
was ever actually compressed in the canal needed demonstra-
tion. In one case that he had seen, the nerve was injured by
the violent grasping of an assistant in turning the humerus so
that the end of the bone could be excised ; this patient recov-
ered spontaneously in two years. It seemed to him that the in-
terference with the function of this nerve was not always the
result of compression, but rather of some unknown factor ; this,
however, need not interfere with the advisability of operating.
He would always seek for the nerve below the point where it
was hidden by cicatricial tissue, and then follow it up..
Dr. Robert Abbe had had no experience in musculo-spiral
paralysis, but the demand for surgical interference should be
heeded in any case where the nerve was probably stretched
across a sharp edge of bone. He recalled a case in which the
popliteal nerve had been stretched across the sharp fractured
end of the femur at the epiphysis that resulted in fatal tetanus
in spite of amputation.
Dr. J. D. Bryant recalled a case of musculo-spiral paralysis
in which the question of a suit for damages arose, the parents
alleging malpractice because paretic symptoms developed after
the injury. It would be wise for the surgeon, in treating fract-
ure of the humerus, to test the muscles supplied by this nerve
at the time of the injury and frequently afterward, so 'as to
"cast an anchor to the windward," in case of subsequent legal
complications.
Dr. Hartley reported a case of paralysis of the posterior
interosseous branch of the musculo-spiral nerve in a case of
fracture through the internal condyle of the humerus above the
capitellum. At the operation he found the bend of the nerve
caught between the ends of the fractured bone ; he released the
nerve and approximated the fracture, and there was complete
recovery. In this case, as in two others published in the Roose-
velt Hospital Reports, this branch was given off rather higher
than usual.
Intestinal Strangulation by a Fibrous Band.— Dr. Bryant
resented a specimen that he had removed from a musician,
aged sixty-six years, who had never suffered from any intes-
tinal or abdominal trouble until forty-eight hours before the
speaker was called in. He had excruciating pain, and was al-
most pulseless when seen, the abdomen was distended, and in-
testinal strangulation was obvious. Despite the grave condition,
the abdomen was opened, and a considerable portion of gan-
grenous jejunum (fifteen inches) was exposed. This was drawn
out until a fibrous band, connected with an intestinal diverticu-
lum, was found constricting it. He removed the band, opened
and cleaned the intestine, and cleansed the abdominal cavity.
The patient lived fourteen hours.
Dr. Dawharn asked whether this was an example of Meckel's
diverticulum.
Dr. Bryant stated that it was connected with the jejunum,
but he could not examine it as he would have desired owing to
inability to obtain a post-mortem; therefore he could not reply
definitely.
NEW YORK ACADEMY OF MEDICINE.
SECTION IN ORTnOI'.-EDIO SURGERY.
Meeting of May 20, 1892.
Dr. Henry LingYTaylor, Chairman.
Congenital Dislocation of Both Patellae.— I >r. S. Ketch
presented a little girl who at first glance seemed to have only
knock-knee, but on flexing the limbs, a complete dislocation of
the patella downward and forward was observed, and the dis-
location could be readily reduced by extending the limb. The
deformity was much more marked on the right side. The con-
dition was probably congenital, although it had not been noticed
by the mother until recently, as the child was able to walk with
no more difficulty than was observed in an ordinary case of
knock-knee. Dr. Shaffer had suggested that this was the oppo-
site of the condition which he had described under the bead of
elongation of the ligamentum patella} at the last meeting of the
American Orthopaedic Association.
Dr. John Ridlon said that he had seen three such cases in
the practice of the late Mr. Thomas. The treatment had con-
sisted in hammering the deficient condyle with an egg-shaped
wooden mallet, and in two of the cases the treatment had al-
ready effected sufficient development to prevent dislocation, and
in the other case the treatment had only just been begun.
Dr. W. R. To wnsend said that lie had presented some time
ago to the Surgical Section of the Academy of Medicine a col-
ored girl who could, by muscular action, produce at will a com-
plete dislocation of both patellae, either to the outer or to the
inner side. A knee-cap was applied, and an effort made to re-
strict the movements of the fibers of the vastus externus and
internus, which seemed to be abnormally developed. She was
kept under observation for six or eight months, and at the end
of this time she could not produce the dislocation at will, and
the dislocation occurred quite infrequently.
Dr. N. M. Shaffer said that in his case of elongated liga-
mentum patella} the man had had a fall which was followed by
an outward dislocation of the patella on the right side. After
consultation with several other surgeons, in view of the fact
that the intercondyloid notch was filled by an exostosis, it
was considered best to make no attempt at reduction, and at
present, although the patella lay on the outer aspect of the
joint, the man was perfectly able to walk ten or fifteen miles a
day. In the case just presented, he did not think the external
condyle was deficient, but the ligamentum patella) was so short
that the patella, instead of passing over the trochlea, was drawn
down to a point where, owing to the knock-knee, it was very
easily dislocated. On this account, he thought that treatment
directed toward securing an elongation of the ligament would
June 25, 1892.]
PROCEEDINGS OF SOCIETIES.
725
be more apt to prove successful than simply hammering the
■outer condyle.
Dr. Ketoh agreed with the last, speaker as to the inr.dvisa-
hility of resorting to operative measures. Not long ago he had
seen a young lady with a somewhat similar condition. Twelve
years hefore, the patella had been dislocated by muscular action,
and this had again occurred shortly before he saw her. Reduc-
tion was easily effected by extending the limb.
Ankylosis of the Hip.— Dr. Ikving S. Haynes, present by
invitation, exhibited a specimen of this condition which he had
found in the dissecting loom of the University Medical ('ollege.
The subject was a man about twenty-five or thirty years of age.
The limb was slightly flexed, adducted. and rotated inward. A
sinus opened about half an inch below Poupart's ligament and
an inch internal to the anterior superior spinous process. It
passed backward and soon divided into two tracts, one leading-
down to the front of the great trochanter, the other up under
Poupart's litiament into the iliacus. and then into the obturator
internus muscle, then around the middle of the outer border of
the obturator foramen into the cotyloid notch, and so into the hip
joint. The iliacus and obturator muscles, as well as all the mus-
cles acting upon the hip joint, had undergone extensive absorp-
tion and fibrous degeneration. The center of the disease, and the
starting point, seemed to have been in the head of the femur, but
there was also a focus in] the epiphyseal line of the great tro-
chanter, which communicated with that found in. the head of the
femur by a sinus running through the neck and also opened in
front through one or two small openings. Another sinus seemed
to have led from the acetabulum through the cancellous portion
of the ilium into the iliac fossa, where the opening was sur-
rounded by bony formations. Between the ilium and the
sacrum there was slight mobility of a gliding nature, which the
speaker had never observed before and which was probably in-
tended to partially compensate for the lack of motion at the
hip. There was no evidence of the disease in the capsule of the
joint. The abscess cavities were limited to the absorbed por-
tions of the iliacus and obturator internus muscles.
Arthritis Deformans. — Dr. Haynes also exhibited a speci-
men of this condition showing erosion and reproduction of bone,
with a depression in the acetabulum and disappearance of the
ligamentum teres. The motions of the joint were slightly lim-
ited in every direction. The specimen had been removed from
an old subject.
The Treatment of Large Abscesses in Pott's Disease.—
Dr. W. O. Plimpton presented several cases of Pott's disease
with large abscesses as an illustration of the treatment which
he advocated. lie did not favor aspiration, because he thought
that after this had been done the abscesses were likely to con-
tinue to enlarge and burrow into the tissues. While admitting
that abscesses were not, infrequently absorbed, 'he wished to
deprecate the let-alone treatment of large abscesses which
tended to burrow deeply into the tissues, threatening to inocu-
late these tissues and often causing mechanical deformities of
other parts.
Dr. Townsend said that the location of the tube in the first
case reminded him of an accident which had occurred about a
year before. He was hastily summoned to the hospital on ac-
count of one of the patients having a haemorrhage. He found
that a patient with a large psoas abscess which had been opened
and a drainage-tube inserted three weeks before, had suddenly
begun to bleed profusely. The haemorrhage was arterial, and,
with the assistance of Dr. W. T. Bull, he cut down and found
that the pressure of the drainage-tube had caused a large per-
foration in the femoral artery. lie accordingly tied the artery
above and below the perforation, and the child recovered with-
out further accident.
Dr. Ketoh thought the cases presented very much the ap-
pearance of tho-r which he had seen in the hospital when it
was the rule to open all abscesses as soon as they approached
the surface. They did not seem to him to differ materially in
their course from those where the abscesses were allowed to
open spontaneously, and be could not see that anything had
been gained by this method of treatment
Dr. Ridlon asked if the drainage-tube had been left in for
so long a time for fear that the opening would close up, and
make another operation necessary. He had always thought
that it was not requisite to leave the tube in more than a few
days.
Dr. A. M. Phelps thought that the second patient had had a
decided advantage over the first in being subjected to the opera-
tion at a much earlier stage. The slightest increase in an ab-
scess, in his opinion, warranted prompt incision. He spoke em-
phatically because the Section had almost been committed to
the idea that it was better for these abscesses to take care of
themselves. But it must not be forgotten that they were origi-
nally collections of tuberculous material, and that when they
became infected with pyogenic germs, as almost inevitably oc-
curred, there would be a rapid burrowing of the pus. Another
reason for opening them was that they exerted an injurious
effect by the internal pressure of the exudate upon the carious
foci in the diseased vertebras, keeping them bathed constantly
and furnishing a fertile source of the subsequent breaking
down of these vertebra and of a consequent increase in the
deformity.
Dr. Ketch thought that the previous speaker had not cor-
rectly stated the position of the Section on this subject. He
thought it would be more correct to say that they took the
ground that so many of these abscesses disappeared spontane-
ously under proper mechanical treatment that something more
than mere accident was necessary to explain it, and that these
collections of pus caused injurious pressure had not been proved.
The proof of this would be found in a marked increase in the
size of the deformity, but in disease of the dorso-lumbar spine,
where these abscesses were the most frequent, this did not oc-
cur, and Dr. Myer.- had recently presented a boy who had had
two large iliac abscesses disappear spontaneously, and yet there
had been no increase in the kyphosis, as shown by repeated and
careful tracings. .
Dr. Shaffer said that extensive observation had taught him
that, with efficient mechanical treatment, the abscesses of Pott's
disease almost uniformly pursued a benign course, and he be-
lieved that the time would come when those who now operated
would see their error. He had seen in the practice of some ot
the best surgeons in New York deaths occur after operating
upon just such abscesses. When an abscess was very tense,
and there were severe local or constitutional symptoms, every-
body recognized the propriety of incision, but ordinarily these
abscesses were flaccid and did not cause any such "damming
up " and injurious pressure as had been described by Dr.
Phelps.
Dr. Whitman could see no good reason tor waiting until
the abscesses appeared below Poupart's ligament. When first
discovered they should be aspirated, and, if this failed, iodo-
form emulsion should be injected. Surely a method of treat-
ing the abscesses of Pott's disease which yielded in the hands
of Brnns fifty successful cases out of fifty-two, and in those of
Fraenkel eighteen out of twenty, was one which deserved a fair
trial before resorting to severer measures. If aspiration and
the injection of iodoform emulsion proved unsuccessful, the
method of evacuation recommended by Barker and Treves, with
immediate closure of the wound, might be employed before re-
sorting to open drainage.
BOOK NOTICES.
[N. Y. Med. Joi k.,
Dr. Plimpton said that the tube had been left in for free
drainage, as it had been found that where it was removed
shortly after operation the exuberant granulations choked up
the sinus and gave rise to a great deal more trouble and dis-
comfort than where the tube was retained. At the time of the
operation he had had in mind the possibility of accident from
having the tube in too close proximity to the femoral artery,
and in this particular case there were dense cicatricial barriers
between the tube and the artery. Small and not readily acces-
sible abscesses should not be interfered with unless they caused
some disturbance, but he would not hesitate, if circumstances
seemed to demand it, to open them above Poupart's ligament-
The existence of pressure within an abscess and its effect upon
the general health were well demonstrated in one case in which
he removed about half a pint of the contents of the abscess by
aspiration, with the result of causing an immediate return of
the child's appetite and a prompt relief from pain. He had
seen the iodoform emulsion used in a number of instances with-
out apparent benefit. In considering the percentage of ab-
scesses which disappeared spontaneously, it must be remem-
bered that many of them were small abscesses or were nothing
but fluid in the joint, so that the statistics on this point were
very defective.
A Contribution to the Study of Non-deforming Club-
foot.— Dr. L. W. Hubbard read a paper with this title.
A New Apparatus for overcoming Abduction of the
Thigh in Hip-joint Disease. — Dr. Shaffer exhibited a new
apparatus which he had devised for the purpose of overcoming
the abduction of the thigh in hip joint disease, and at the same
time avoiding the infliction of any traumatism upon the joint.
It consisted of a thoracic attachment to the ordinary long hip
splint, with an arrangement of curved levers actuated by a key,
by which motion was imparted to the limb in a direction down-
ward and inward, instead of, as in other instruments of this
class, inward and upward. This was the chief feature, and it
was on this account that traumatism was avoided. It could be
attached to any ordinary long traction splint, and, like the tho-
racic part, it was to be used only as a temporary arrangement
for reducing the deformity.
Dr. Phelps said that he was glad to see that Dr. Shaffer had
come to recognize the fact that we could not act upon the hip
joint with any degree of precision without taking hold of the
' thorax ; but he failed to see any necessity for such an apparatus
as the one shown, because his lateral traction splint did the
same thing, and no patient with hip-joint disease need recover
with angular deformity. Since he had devised and made use of
his lateral traction fixation splint, which acted on the same
principle as the apparatus just exhibited, he had not seen a case
of angular deformity. If such a thoracic splint was applied
after the deformity had once been overcome, recovery must
take place without angular deformity.
Dr. Shaffer explained that the apparatus he had just pre-
sented was intended only as a temporary apparatus for over-
coming persistent abduction of the thigh, and he considered it
a very serious mistake to use the thoracic attachment in the or-
dinary treatment of hip-joint disease, because it limited the
motion of the spinal column, and this would necessarily in-
crease the strain upon the diseased joint. It was for this
reason that he had discarded the thoracic addition to the hip
splint many years ago. The idea of his new apparatus was to
provide a temporary means of overcoming abduction, and it was
only to be worn long enough to accomplish this purpose, and
then it was so arranged that the abduction and thoracic por-
tions could be removed readily, leaving the ordinary hip splint,
which permitted a free movement of the dorso lumbar spine,
and thus diminished the traumatism at the hip, which was best
shown when a patient with hip-joint disease and dorso-lumbar
caries attempted locomotion.
it'iooh Notices.
The" Diseases of the Mouth in Children (Non-surgical). By F.
FoRcnHEiMER, M. D., Professor of Physiology and Clinical
Diseases of Children, Medical College of Ohio, etc. Phila-
delphia: J. B. Lippincott Company, 1892.
The contents of this volume were first published in the form
of a series of articles in the Archives of Paediatrics. Many of
the articles have, however, been revised and added to.
One of the principal motives of their republication was to
furnish the medical student with a systematic course which
should give him a working basis for his usefulness as a practi-
tioner. The author has endeavored to bring together the facts
in connection with the non-surgical diseases of the mouth in
children — something which has never been done before in the
English language.
The older physicians were very careful about the examina-
tion of the mouth, especially the tongue, but in these days the
examination is usually performed in rather a perfunctory man-
ner. The diagnostic value of certain changes is largely dis-
puted, and probably justly so. At the same time it is certain,
as the author says, that the older physicians, with their limited
means, made diagnoses that were very wonderful ; and it is
equally certain that we, with all our appliances, overlook very
important conditions.
There are chapters on the various forms of stomatitis, each
variety being thoroughly discussed as regards its aetiology, pa-
thology, diagnosis, prognosis, and treatment. The phenomena
of dentition are also considered in a separate chapter. The au-
thor takes strong ground against lancing the gums, believing it
to be useless either as giving relief to symptoms, or as facilitat-
ing or hastening teething.
The book is well printed, the style is clear and forcible, and
the views expressed are evidently based upon wide reading as
well as a full personal experience.
A Treatise on Practical Anatomy for Students of Anatomy and
Surgery. By Hexry C. Boexnixg, M. D., Lecturer on
Anatomy and Surgery in the Philadelphia School of Anato-
my, etc. Philadelphia and London : F. A. Davis, 1891.
The author has endeavored to arrange the subject-matter in
this book so as to make it equally serviceable as a text-book on
anatomy and as a guide in dissection.
It is illustrated with one hundred and ninety-eight wood-
engravings, all of which are well executed and unusually clear,
considering the reduced scale required by the small size of the
volume.
As stated in the title, the work is intended mainly for stu-
dents, and is probably meant to be used more as a convenient
manual than as a substitute for the larger treatises, such as
Quain's and Gray's.
The author's style is agreeable, and the typographical execu-
tion is such as to make a very attractive-looking volume.
BOOKS, ETC., RECEIVED.
Treatise on the Diseases of Women, for the Use of Students and
Practitioners. By Alexander J. C. Skene, M. D., Professor of Gynae-
cology in the Long Island College Hospital, Brooklyn, X. Y. ; formerly
June 25, 1892.J
MISCELLANY.
727
Professor of. Gynecology in the New York Post-graduate MeHical
School, etc. Second Edition, revised and enlarged. With 251 Engrav-
ings and 9 Chromolithographs. New York: D. Appleton & Co., 1892.
Pp. xiv to 968.
How to feel the Pulse and what to feel in it. Practical Hints for
Beginners. By William Ewart, M. D. Cantab., F. R. C. P., Physician to
St. George's Hospital, etc. With Twelve Illustrations. New York:
William Wood & Co., 1892. Pp. xv to 112.
On Contractions of the Fingers (Dupuytren's and Congenital Con-
tractions) and on " Haminer-toe." Including Two Essays on Dupuy-
tren's Contraction of the Fingers, and its Successful Treatment by Sub-
cutaneous Divisions of the Palmar Fascia, and Immediate Extension.
One Essay on Congenital Contraction of the Fingers and its Association
with Hammer-toe ; its Pathology and Treatment. One Essay on the
Successful Treatment of Hammer-toe by the Subcutaneous Division of
the Lateral Ligaments. And One Essay on the Obliteration of De-
pressed Cicatrices after Glandular Abscesses, or Exfoliation of Bone, by
a Subcutaneous Operation. By William Adams, F. R. C. S. Eng. With
Eight Plates and Thirty-one Wood Engravings. Second Edition. Lon-
don: J. & A. Churchill, 1892. Pp. xx to 154.
Zeitschrift fur orthopiidische Chirurgie einschliesslich der Heilgym-
nastik und Massage. Unter Mitwirkung von Professor J. Wolff in Ber-
lin, Dr. Beely in Berlin, Professor Dr. Lorenz in Wien, Privatdocent Dr.
W. Schulthess in Zurich und Dr. Nebel in Frankfurt a M. Herausge-
geben von Dr. Albert Hoffa, Privatdocenten der Chirurgie an der Uni-
versitiit Wurzburg. 1. Band. Mit 85 in den Texte gedruckten Ab-
bildungen und 12 Tafeln. Stuttgart: Ferdinand Enke, 1892. Pp. iv
to 487.
A System of Practical Therapeutics. Edited by Hobart Amory Hare,
M. D., Professor of Therapeutics and Materia Medica in the Jefferson
Medical College of Philadelphia. Assisted by Walter Chrvstie, M. D.,
formerly Instructor in Physical Diagnosis in the University of Pennsyl-
vania. Vol. III. Diseases of the Skin — Diseases of the Nervous Sys-
tem— Diseases of the Genito urinary Apparatus — Diseases of the Eye —
Diseases of the Ear. With Illustrations. Philadelphia : Lea Brothers
& Co., 1892. Pp. 11-17 to 1352.
Materialism and Modern Physiology of the Nervous System. By
William H. Thomson, M. D., LL. D., Professor of Materia Medica and
of Diseases of the Nervous System in the University of New York.
New York : G. P. Putnam's Sons, 1892. Pp. 112.
Psoriasis and the New Remedy — Gallacetophenone. By Julia W.
Carpenter, M. D. [Reprinted from the Lancet-Clinic]
Suppuration of the Middle Ear, complicated with Abscess of the
Neck, with Report of a Case. By E. Oliver Belt, M. D., Washington,
D. C. [Reprinted from the Ophthalmic Record.]
What is Ho meopathy ? A New Exposition of a Great Truth. By
William H. Holcombe, M. D. Philadelphia: Boericke and Tafel.
The Successful Treatment of Chronic Diseases. A Plea for their
more Methodical Management. By Simon Baruch, M. D. [Reprinted
from the Dietetic Gazette]
Expert Witnesses. By J. T. Eskridge, M. D., Denver, Colorado.
[Reprinted from the Denver Medical Times.]
Charge to the Graduating Class. By J. M. Masters, M. D., Professor
of Ophthalmology and Otology in the Tennessee Medical College. De-
livered at the Third Annual Commencement. Knoxville, Tenu., March
17, 1892.
Opening of the Mastoid Process. By Dr. Harry Friedenwald, Balti-
more.
The Pathology and Treatment of Tetanus ; including a Series of In-
vestigations in regard to the Micro-organism of the Disease and the In-
fluence of Disinfectant Substances on the same. A Study from the
Pathological Laboratory of the Jefferson Medical College. By D.
Braden Kyle, M. 1). [Reprinted from the Therapeutic Gazette.]
A Plea for the Medical Expert. By L. Harrison Mettler, A. M.,
M. D., of Chicago. [Reprinted from the Journal of the American Medi-
cal Association.]
Accidental U torn-vaginal Fistula following Hysterectomy; Cure by
Kolpo-urotcro-cystot y, Gradual Preparatory Treatment, and Button-
suture. By Nathan G. Bozeman, Ph. It., M. D. [Reprinted from the
New York Journal of Gynecology and ()listetrics.\
Some Remarks on Pulmonary Tuberculosis, with Especial Reference
to our Most Recent Knowledge on the Subject. By Louis F. Criado,
M. D. [Reprinted from the Brooklyn Medical Journal.]
Results of Experiments with Inoculation for the Prevention of Hog
Cholera. By Dr. D. E. Salmon, Chief of the Bureau of Animal In-
dustry. [lT. S. Department of Agriculture, Farmers' Bulletin, No. 2.]
Ueber intraoculare Erkrankungen im Gefolge von Nasenkrank-
heiten. Von Dr. Ziem in Danzig. [Separatabdruck aus der Miinchener
medic. Wbchenschrift.]
Traitement de l'hysterie. Par le Dr. Paul Blocq. [Extrait de la
Gazette des hopitaux.]
Traitement de l'hypertrophie des amygdales. Par Dr. E. J. Moure.
[Extrait des Memoires et bulletins de lei Soeiete de medecine ct de chirurgie
de Bordeaux.]
Report relating to the Registration of Births, Marriages, and Deaths
in the Province of Ontario, for the Year ending 31st December, 1890.
Acromegaly — Paralysis Agitans. By Simon Baruch, M. D. [Re-
printed from Illustrated Medicine and Surgery.]
|H i s c 1 1 ( a n n .
The Commitment and Care of the Insane in the State of New
York. — The State Commission in Lunacy has issued the following cir-
cular :
By the statute no insane person can be admitted to an institution for
the care and treatment of the insane except upon a medical certificate
of lunacy, made jointly by two physicians, under a form prescribed by
the State Commission in Lunacy. The form at present in use went
into effect July 1, 1890, and commitments can now only be made under
such form and upon blanks prepared and furnished by the State. These
blanks can be obtained upon application to the State Commission in
Lunacy, county clerks, superintendents of the poor, and superintendents
of asylums or hospitals for the insane, both public and private. The
medical certificate must be filled out strictly according to its terms in
order to secure the commitment of a patient. There must be a final
examination of the patient on the same day by both certifying physi-
cians, although the final examination need not be conducted by each
physician in the presence of the other. The date of the final examina-
tion is the date of the certificate. A patient can be admitted under such
medical certificate at any time within ten days from its date — namely,
the date of the final examination. While a patient may be admitted
upon such certificate prior to its approval by a judge of a court of rec-
ord, the patient can not be detained more than five days without such
approval, and therefore it is advisable, in order to avoid delays and a
re-examination when such approval is not made within the required
time, to procure the approval prior to the admission of the patient.
The approval must be made by a judge of a court of record, of the
county or judicial district in which the patient resides. If, however,
the patient has no fixed residence within the State, then the certificate
may be approved by a judge of a court of record of the county or ju-
dicial district wherein such patient may be. A medical certificate pre-
scribed by the commission is an absolute requisite to the commitment
of a patient; a judge, however, may require other and additional evi-
dence. He may summon witnesses or additional physicians, or may, in
Ids discretion, call a jury in each case to determine the question of
lunacy. Therefore, in order to avoid expense and delay, it is essential
that great cue should be taken in the preparation of such medical
certificate. The statute provides that onlj such physicians as have
been properly certified by a judge of a court of record, and onh after a
certified copj of their certificate of qualification has been tiled in the
office of the State Commission in Lunacy, can prepare such medical cer-
tificate. A medical certificate prepared by either one or both physicians
whoso certificate of qualification has not been filed in the office of the
commission is void by statute and a re-examination of the patient must
be had.
Section 2, chapter 44t>, Laws of 1874, provides that "It shall not
728
MISCELLANY.
[N. Y. Med. Jour.
be lawful for any physician to certify to the insanity of any person for
the purpose of securing his commitment to an asylum, unless said phy-
sician be of reputable character, a graduate of some incorporated medi-
cal college, a permanent resident of the State, and shall have been in
the actual practice of his profession for at least three years. And
such qualifications shall be certified to by a judge of any court of
record."
Section 7 of chapter 283, Laws of 1889, as amended by chapter
273, Laws of 1890, provides that "One year after the date of the pas*
sage of this act (May 14, 1889) it shall not be lawful for any medical
examiner in lunacy to make a certificate of insanity for the purpose of
committing any person to custody unless a certified copy of his certifi-
cate has been so filed and its receipt in the office of the commission
(State Commission in Lunacy), as above provided, has been acknowl-
edged."
Public patients, except in the counties of New York and Kings, are
required by the statute to be cared for in State hospitals situated with-
in the hospital district in which they reside, the statute requiring that
the State be divided into as many districts as there are State hospitals.
A patient, however, who desires care and treatment in a State hospital
situated beyond the hospital district in which he resides may be admit-
ted to such hospital upon the following conditions:
a. When there is a vacancy, b. In the discretion of the president
of the State Commission in Lunacy and the superintendent of the hos-
pital to which the admission of the patient may be desired. <:. That
any expense of removal beyond the limits of the hospital district in
such case must be borne by said insane person's guardians, relatives, or
friends, as the case may be.
This statute is liberally construed, and in no instance has the con-
sent of the president of the commission been refused or will such con-
sent be refused in any proper case. When applications are made by
mail or telegraph to the office of the commission, in Albany, such con-
sent will be promptly given.
Public patients from the counties of New York and Kings may be
admitted to any State hospital within the State, with the consent of tin.'
authorities of such hospital and the Commissioners of Charities and
Corrections of either of said counties.
Private or pay patients may be admitted to any State hospital with-
out reference to the hospital district in which they reside upon the fol-
lowing conditions :
a. That there is room. b. That the hospital authorities are willing
to receive the patient, c. That no patient shall be permitted to pay a
sum in excess of ten dollars per w-eek.
The maximum sum of ten dollars per week to be charged for the
care and treatment of a private or pay patient in a State hospital was
agreed upon at a conference of the State Commission in Lunacy and the
trustees and superintendents of State hospitals. This limit of price was
fixed upon in order that the rights of the dependent insane for whom
the State hospitals were established should not be encroached upon by
patients who are able to pay a greater sum and who would require in
return therefor a corresponding amount of room-space and other allow-
ances which, in view of the constant demand for accommodations for
the dependent insane, could not properly be accorded them. Each
State hospital being established upon the principle of the greatest
good to the greatest number, and recognizing no class distinctions, obvi-
ously no advantages, in the way of extra room-space, etc., can properly
be given, and especially in view of the fact that adequate and compe-
tent private care and treatment, both allopathic and homoeopathic, can
now readily be obtained for the non-dependent insane in private insti-
tutions, under the supervision of the State, for ten dollars per week
and upward.
All private institutions for the care and treatment of the insane are
required by statute to be licensed by the State Commission in Lunacy,
and the commission is empowered to revoke any such license in its dis-
cretion, when proper cause exists therefor, and no insane person can be
committed to any institution, retreat, home, or sanitarium which is not
so licensed.
The following is a list of the licensed private institutions for the
insane, with the name of the physician in charge, the location, and the
minimum sum charged per week:
Institution.
Bloomingdale Asylum . . .
Providence Retreat
Marshall Infirmary
Long Island Home
Brigham Hall
* St. Vincent's Retreat...
Sanford Hall
*Dr. Wells's Sanitarium.
Dr. Combes's Sanitarium .
Dr. Choate's House
Dr. Parsons's House
Falkirk
Vernon House
Breezehurst Terrace.
Waldemere
The Pines
Glenmary Home
Dungarthel
Physician in
charge.
Location.
S. B. Lyon
Harry A. Wood.
J. D. Loinax . . .
O. J. Wilsey .
1). li. Burrell...
J. A. Underbill,
J. W. Barstow .
T. L. Wells
I!. ( '. F. Combes
G. C. S. Choate.
K. L. Parsons . .
J. P. Ferguson .
W. I). Granger. .
D. A. Harrison . .
E. N. Carpenter .
Fred Sef ton. . . .
J. T. Greenleaf . ,
H. R. Stiles
New York . . .
Buffalo
Troy
Amityville . . .
. ! Canandaigua .
Harrison
Flushing
Brooklyn ....
VVoodhaven . . ,
Pleasantville . ,
Sing Sing. . . .
Central Valley
Bronx ville.
Whitestone. . .
Mamaroneck. .
Auburn
Owego
Lake George .
Minimum
rate per
week.
$6 00
6 00
5 00
10 00
10 00
10 00
25 00
10 00
10 00
75 00
75 00
20 00
35 00
20 00
25 00
20 00
10 00
25 00
* Receive female patients only.
Respectfully,
T. E. McGarr, Secretary.
To Contributors and Correspondents. — The attention of all wlio purpose
favoring us with communications is respectfully called to the follow-
ing:
Authors of articles intended for publication under the head of " original
contributions " are respectfully informed that, in accepting such arti-
cles, we always do so with the understanding that the following condi-
tions are to be observed: (1) when a manuscript is sent to this jour-
nal, a similar manuscript or any abstract thereof must not be or
have been sent to any other periodical, unless we are specially notified
of the fact at the lime the article is sent to us ; (2) accepted articles
are subject to the customary rules of editorial revision, and will be
published as promptly as our other engagements will admit of — we
can not engage to publish an article in any specified issue ; (3) any
conditions which an author wishes complied with must be distinctly
slated in a communication accompanying the manuscript, and no
new conditions can be considered after the manuscript has been put
into the type-setters' hands. We are often constrained to decline
articles which, although they may be creditable to their authors, are
not suitable for publication in this journal, either because they are
too long, or are loaded with tabular matter or prolix histories of
cases, or deal with subjects of little interest to the medical profession
at large. We can not enter into any correspondence concerning our
reasons for declining an article.
All letters, whether intended for publication or not, must contain the
writer's name and addrtss, not necessarily for publication. No at-
tention will be paid to anonymous communications. Hereafter, cor-
respondents asking for information that we are capable of giving,
and that can properly be given in this journal, will be answered by
number, a private communication being previously sent to each cor-
respondent informing him under what number the answer to his note
is to be looked for. AH communications not intended for publication
under the author's name are treated as strictly confidential. We can
not give advice to laymen as to particular cases or recommend indi-
vidual practitioners.
Secretaries of medical societies will confer a favor by keeping us in-
formed of the dates of their societies' regular meetings. Brief notifi-
cations of matters that are expected to come up at particular meet-
ings will be inserted when they are received in lime.
Newspapers and other publications containing matter which the person
sending them desires to bring to our notice should be marked. Mem-
bers of the profession who send us information of matters of interest
to our readers will be considered as doing them and us a favor, and,
if the space at our command admits of it, we shall lake pleasure in
inserting the substance of such communications.
All communications intended for the editor should be addressed to him
in care of the publishers.
All communications relating to the business of the journal should be ad-
dressed to the publishers.
INDEX TO VOLUME LY.
PAliR
Abbe, H. A Tooth-plate lodged in the Lower
(Esophagus more than a Year 31!)
Abbe, H. Cases of Gall-bladder Surgery.. 120, 184
Abduction of the Thigh in Hip-joint Disease, A
New Apparatus for overcoming 726
Abortion, Asafcetida as a Remedy for Habitual. 32(5
Abortion for Relief of Nausea and Vomiting, A
Case of Induced 21
Abortion per vias nat urates at the Fourteenth
Week in a Case of Twin Extra-uterine
Pregnancy 690
Abscess in Pott's Disease, On the Benign Course
of, under Efficient Mechanical Treatment. . . 206
Abscess of the Brain in Aural Disease 527
Abscesses in Pott's Disease, The Treatment of
Large 725
Abscesses, The Disappearance of Large Psoas.. 215
Academy of Medicine, The American 412
Academy of Medicine, The New York . 112, 168, 224,
880, 326, 410, 476, 532, 588, 644
Academy of Medicine, The New York, Section
in General Surgery 47
Accommodation, A Case of Tonic Spasm of 408
Accommodation, Notes on Spasm of the 632
Achromatopsia, Two Cases of Total 247
Aconite, The Maximum Dose of 70
Aconitum Napellus, the Alkaloids of 476
Acromegaly, A Case of 138
Address, Changes of. . 156, 323, 352, 888, 413, 439, 496,
523, 547, 579, 608, 693. 719
Adenoma 584
Adenoma of the Sebaceous Glands of the Ex-
ternal Ear 666
Adirondack Region, the Relative Humidity of
the 631
Adler, I. A Case of So-called Laryngeal Ver-
tigo 128
Agnew, The Death of Dr. D. Hayes, of Phila-
delphia 352
Agnew, The late Dr. D. Hayes 412, 719
Ainsworth, Surgeon, of the Army 635
Air Passages, The Effects of Altitude upon the
Mucous Membranes of the Upper 407
Albuminuria as a Means of Diagnosis, The
Value of 352
Albumosuria 546
Alleman, L. A. W. Essentials in Ophthalmolo
gy for the General Practitioner 259
Allen, C. W. Phthciriasis Ciliorum 658
Altitude, The Effects of, upon the Mucous Mem-
branes of the Upper Air Passages 407
Aluminium, A New Use for 447
Amblyopia, Congenital 216
Ambrose. The Death of Dr. John K 608
Amputation at the Hip Joint, A Modification of
Wyeth's Method of Bloodless 520
Amputation, Consecutive, in Traumatism of the
Extremities 303
Amputation in Senile Gangrene, Early High 212
Amputation of the Vaginal Portion of the Cervix
Uteri in Cases of Suspected Carcinoma 294
Amputation, Primary, in Traumatisms of the
Extremities 303
Amygdalitis and Cutaneous Eruptions 469
Anaemia : its Treatment with a New Preparation
of Iron 512
Anaemia, The Treatment of 132
Anaesthesia, A Neglected Method of modifying
General 722
Anaesthetic, Pental, A New 75
Anaesthetic, Warmed Ether as an 184
Anaesthetics. A Collective Investigation regard-
ing 270
Anastomosis, Intestinal 135
Anatomy, Comparative, and Zoology for Medi-
cal Students 155
Anatomy, The Systematic Use of the Eye in
teaching 222
Aneurysm of the Ascending Aorta 510
Angeioma of the Liver 78
Aniridia and Glaucoma 219
Ankle, Pott's Fracture at the 701
Ankylosis of the Hip 725
Ankylostomiasis the Beriberi of Assam 352
Annals of Surgery, The 297
Anomalies of the Ocular Muscles 274
Anthrax successfully treated by Excision of
the Pustule 527
Antipyretics in Influenza, On the Use of the
Newer 82
Antisepsis in Skin Diseases 469
Aphakia, The Correction of, by Glasses 220
Appendicitis 42, 158, 583
Appendicitis, Cases of, illustrating Different
Forms of the Disease 384
Aprosexia and Headache in School Children 332
Arixtol for Venereal Ulcers 171
Arm Center, Wound of the 10
Armstrong, S. T. Morvan's Disease 482
Army, Changes of Medical Officers of the :
Ainsworth, Fred C 720
Alden. Charles L 18
Appel, Aaron H 133, 181, 18."), 110, 523, 517
Arthur, William H 468
Baily, Joseph C 381, 608
Ball. Robert R 547
Bradley, Alfred E 18, 410. 547
Brechemin, Louis 133, 4fi8
Brewer, Madison M 720
Brooke, John 185
Burton, Henry <; 102.181 21'.'
Cabell, Julian M 133. 181. 410. 523. 661
Ahmy, Changes of Medical Officers of the :
Carter, W. Fitzhugh 103
Chapin, Alonzo R 468
Crampton, Louis W 547
Davis, William B 720
De Loffre, Augustus A 523, 637
Deshon, George D 720
De Witt, Theodore F 384, 609
Dunlop, Samuel R 185, 720
Fisher, Henry C 720
Fisher, Walter W. R 18, 103, 242, 327
Forwood, William H 608
Gardner, Edwin F 18, 440
Gibson, Joseph R 608
Girard, Alfred C 18
Glenuan, James D 102,242, 408
Gorgas, William C 468, 720
Harris, Henry S. T 720
Hartsuff, Albert 440
Heger, Anthony 720
Hoff, John Van R 440
Huntington, David L 300, 327, 608, 661
Ireland, Merritte W 440, 720
Irwin, Bernard J 18
Janewav, John H 523
Johnson, R. W 384
Kean, Jefferson R 102, 300
Kilbourne. Henry S 103, 327
Kimball, James P 103, 609
Lippitt, William F., Jr 608
Macaulay, C. N. B 439, 661
McCreery, George 547
McCulloch, Champe C, Jr 720
Mearns, Edgar A 18
Meriwether. Frank T 439
Moseley, Edward B 720
Mundav, Benjamin 384, 523, 637
Norris, Basil 327
O'Reilly. Robert M 103, 661
Patzki, Julius H 102, 103
Phillips, John L 523
Purviance, William E 384, 440, 608
Raff erty, Ogden 523, 6118
Reynol Is, Frederick P 720
Robinson, Samuel A 18
Shaw, Henry A 609
Skinner, John O 384
Smith, Allen M 637
Smith, Joseph R 661
Snyder, Henry D 185, 523
Sternberg, George M 185
Suter, William N 327, 440, 609
Taylor, Arthur W 242
Taylor, Marcis E 300
Town. Francis L 384
Turrill, Henry S 327, 608, 637
Wales, Philip G 18, 327
Walker, Freeman V 661
Ware, Isaac P 720
Wells, George M 468
Winter, Francis A 384,440.608
Wolverton, William D 384, 547
Wood, Marshall W. 103. 439
Woodhull, Alfred A 327
Woodson, Robert S 720
Wright, Joseph P 184
Wyeth, Marlborough C 390
Armv Medical Corps. Promotion Examinations
in the 352
Army Medical Officers, Meritorious Services by. 18
Army, Supplies for the Medical Corps of the 351
Arthritis, A Remedy for Chronic Rheumatic. . . . 878
Arthritis Deformans 725
Arthritis, The Local Treatment of Chronic
Rheumatic 26
Asafoetida as a Remedy for Habitual Abortion. . 326
Asch, M. J. A Case of Intrinsic Epithelioma of
the Larynx 332
Asepsis and Antisepsis in Obstetrical Practice. . 185
Asheville as a Winter Resort 273
Association, An Alumni, of the Ex-internes of
the Presbyterian Hospital of New York 272
Association of American Physicians, The . . 307, 586
Association of Central New York, The Medical. 547
Association of Charity Hospital, The Alumni.. . 495
Association of Georgia, The Medical 242, 412
Association of Medical Superintendents of
American Institutions for the Insane 503
Association of Military Surgeons of the National
Guard of the United States 413
Association of Mt. Sinai Hospital, The Alumni. 18
Association of the Alumni of the New York
Hospital 351, 383
Association of the College of Physicians and
Surgeons. The Alumni 47
Association. Presentation of Instruments at the
Thirteenth Meeting of (he American l.aryn-
gological 276
Association, The American Climatologieal 699
Association, The American Dermatological 511
Association, The American Electro-therapeutic. 503
Association, The American Laryngological 700
Association, The American Medical 363
Association, The American Neurological 699
Association, The American Surgical 517
Association, The Bnfl'alo Medical and Surgical.. .".17
Association. Tin' Harlem Medical 17. 156
Association, The Kings County Medical 656
Association, The Mississippi Valley Medical 413
Association, The New York County Medical 102
Association, The New York Physicians' Mutual
Aid 719
AGE
579
84
883
458
346
191
184
497
657
71
068
('65
Association, The New York State Medical.. 150,
Association, The, of Military Surgeons of the
National Guard of the United States
Association, The Physicians' Mutual Aid
AssocrATroNs, Meetings of. See Societies.
Asthma : its Purely Nervous Origin and an Effi-
cient Treatment
Asthma, Result of Treatment of the Upper Air
Passages in producing Permanent Relief in.
Asthma, Treatment of the Upper Air Passages
in producing Permanent Relief in
i Asylum, The Kings County Insane
I Asymmetry of the Extremities
Atheto-choreic Movements..
J Athetosis, A Case of General
I Auditory Organs, A Case of Partial Development
of Both
Auditory Reflexes, A Rare Case of
Auricle," A Contribution to the Morphology of
the Human 666
Auricle, Carcinoma of the 666
| Auscultation, Retrosternal 495
I Avulsion of the Stapes in Animals 667
Ayres, The Death of Dr. Daniel, of Brooklyn ... 102
Babies, Cheap Sterilized Milk for Tenement-
house 661
Bacilli of la Grippe, The Song of the 615
Bacillus, Longevity of the Tubercle 103, 287
Bacillus of Influenza 75
Bacillus, The Alleged Discovery of a Measles. . . 523
Bacillus, The Influenza 167
Bacteria, The Action of Chloroform on 75
Baldwin, J. F. Letter to the Editor 300
Bandage Cutting 720
Barker, P. C. A Contribution to the Study of
Cerebral Tumors 710
Barker, T. R. Placental Localization by Ab-
dominal Palpation 675
Bartley, E. H. Letter to the Editor 76
Bates, W. H. A Case of Traumatic Deafness. . . 72
Bates, W. H. Notes on Spasm of the Accommo-
dation 632
Beach, W. The Office of Coroner in New York. 34!)
Becker, P. G. Letter to the Editor 638
Beely. F. On the Scope of Orthopiedics 533
Bensel, W. A Case of Compound Depressed
Fracture of the Skull, etc 70
Bequest for Hospital Purposes, A Large 693
Bermuda, The Climate of 13
Bierwirth, J. C. Letter to the Editor 103
Bicyclist, The Sudden Death of a 608
Bill, A Protest against the Baby Students' Re-
lief 326
Bill, The Baby Students' Relief : 305
Birdsall, The Death of Dr. William R 661
Birdsall. The late Dr 693
Birdsall, The late Dr. William R 700
Birmingham. H. P. Irreducible Umbilical Her-
nia (Omental) simulating Lipoma 577
Birthday, Dr. Lewis A. Savre's 336
Black, G. M. The Effects of Altitude upon the
Mucous Membrane of the Upper Air Pas-
sages 407
Blanc, II. W. Five Years of Dermatological
Practice in New Orleans 281
Blennorrhoea of the Lacrymal Sac in New-born
Infants, The So-called 220
Blepharospasm, The Treatment of 221
Blindness, The Lesion in Quinine 218
Blindness, Uniocular, immediately following In-
juries of the Skull 214
Board, An Armv Medical 28
Board of Health, The City 468
Bone, The Removal of Necrotic and Carious,
with Hydrochloric Acid and Pepsin 311
Bones, Tardy Hereditary Syphilis of the 85
Book Notices :
Albarran, J. Les tumeurs de la vessie 526
Aulde, J. The Pocket Pharmacy 642
Ballance, C. A., and Edmunds, W. A Treatise
on the Ligation of the Great Arteries in
Continuity . 388
Bartholow, R. A Manual of Hypodermatic
Medication 415
Bauduv, J. K. Diseases of the Nervous System. 695
Beard, G. M., and Rockwell, A. D. On the
Medical and Surgical Uses of Electricity 244
Blackburn, I. W. A Manual of Autopsies 500
Boenning, II. ('. A Treatise on Practical
Anatomy 726
Bramwell, B. Atlas of Clinical Medicine 501
Brocq, L. Traitement des maladies de la
peau 500
Bnrdett, II. C. Hospitals and Asylums of
the World 442
Charcot, J. M. Hospice de la Salpetriere ... . 585
Coltman, R., Jr. The Chinese, their Present
and Future 415
Coulston, T. S. The Neuroses of Develop-
ment 22
Culver, E. M., and Hayden, J. R. A Manual
of Venereal Diseases 106
Davies-Colley, W., and White, W. H. Guy's
Hospital Reports 244
Eisenberg, J. Bacteriological Diagnosis 525
Forchheimer, F. The Diseases of the Mouth
in Children 726
Foster. M. A Text-book of Physiology 107
Gage, S. II. The Microscope aiid Histology. . 303
Gibson, G. A., and Russell, W. Physical Dug-
110813 415
730
INDEX TO YOU'VE L V.
[N. Y. Med. Jour.
PAGE
Book Notices :
Qouley, J. W. S. Diseases of the Urinary
Apparatus 525
Hirst. B. C. Human Monstrosities 105, 501
Huidekoper, R. S. The Age of the Domestic
Animals 500
Knapp, P. C. The Pathology. Diagnosis', and
Treatment of Intracranial Growths 243
Lang, A. Text-book of Comparative Anato-
my 217
Lovett, R. W. The .Etiology. Pathology, and
Treatment of Diseases of the Hip Joint 415
Lusk. W. T. The Science and Art of Mid-
wifery 641
Martin, E. The Surgical Treatment of
Wounds and Obstruction of the Intestines.. 108
Mills, C. K. Philadelphia Hospital Reports.. 243
Osier, W. The Principles and Practice of
Medicine 499
Poole, W. H. and Mrs. Cookery for the Dia-
betic 193
Remondino, P. C. History of Circumcision.. 217
Reynolds, E. Practical Midwifery 585
Rohe\ G. H. A Practical Manual of Diseases
of the Skin 525
Roosa. D. B. St. J. A Practical Treatise on
the Diseases of the Ear 193
Schafer.E.A. Quain's Elements of Anatomy . 106
Sexton. S. Deafness and Discharge from the
Ear 105
Sheild, A. M. Surgical Anatomy for Students. 389
Smith, J. G. Abdominal Surgery 443
Smith, P. On the Pathology and Treatment
of Glaucoma 106
Tavlor, J. J. The Physician as a Business
Man 217
The Medical Annual and Practitioners' Index. 525
Thomas, T. G. A Practical Treatise on the
Diseases of Women 104
Transactions of the American Association of
Obstetricians and Gynaecologists 443
Treves, F. Manual of Operative Surgery 550
Tuckey, C. L. Psycho-therapeutics 526
Watkius, W. J. A Compcnd of Human Physi-
ology 22
Willard. De F. Artificial Anaesthesia and
Anaesthetics 22
Wood, C. A. Lessons in the Diagnosis and
Treatment of Eye Diseases 243
Wood. H. C. Therapeutics : its Principles
and Practice 243
Boro-Borax 132
Bosworth, F. H. The Result of Treatment of
the Upper Air Passages in producing Perma-
nent Relief in Asthma 346
Bowditch, The Death of Dr. Henry Ingersoll, of
Boston 102
Bowditch, The late Dr. Henry 1 503
Brain, A Bullet in the '. 134
Brain, A Case of Tumor of the 41
Brain, The. in Microcephaly ISO
Brain, The. of a Great Ohes's Player 52
Brannan, J. W. Reports on General Medicine.. 23
Braune, The Death of Professor WUhelm, of
Leipsic 608
Bremner, W. W. Hot Blanket Packs in the
Treatment of Fevers 606
Broadbent, Dr., of London 633
Bromamide : a New Antipyretic and Antineu-
ralgic Remedy 208
Brown, The Death of Dr. Buckminster. of Bos-
ton 18
Briicke, The Death of Professor yon 184
Buboes, Experience in the Treatment of. by Ex-
cision and Injection 582
Bull, C. S. A Case of Tumor of the Brain 41
Bull. C. S. Reports on Ophthalmology. 218, 244, 273
Bull. C. S. Reports on Otology.. 664
Bullet. Removal of a Revolver, from the Tem-
poral Bone 667
Buphthalmia, The Pathological Anatomy of 247
Burial, Ante-mortem 352
Burnett, S. G. New Observations in the Use of
Sulphonal 406
Burnett, S. G. Pseudo-experts in Lunacy 57
Burns. Glycerin for 297
But-rough, E. Y. A Case of Basilar Meningitis
developing Five Weeks after an Injury to
the Head 46
Burrs. D. Letter to the Editor 548
Burwell. J. P. Report of a Case of Diabetes
Mellitus and Treatment 16
Caesarean Section, Two Successful Cases of the
Conservative 186
Caille, A. Bromamide : a New Antipyretic and
Antineuralgic Remedy 208
Calculus, The Surgical Management of Genito-
urinary 213
Cancer, A Study of 297
Cancer of the Rectum, Obstructing 133
Cancer of the Tongue 134
Carcinoma, Amputation of the Vaginal Portion
of the Cervix Uteri in Cases of Suspected. . . 294
Carcinoma of the Auricle 666
Cardiac Disease, The Significance of Cheyne-
Stokes Respiration as a Symptom in " 23
Carotids, Compression of the, as a Therapeutic
Measure 241
Carr, W. P. The Nature of Inflammations in
the Light of Recent Discoveries 461
Cataract. Bacteriological Researches in 247
Cataract. Four Hundred and Fifty Simple Ex-
tractions of Senile 274
PAGE
Cataract, Incipient 219
Cataract. The Simplification of the Operation
for Extraction of 246
Cathcterism of the Biliary Passages 439
Cells of the Ethmoid. The Functions of the 667
Cervix Uteri. Amputation of the Vaginal Portion
of the, in Suspected Cases of Carcinoma... . 2!M
Chaddock. C. G. Primary Rheumatic Endo-
carditis w itii Erythema Nodosum 290
Chancre of the Cheek, Primary 470
Chancres. Genital, in Women 1
Chappele, W. F. Hints in Coughs ; their Causes
and Treatment 600
Cheese, The Digestibility of 101
Cheyne-Stokes Respiration as a Symptom in ( ar-
diac Disease, The Significance of 23
Chiasm of the Optic Nerve. The Development
and Course of the Medullated Fibers in the. 273
Chicago, The World's Fair and the Water Sup-
ply of 391
Child. Hysteria in a 414
Children, Common Errors and Fallacies in the
Treatment of 389
Children, Jaundice in 331
Children, Prolapse of the Rectum in 330
Children, Vulvo-vaginal Inflammation in-. 331
Chloroform, A Death following the Administra-
tion of 350
Chloroform. Death from 635
Chloroform in Parturition ? Does Organic Dis-
ease of the Heart preclude the Use of 642
Chloroform in the Treatment of Typhoid Fever. 439
Chloroform on Bacteria, The Action of 75
Chloroform, The Toxic Action of Impure 184
Cholesteatoma of the Ear 667
Cholesteatoma of the Middle Ear, The Treat-
ment of 668
Chorea. The Treatment of. with Exalgine 308
Chorioid. The Pigment Cells of the 275
Cigars, The Spread of Syphilis by 327
Circumvasculitis Retinae 274
Claiborne, J. II. The Axis of Astigmatic Glasses 717
Clark, The Death of Dr. Charles Fremont, of
Brooklyn 547
Clark. The Death of Dr. Simon T.. of Lockport,
N. Y 18
Cloquet, Persistence of the Canal of 245
Clothing, Hygienic 464
Club, The Flint 383
Club. The Hospital Graduates' 210, 327, 439
Cocaine Fatalities 457
Cocaine Poisoning . . 353
Cod-liver Oil in Lupus Vulgaris 470
Cohen. J. Solis-. The Symptoms and Patho-
logical Changes in the Upper Air Passages
in Influenza 344. 356
Colchicum, A Case of Ptvalism by 15
Colds. Influenza 100
College, A New Medical, in Chicago 661
College, Bellevue Hospital Medical 523
College, New Buildings for the Jefferson Medi-
cal 271
College of Physicians and Surgeons of Chicago. 412
College of Physicians and Surgeons, The St.
Louis 297
College of the New York Infirmary, The Wo-
man's Medical 693
College, The Chattanooga Medical 272
College, The Jefferson Medical, of Philadelphia. 437
College, The Medical School of Columbia. . 635, 661
College, The Medico-chirurgical, of Philadel-
phia 297. 693
College, The Rush Medical. Chicago 252
Colleges, The Ohio Medical 28
Collyria, Infection and Disinfection of 276
Coloboma of the Optic Nerve 210. 245
Color-blindness in the Navy — 637
Color-blindness, The Examination of the Eves
separately for *. .. 383
Compress. The History of a Forgotten 475
Congestion of the Lungs, A Case of 322
Congress of 1892, The International Dermato-
logical 46
Congress of Gynaecology and Obstetrics. An In-
ternational Periodical 323
Congress of Surgery, The French 271
Congress, The Eleventh International Medical. .323
Congress. The German Medical 196
Congress. The Pan- American Medical 112. 210,
242, 663, 693
Congress, The Section in Gynaecology and Ab-
dominal Surgery of the Pan-American 350
Conjunctiva, Fatal Haemorrhage in an Infant
after Scarification of the \. 15
Conjunctiva, Papilloma of the 275
Conjunctiva, The Anatomy of Chronic Inflam-
mation of the 247
Constipation 269
Consultant, The Ideal 672
Convergence, The Anomalies of 247
Copulation. Epispadias subsequent to Injury in. 579
Cornei. Filamentous or Fibrous Formation in
the 219
Cornea, Papilloma of the 220
Cornea, The Refracting Power of the 221
Cornea, The Shape of the Human 245
Cornea, Tincture of Iodine in Infectious Ulcers
of the 246
Cornea, Transplantation of the 271
Corning, J. L. Pain, its Nature, Diagnostic Sig-
nificance, and Treatment 428
Cornutine as a Pelvic Haemostatic 326
Coroner in New York, The Oftice of 349
Correction, A 523
PAGE
Correspondents, Answers to 76, 131, 185. 242,
300, .353, 413, 419, 609, 693
Cortex as a Drug, The Cerebral 326
Coste, A Monument to Dr 608
Coughs : Hints on, their Causes and Treatment. 600
Crandall. F. M. Management of lie- New-bom
Infant 684
Crandall. F. M. Reports on Paediatrics 329
Croup, Intubation in 331
Curette. A Lateral Cutting 444
Currier, A. V. Amputation of the Vaginal Por-
tion of the Cervix Uteri in Cases of Suspect-
ed Carcinoma 294
Currier, C. G. Origin and Restriction of Tuber-
culosis 204
Curvature of the Spine, Rotary Lateral, after
Empyema and Poliomyelitis 386
Cutaneous Diseases, Reports on 469
Cyclopia, The Mode of Development of 247
Cyst, Dermoid, of the Internal Wall of the Or-
bit 246
Cyst of the Mesentery, Abdominal Section in a
Case of 20
Cyst of the Middle Turbinated Bone 309
Cystoscope, Errors in the Use of the 51
Cystoscopy in the Last Three Year-. The Prog-
ress of 113, 141 170
Cystotomy, The Value of Suprapubic, in the
Treatment of Tuberculosis of the Urinary
Bladder 250
Dana, C. L. The Nature and Cause of the Sclero-
sis of the Spinal Cord
Daniels, F. II. Hygienic Clothing
Davis, G. G. Tardy Hereditary Syphilis of the
Bones
Deaf-mutism caused by Measles
Deafness, A Case of Traumatic
Deafness caused by Dry Inflammation of the
Middle Ear •..
Deafness due to Chronic. Non-purulent Otitis
Media, Diagnosis, Prognosis, and Treatment
of Progressive
Deafness due to Mumps, The Lesion in
Deafness, Operation for the Relief of
Death from Chloroform
Death Penalty. The Infliction of the, by means
of Electricity 505,
Debility, The Treatment of
Deformities, Congenital, of the I'pper and Lower
Extremities
Deformities, Infantile
Deformity in Hip Disease, An Appliance for the
Prevention of
Deformity of the Leg relieved by Fracture and
Wiring
Deformity of the Lower Extremity following
Excision of the Hip Joint
Deformity of the Thigh from Faulty Union of
a Fractured Femur
Degrees, Honorary
Delavergne, The Death of Dr. Charles E., of
Brooklyn
Dermatitis, Exfoliative
Dermatitis Herpetiformis of Duhring, Some
Cases of the
Dermatitis Tuberosa, A Case of
Dermatological Practice in New Orleans, Five
Years of
Dermatonenroses, Hydrotherapy and Nerve
Remedies in
Dermato-therapeutic Agent, Gallacetophenone,
A New
Desk and Chair, An Improved Adjustable School
Development, A Precocious
Development, The Neuroses of
Diabetes Mellitus and Treatment, Report of a
Case of
Diabetes Mellitus. Disappearance of Sugar in a
Case of
Diabetes, The .Etiology of
Diagnosis, A Case for
Diaphanoscope. The Polyscope and the
Digestion ? Does Ether assist
Diphtheria. A Pathological Review of. etc
Diphtheria, Steam as an Aeent in causing the
Spread of
Diphtheria, The Histological Lesions produced
by the Toxalbumin of
Disease, A Pernicious Osseous
Disease of the Brain following a Simple Nasal
Operation
Disease of the Ethmoid Cells. Various Forms of.
Disease, The Diagnosis of Pancreatic
Diseases and Conditions to which the Rest Treat-
ment is Adapted
Dislocation, Congenital, of Both Patella'
Dislocation of the Head of the Femur. Supra-
pubic
Dislocation of the Head of the Fibula
Dislocation of the Inferior Maxilla, A Cutting
Operation for the Relief of an Old
Dispensary, The Good Samaritan
Dispensary, The Manhattan
Displacements of the Uterus, The Surgical
Treatment of Anterior
Dissecting Rooms for the " Outside Man "
Drainage of the Uterus in Chronic Endometritis,
Drainage Tubes. The Objections to the Insertion
of, "into Wounds
Dramatist. A Medical
Drinking-water, The Necessity of Pure
Drug, The Cerebral Cortex as a
29
464
66H
72
667
r,i;i;
666
635
535
132
188
109
387
583
723
640
297
661
469
593
452
281
469
153
189
669
138
16
48
24
610
529
180
185
299
447
417
299
356
365
411
724
527
158
302
637
604
20
77
719
495
196
326
IX J J EX TO VOLUME LV.
731
PAGE
Drills, The Non-medical Uses of Poisonous 383
Dunn, J. A Caw of Scleroderma 337
Dunn, J. Five Cases of the Pin Sensation in
the Throat 645
Dunn, J. The Adenoid Tissue of the Pharynx
and Naso-Pharvnx 397
Durant, G. The Loss of Smell 634
Duryee, C. C. Taenia as a Cause of Persistent
Intercostal Neuralgia, etc 269
Dynamite. Wounds with 692
Dysentery, The Anatomical Lesions of Amoebic. 251
Dyspnoea after Tea-drinking 411
Ear, A Blow upon the, followed by Death in a
Week 665
Ear, Adenoma of the Sebaceous Glands of the
External 666
Ear, Cholesteatoma of the 667
Ear-drum, Facial Paralvsis due to Rupture of
the 138
Ear, Electricity in Chronic Affections of the
Middle 667
Ear, Malignant Tumors of the 668
Ear, Stvrone in Chronic Suppuration of the
Middle 666
Earle, The Death of Dr. Pliny 608
Echinococcus of the Orbit... 527
Eclampsia, The .Etiology of Puerperal 468
Ectopic Gestation Sac, Expectant Treatment of
Intraligamentous Rupture of an 78
Eczema, Nitrate of Silver for Weeping 469
Eczema of the Face and Sealp in the infant 469
Eczema, The Tr atment of, by Thilanine 469
Edinger's Dressing Apparatus' for Low Magnifi-
cation 81
Editor, A Medical, assaulted 523
Educational Qualifications of English Medical
Students, The Preliminary 637
Education, The Standard of Medical 693
Elder, The Death of Dr. Lorenzo W., of Ho-
boken, N. J 547
Electricity, Beard and Rockwell on 353
Electricity in Chronic Affections of the Middle
Ear 667
Electricity, The Infliction of the Death Penalty
by Means of 505, 535
Electro-acoumeter, An 666
Eliot, E., Jr. Treatment of Acute Osteomye-
litis 368
Elliot, G. T. Some Cases of the Dermatitis
Herpetiformis of Duhring 593
Ellis. H. B. Analyses of Two Hundred Cases
of Errors of Refraction 490
Eisner. H. L. On the Early Diagnosis and Treat-
ment of Septic Peritonitis 673
Eisner. H. L. Perforation of Typhoid Fleer,
with Adhesive and Protective Peritonitis. .. 400
Emin Pasha 719
Empyema, Rotary Lateral Curvature of the
Spine after 386
Encephalocele 332
Endocarditis, Primary Rheumatic, with Ery-
thema Nodosum 290
Endometritis, Chronic 305
Endometritis, Drainageof the Uterus m Chronic. 77
Endometritis, The Treatment of 185
Endometrium, Dilatation and Drainage of the
Litems for Disease of the 214
Enterorrhaphy, A New Metho : of 467
Epidemics and the Convulsions of Nature 325
Epiglottis, Symptoms caused by Enlargement of
the 190
Epiglottis, The Troublesome Symptoms caused
oy Enlargements of the 393
Epilepsy, The Surgical Treatment of 301
Epilepsy, Trephining for Traumatic 50
Epilepsy ? What can we expect from the Sur-
gical Treatment of 197
Epileptics, Attacks of Tremor among 138
Epileptics, The Visual Field in 246
Epispadias subsequent to Injury in Copulation . 579
Epitaph. Ricord's 211
Epithelioma of the Larynx, A Case of Intrin-
„ sic 232, 328
Epithelium, Human Olfactory 668
Equilibrium, The Sense of 405
Eruptions, Amygdalitis and Cutaneous 469
Eruptions from Iodide of Potassium 452
Erythema Nodosum. Primary Rheumatic- Endo-
carditis with 290
Erythema, Syphilidiform 470
Ether as a Stimulant 383
Ether-drinking in Russia 43!)
Ether, Warmed, as an Anaesthetic 184
Ethmoid Cells, Various Forms of Disease of the. 356
Eucalyptus in the Treatment of Scarlet Fever 332
Eucalyptus, Oil of 607
Europhen in Minor Surgery 638
Exalgine, The Treatment of Chorea with 308
Excision of a Large Ulcer of the Stomach 584
Excision of the Elbow Joint 584, 640
Excision of the Hip for Disease 612
Excision of the Hip Joint. Deformity of the
Lower Extremity following 723
Excision of the Knee Joint in Children, The
Pernicious Effect of Early 49
Execution, Electrical 5-12
Exophthalmia, Pulsating 275
Extremities, Congenital Abscess of a Portion of
Both Lower 188
Eye, A Case of Lepra of the 221
Eye, A New Instrument for quickly determin-
ing Befractive Errors of the. 404
Eye Disease of Miasmatic Origin 247
PAG*
" Eye-strain " as a Cause of Nervous Derange-
ments, Some Prevalent Errors relating to...
648, 676
Eye, The Use of Gelatin Discs in the 445
Eyelids, Skin-grafting by the Thiersch Method
for Cicatricial Deformity of the 181
Eyes blinded by Sympathetic Ophthalmitis, Op-
erations upon 218
Eyes, Physiology of the Movements of the 245
Farmer, M. H. Letter to the Editor 720
Favus, Recent Investigations regarding 276
Fees, Physicians', for per diem Services 636
Felon ? What is a 526
Femoral Abduction. Adduction, and Flexion .. 388
Femur, Sarcoma of the 641
Ferguson, J. Atheto-choreic Movements 657
Fever, Acute General Miliary Tuberculosis with-
out 25
Fever at Florida Resorts '. 547
Fever, 1 1 tirh Temperature in Intermittent 241
Fever, Methylene Blue in Malarial 607
Fever, On the Reduction of, particularly in
Typhoid ' 320
Fevers, Hot Blanket Packs in the Treatment of. 606
Fibroid of the Orbit, A Case of Malignant 220
Fibula, Dislocation of the Head of the 158
Filariasis 494
Pi: tnl i Bs33al fclliwlng Fsrityphlltla ... . f;l?
Flat-foot, The Radical Cure of Confirmed 227
Fleischtnan, The Death of Dr. David, of Albany. 181
Foot, The Anatomy of the 188
Football Casualties 326
Formad. Death of Dr. Heurv F., of Philadelphia 720
Fortnightly. The Medical 75
Foster, M. L. Reports 011 General Surgery 526
Fracture, Compound, of the Skull ' 40
Fracture of the Base of the Skull 585
Fracture of tin: Head of the Radius 134
Fracture of the Humerus, Musculo-spiral Pa-
ralysis complicating 708
Fracture of the Radius 396. 437
Fracture of the Skull, A Case of Compound
Depressed ,, 70
Fracture ( f the Sternum, etc 716
Fracture of the Temporal Bone, etc 581
Fracture of the Tibia, The Fibula used to Effect
. LJnion after Compound 50
Fracture, Pott's, at the Ankle. 701
Fracture, Vicious Union following Pott's 423
Fractures. Compound, and their Treatment 187
Fractures/rile Physician's Responsibility in the
Treatment of 604
Fractures. The Use of Wire and Pins in Un-
united 134
France, Infant Mortality in 718
French, T. R. A Device to prevent Mouth-
breathing during Sleep 436
Gallacetophenone. a New Dermato-therapeutic
Agent 153
Gall-bladder, Some Surgery of the Liver and . . . 5S9
Gall-bladder. Surgical Treatment of the 528
Ganglion, Physiology of the Ophthalmic 214
Gangrene, Early High Amputation in Senile 212
Gnngrene of the Testicle 159
Gangrene of the Toes, Senile 576
Gastrolith, A, in Man 181
Gelatin Discs in the Eye, The Use of 445
Genius, The Pathology of 307
Gcrster. A. (J. A Contribution to the Surgery of
the Oesophagus 141, 158
Gerster. A. G. Letter to the Editor 384
Gestation, Some Moot Points in Ectopic 90
"Ginger-beer Plant," The 502
Gland. The, of the Aqueous Humor 221
Glaus Penis. Paget's Disease of the 101
Glasses, The As is of Astigmatic 717
Glaucoma, A Theory of 220
Glaucoma and Affections of the Optic Nerve 275
Glaucoma, Aniridia and 219
Glaucoma of Different Varieties 314
Glioma Retime, Notes on 245
Glycerin for Burns 297
Goldenberg, II. Gallacetophenone, A New Der-
mato-therapeutic Agent 153
Gonorrhoea, Nervous Complications of 137
Gonorrhoea of the Rectum 379
Gottheil, W. 8. Letter to the Editor 327
Gould, G M. A Simple Method of treating
Many Cases of Lacry mal Obstruction 627
Gouley, J. W. S. Diseases of the Urinary Ap-
paratus 5. 31, 61. 92, 122, 147, 176
Gout, A Case of Hereditary Nervous 575
Gowers on the Nervous System 439
Grafting in Plastic Operations on the Nose, The
Thiersch Method of 51
Grippe, The Song of the Bacilli of la 615
Gruening, E. Notes on Operations upon the
Mastoid Process 11
Gruening, E. On the Operative Treatment of
Divergent Strabismus 292
Guarana in Migraine 1.37
Gynaecology, A Year's Work in Minor Surgical. 416
Hemorrhage, A Case of Umbilical 45
Hemorrhage, Cerebral 585
Haemorrhage, Fatal, in an Infant after Scarifica-
tion of the Conjunctiva 15
Hiemorrhage, The Management and Care of Pa-
tients with Hemiplegia resulting from Cere-
bral : 202
Haemorrhage, The Treatment of 51
Hemostatic, Cornutine as a Pelvic 326
PAUE
Hagan, H. A Case of General Athetosis 71
Hair-tufts in Man, The Function of the 224
Harris Case, The 155
Harris, W. H. Letter to the Editor 48
Hartley, F. Intracranial Neurectomy of the Sec-
ond and Third Divisions of the Fifth
Nerve 317
Hartley, F. Typhlitic Ulcer. Perforation : Op-
eration ; Recovery 715
Hawkes, W. M. Letter to the Editor 76
Havnes, I. S. Vicious Union following Pott's
"Fracture 423
Headache in School Children, Aprosexia and. . . 332
Head Support, An Inexpensive 610
Hearing, Operative Measures for the Relief of
Impaired 664
Heart Disease, The Dietetic Treatment of 643
Heart, Fibroid Disease of the 214
Heart, Functional Disturbances of the, and
their Remedies 236
Heart, The Physiology and Pathology of the
Mammalian 528
Heart, The Therapeutics of the Senile 27
Heat in the Treatment of Syphilis 470
Heat, The Red Blood-corpuscles as a Source of
Animal 546
Heiman, H. Longevity of the Tubercle Bacillus 287
Helenin in the Treatment of Leucorrhoea 102
Hemianopsia, Bilateral . 273
Hemiplegia resulting from Cerebral Haemor-
rhage, The Management and Care of Pa-
tients with 202
Hendee, The Death of Dr. Horat io S 75
Henry, F. P. Gastric Olcer 225
Hepatitis, The ^Etiology of Suppurative 719
Heredity, Syphilis and." 471
Hernia, Irreducible Umbilical 577
Hernia, Urethrotomy as a Preliminary to an
Operation for Inguinal " 613
Herpes Corneas in Influenza and its Treatment
by Pyoctanin 246
Herpes Zoster, Taenia as a Cause of 269
Herter, C. A., and Smith, E. E. Observations
on the Excretion of Uric Acid in Health and
Disease 617, 639
Heterophoria, An Instrument for the Determi-
nation of 80
Hilton, The Death of Dr. Joseph 76
Hinkson, J. R. Multiple Fracture of the Ster-
num, etc 716
Hip, Ankylosis of the 725
Hip, Excision of the, for Disease 612
Hip-joint Disease 609
Hip-joint Diseases, Results in Cases of 477
Hip .Joints, Statistics of Operations upon Tu-
berculous 449
Hippocrates 471
Hodgman, W. H. Fracture of the Radius. Non-
union ; Operation ; Recovery 437
Holidays, Ocean 501
Holsten, G. D. Eruptions from Iodide of Po-
tassium 452
Hopkins, F. E. Intubation for the Relief of
Stenosis in Tubercular Laryngitis 234
Hospital, Bellevue 693
Hospital for the Insane, The, at Asbnry. Iowa. . 184
Hospital Nursing Pupils, The Question of Pay-
ing 53
Hospital, The Conemaugh Valley Memorial 184
Hospital, The Harlem 410
Hospital, The London Temperance 548
Hospital, The Manhattan Eye and Ear 637
Hospital, The New York 523
Hospital, The Presbyterian 4C4, 468
Hospital, The Sloane Maternity 18
Hospital, The Woman's, and the Aldermen 578
Hospitals, Bequests to 73
Hospitals, The Randall's Island 242
How ai d, W. R. A Precocious Development . . 659
Hubbell, A. A. Optic Neuritis as a Form of
Peripheral Neuritis 95
Humerus. Musculo-spiral Paralysis complicating
Fracture of the 708
Humor, The Channels of Exit of the Aqueous.. 276
Hyaloid System, Remains of the Foetal 245
Hydrocele in Infants 330
Hydrogen-gas Test, Senn's 303
Hydrotherapy and Nerve Remedies 111 Dermato-
neuroses 469
Hygiene, Laboratories of 249
Hyoscyamine in Lettuce 75
Hypermetropia, The Ophthalmoscopic Appear
ances in 220
Hypnotism, A Bill to restrict the Use of 240
Hypnotism, The Therapeutic Value of llil)
Hypodermic-syringe Tubes, The Preservatio 1 of 113
Hysterectomy for Prolapsus Uteri 50
Hysterectomy, The Pedicle in 19
Hysterectomy, Vaginal 582
Hysteria in a Child 414
Hysteria, Metallotherapv in a Case of 467
Hysteria, The Nature of 814
Ichthyol in Small pox 201
Idiocy of Myxnedema, The 380
Ileus, Lavage in the Treatment of 188
Impostor, An 381
Impressions and Emotions. Maternal 100
India, An Opening for Medical Ladies in 410
Indian, Large Vital Capacity of a \"cz Perce.... 184
Induration of the Sterno-cleido-mastoid Muscle
in the New Born 467
Induration of the Sterno-inastoid in New-born
Children 332
1 XI) EX TO VOLUME LV.
[N. Y. Mei>. Joub.
Inebriety, Synopsis of opium 189
Inebriety, The Keeley "Cure'1 for 405
Infant, Eczema of the Face and Scalp in the . . . 409
Infant, Fatal Haemorrhage in an, after Scarifica-
tion of the Conjunctiva 15
Infant, Laparotomy in an 332
Infrhit, Management of the New-born 684
Infant Mortality in France 718
Infants, Bacteriological Examinations of the
Contents of the Tympanic Cavities in Cadav-
ers of New-born and Young 665
Infants, Hydrocele in 330
Infants, The So-called Blennorrhea of the
Lacrymal Sac in New-born 220
Infection, The Influence of the Nervous System
upon 300
Infirmary. The New York Eye and Ear 547
Inflammation, Laceration of the Cervix Uteri
and Pelvic 248
Inflammation of the Conjunctiva, The Anatomy
of Chronic 247
Inflammation, Vulvo-vaginal. in Children 331
Inflammations, The Nature of 461
Influenza, Acute Orchitis following 526
Influenza and Life Insurance 272
Influenza and the Birth-rate 17
Influenza, Deaths by 579
Influenza from a Veterinary Point of View 81
Influenza, Herpes Cornea: in, and its Treatment
by Pyoctanin 246
Influenza in Northern New England 544
Influenza, Neurotic 271
Influenza, Note on the Treatment of 38
Influenza, On Some Painful Affections follow-
ing 108
Influenza. On the Use of the Newer Antipyretics
in 82
Influenza, Some Nasal, Throat, and Aural Symp-
toms and Disorders met with in
Influenza, The Bacillus of
Influenza, The Nervous and Mental Phenomena
and Sequelae of
Influenza. The Prophylaxis and Treatment of.. .
Influenza, The Symptoms and Pathological
Changes in the Upper Air Passages in. . 344,
Influenza, The Treatment of
Infusion. Intravenous Saline, for the Relief of
Shock and Anaemia
Inhaler, Ether Narcosis as induced by the Orms-
by
Injury to the Ulnar Nerve
Insane in the State of New York, The Commit-
ment and Care of the
Insanity in Paris
Institute in Tokio, A Bacteriological
Insiruction. Physical, in the Public Schools
Instruments. An Asylum for Superannuated
Instruments, Some New and Improved
Insufficiency of the Oblique Muscles
Interne, The Oldest American Ex-Hospital
Intestinal Obstruction
Intestinal Perforation in Typhoid Fever
Intestinal Strangulation by a Fibrous Band
Intestines, The Effect of Lead Poisoning upon
the Peristaltic Action of the
Intubation
Intubation for the Relief of Stenosis in Tuber-
cular Laryngitis
Intubation in Croup
Intubation in Tubercular Laryngitis
Intussusception
Iodine in Infectious LTlcers of the Cornea, Tinct-
ure of j
Iodoform in the Local Treatment of Strumous
Joint Disease
Iodoform. To Deodorize
Iodopyrine 75
Iron. Anaemia : its Treatment with a New Prep-
aration of 512
Irrigator. A Urethral 391
p25
24
724
382
270
234
331
300
527
246
215
3K3
Jacobi, A., \Yey, W. C, Sherman, B. F. Report
on Capital Punishment 265
Japan. The Vernacular Medicine and S rgerv
in 194
Jaundice in Children 331
Jaw. Artificial Appliance after Removal of One
Side of the Lower 135
Jaw. Osteoplastic Resection of the Upper, for
Naso-pharyngeal Polypus 5S0
Jaw, Osteosarcoma of the 580
Jenks, W. J. Electrical Execution 542
Joint Disease, Iodoform in the Local Treatment
of Strumous 215
Joints, Injuries and Diseases of the 188
Journal. A Bengali Medical 241
" Kaiserquelle." The. at TOlz 547
Kakeles, M. S. Senile Gangrene of the Toes. . . 576
Kelsey. < . B The Second Year's Work in Dis-
eases of the Rectum at the New York Post-
graduate Hospital 347
Kelvin, The 661
Keratitis, Septic 276
King. O. \v. The Physician's Responsibility in
the Treatment of Fractures 60J
Kinloeh, The Death of Dr. Robert A., of Charles-
ton 18
Kinnear, B. (). Asthma: its Purely Nervous
Origin and an Efficient Treatment 458
Kinnlcnt, I'. P. New Outlooks in the Prophy-
laxis and Treatment of Tuberculosis 561
Knee-jerk. The. in the ( 'ondition of Supervenosi-
tv 325
Knee Joint in Children, Pernicious Effect of
Early Excision of the 49
Knee, Voluntary Subluxation of the, produced
lis Muscular Ael ion 387
Knight, C. II. Cyst of the Middle Turbinated
Bone 30'J, 328
Kupfer, S. Reports in Cutaneous and Venereal
Diseases 469
Laceration of the Cervix Uteri and Pelvic In-
flammation 248
Laceration of the Perina-um, The Part the
Shoulders play in producing 20
Lacrymal Obstruction, A Simple Method of treat-
ing many Cases of 627
Lacrymal Sac, The Curetting of the 246
Lactic Acid locally, The Treatment of Laryn-
geal Tuberculosis with 44
Lancaster, T. A. Letter to the Editor 328
Laparotomy in an Infant 332
Laparotomy in he Seventeenth Centurv, A Suc-
cessful 412
Larva? in the Ear, A Case of Living 664
Laryngitis, Intubation for the Relief of Stenosis
in Tubercular 234
Laryngitis, Intubation in Tubercular 300
Larvnx, A Case of Intrinsic Epithelioma of the.
232, 328
Larynx, Cicatricial Contraction of the 358
Lateral Curvature, An Extreme Case of Congeni-
tal 441
Lavage in the Treatment of Ileus 132
Leading Articles :
Adulteration of Food and Drugs, A Bill to pre-
vent 323
Albuminuria and Life Insurance 73
Anus, A Musical 545
Asparagus, The Pharmacology of 636
Asylums, Reforms needed in New York City
Insane 350
Atrophv of the Face, Progressive Unilateral . 297
Bill. The Baby Students' Relief 240
Chancroid, The /Etiology of 182
Conjunctival Sac, A Large Foreign Bodv tol-
erated in the " 438
Consumptives, New7 Mexico as a Resort for. . 660
Craniectomy in Microcephaly 166
Desquamation in Scarlet Fever, Can the Pe- .
riod of, be Shortened ? 467
Drunkenness successfully combated in North-
ern Europe 101
Drunkenness, The Diagnosis of 351
Eclampsia, Puerperal 522
Endometritis. The Treatment of :182
Floating Kidney and Nephrydrosis UK)
Gall-stones, Unsuspected 16
Gonorrhoea in Women, Ascending 607
Gout of the Penis 325
Hemorrhoids, Dr. Lauder Brunton on 578
Hospital. The Brooklyn Methodist Episcopal. 382
Hospitals, Athenian 410
Hospitals, The Legal Liability of, in Cases of
Alle ed Malpractice 269
"Hydrargyrum Lactatum," So-called 17
Insanity, Post-febrile 660
Lectures. The Cartwright 210
Legislation, An Unwarrantable Attempt to se-
cure Special .' 182
Leprosy in Bogota . . 324
Library of the Surgeon-General's Office 297
Medical Missionary Work in East Central
Africa 438
Meningitis, Microbic 636
Moliere and the Medical Profession 131
Myxoedema, The Thyreoid Gland as a Causa-
tive and Curative Agent in 545
New York State in 1891, The Health of 27C
Opium-smoking 692
Pensions for the City Health Department Offi-
cers and Employees 522
Physicians' Business Methods 494
Poisoning, Fatal Malarial 433
Pvoctanin in Diseases of the Eve 411
" Railroad Kidney," The ". 718
Surgeons of New York. The Ambulance 154
Tears, The Physiology of 46
Tetanus Neonatorum 47
Will-training as a Therapeutic Measure 324
Lecture, The Middleton Goldsmith 439
Lectures, The Cartwright. of the Alumni Asso-
ciation of the College of Physicians and Sur-
geons 155
Leitch, M. and M. W. Letter to the Editor ... 441
Lepra of the Eye, A Case of 221
Leprosy and Syringomyelia, The Diagnosis of
Anaesthetic 137
Leprosy in Minnesota 467
Leprosy, The Contagiousness of 469
Leprosy, The Philadelphia Board of Health and. 74
Leprosy, The Question of Contagiousness of 351
Leszynsky, W. M. The Management and Care
of Patients with Hemiplegia resulting from
Cerebral Haemorrhage 202
Lettuce, Hyoscyamine in 75
Leucocvtluemia, Aural Complications in the
Course of 668
Leucorrhrea, Helenin in the Treatment of 102
Lightning, A Curious Injury by a Stroke of 326
Limb. The Mechanism of the Mammalian 362
Link, W. II. Appendicitis 42
Lipoma, Irreducible Umbilical Hernia simulat-
ing 577
Liver and Gall-bladder, Some Surgery of the 589
Liver, Angeioma of the 78
Liver, Resection of the 133
LL. D., Tin- Honorary Degree of 661
Lockwood, C. E. A Peculiar Case of CI ronic
Ascending Poliomyelitis Anterior 711
Lockwood, c. E. Functional Disturbance! "I
the Heart and their Remedies 236
Long, The late Surgeon W. H 75
Lunacy, Pseudo-experts in 57
Lungs, A Case of Congestion of the 322
Lupus Vulgaris, Cod-liver Oil in 470
Lustgarten, S. On Tannate of Mercury 292
Luxation of the Internal Meniscus 583
Lymphatism and Trachoma 247
MacDonald. C. The Infliction of the Death
Penalty by Means of Electricit 605, 535
Mackenzie, The Death of Dr. Colin 75. 102
Mn.-k.-ii/i-. T1m Death of Sii Mor. ll, of London. 156
Mackenzie, The late Sir Morel 1 195
Magazine. An International Medical 102. 271
Major. (;. W. Observations on Paralvsis of the
External Tensors of the Vocal Bands 209
Mabine-IIospitai. Sehvk e. Changes of Medi-
cal Officers of the-:
Austin, H. W 413
Bailhache, P. H 48, 413, 496, 548
Banks, C. E 48. 496. 609
Brooks, S. I) 1*5
Brown. B. W 48, 41?. 496
Carmichael, D. A 212, 413, 496
Carrington. P. M 242
Carter. H. R 48. 185, 242, 272. 609
Cobb, J. 0 242, 413
Cofer, L. E 48. 496
Condict, A. W 48, 242
Devan, S. C 48. 609
Decker, C. E 413, 548
Eager, J. M 413. 496
Gardner, C. H 242, 496. 548
Gassaway, J. M 609
Geddings, H. D 496
Glennan, A. H 242
Godfrey, John 496, 609
Goodwin, H. T 48
Guiteras, G. M • 18, 413
Hamilton, J. B 272, 496. 609
Houghton, E. R 609
Hutton. W. H. H 242
Irwin. Fairfax 185, 212, 272, 413. 609
Kalloch, P. C 548
Kinvoun. J. J 413, 496, 548
Long, W. H 185
Magruder, G. M 185. 242. 496
Mcintosh, W. P 496
Mead. F. W 242. 496. 548
Murray, R. D 609
Perrv, J. C 496
Perry, T. B 185. 413, 609
Pettits, W. J 48, 185, 496
Purviance, George 242, 272. 413. 496
Rosenau, M. J 496
Sawtelle, H. W 242
Stimpson. W. G 48. 496
Stoner, G. W 48, 272
Stoner, J. B 48, 242. 548
Vanghan, G. T 242, 272, 496. 609
Wertenbaker. CP 496. 609
Wheeler, W. A 272. 548, 609
White, J. H 242. 413
Williams, L. L 185
Woodward. R. M 609
Young^ G. B 496
Marine-Hospital Service, The 211
Marine-Hospital Service, The United States 279
Martin. The Death of Dr. Charles, of the Navy- 102
Massage at Rapid or Vibratory Rates 371
Mastoid Apophysis, The Functions of the 667
Mastoid Process, Notes on Operations upon
the 11
Mastoid Process. Some Points concerning the
Opening of the 665
Matthews, H. E. The Climate of Bermuda 13
Maury. The Death of Dr. Rutson 579
Maxson. E R. Vertigo 97
McCurdy, S. L. A Modification of Wyeth's
Method of Bloodless Amputation at the Hip
Joint 520
Measles, Deaf-mutism caused by 668
Medical Attendance in the Jury-room 48
Medical Board, An Army 223
Medical Examiners, The New Jersey State
Board of 17
Medical Manhood and Methods of Professional
Success 696
Medical Mi-information 560
Medicine and Surgery in Japan, The Vernacular. 194
Medicine, Intellectual Progress in 694
Medicine in the State of New York, The Legal
Requirements for entering upon the Prac-
ticeof 669
Medicine, Reports on General 23
Medicine, The Evolution of 662
Medicines, Recommendations of Proprie tary 693
Medicus, The Natural History of the Species . . . 553
Meningitis, A Case of Basilar. 46
Meniscus/Luxation of the Internal 583
Menopause. The Growth of Fibroid Tumors of
the Uterus after the 19
Menstruation and Pregnancy. The Influence of
Purpura Hemorrhagica on 467
Menthol. A Novel Use of a Benzoinol Solution
of 211
Mercury for Injections, Succinimide of 470
Mercury, On Tannate of 292
INDEX TO VOLUME LV.
733
PAGE
Mesentery, Abdominal Section in a Case of Cyst
of the 20
Mctallotherapv in a Caw of Hysteria 407
Methylene lilue in Malarial Fever 007
Methylene Hlne, The Treatment of Malarial Af-
fections with 211
Mettler, J. II. Note on the Treatment of Influ-
enza 38
Mever, W. The Progress of Cystoscopy in the
"Last Three Years 113. 113, 170
Meynert, The Death of Professor 003
Microcephaly, The Brain in 130
Midwifery, An Act. to regulate the Practice of,
in the State of New Jersey 588
Migraine, (Juarana in 187
Misquotation, A 102
Missionary, An Opportunity for a Medical 73
Moliere and Physicians 420
Montgomery, R°. II. A Case of Umbilical Hiem-
orrhage ... 45
Monument, The Grant, and the Medical Pro-
fession 408
Morris, R. T. The Removal of Necrotic and
Carious Bone w ith Hydrochloric Acid and
Pepsin 311
Mortality in Cities in the United States 112. 130,
224; 280, 808, 330, 304, 301, 420, 532. 500, 010, 700
Mot van's Disease 482
Motion, The Effect of Persistent 000
Mouth-breathing during Sleep. A Device to pre-
vent 436
Mucous Membrane of the Upper Air Passages.
Disturbances of the 340, 350
amps, The Lesion in Deafness due to 660
urphy. G. N. Uncontrollable Vomiting of
Pregnancy 634
Murray, F. W. Musculo-spiral Paralysis com-
plicating Fracture of the Humerus 708
Myelitis 301
Myelitis, Compression, in Connection with
Pott's Disease 722
Myopia of the Highest Degrees, The Injurious
Influence of the Accommodation upon the
Increase of 221
Myositis Ossificans, A Case of 332
Myotonia, Acquired 030
Myxoedema, The Idiocy of 330
Myxomata, The Radical Treatment of Nasal. . . . 254
Narcosis, Ether, as induced by the Ormsby In-
haler 629
Naso-pharynx, The Adenoid Tissue of the
Pharynx and 397
Nausea and Vomiting, A Case of Induced Abor-
tion for Relief of 21
Navy, Changes of Medical Officers of the :
Arnold, W. F 353. 720
Babin, H. J 609
Barber, George H 185
Bagg, Charles Perry 384
Bailey, T. B 720
Barnuin, M. W 440, 720
Bates, N. L 440
Berryhill, T. H 440
Biddle, Clement 609
Bogert, E. S., Jr 009
Boyd, J. C 440
Braithwaite, F. B 327
Brown, J. Mills 440
Brush, George R 300
Bryant. Patrick H 103, 242
Byrnes, J. C 037, 720
Cabell, A. G 185
Cordeiro, F. J. B 272
Crandall, R. P 009
Decker, C.J 242
Dickinson, D 353
Dixon, W. S 408
Drake, N. H 185
Eckstein, H. C 609
Farwell, W. G 185. 440
Field, James G 609
Gates, Manly F 327, 037
Gatewood, J. D 387
Guest, M. S 1(3, 1H5
Guthrie, Joseph A 242,000
Harris, H. N. T 637
Heneberger, L. G 548
Hoehling, A. A 384
Horwitz, P.J 609
Kershner, E 327
Lamotte, Henry 327
Lane, George A 272
Lewis, D. 0 440
Loverings, P. A 609
Lowndes, 0. H. T 353
Lung, George A 103
Marsteller, E. II 372, 353, 009
McCormick, A. M. D 185
McCullough, Champ C 440
Means, V. C. B 272
Moore, A. M 353
Neilson, J. L 185, 384
Norneet, E 353
Page, J. E 547
Parker, J. B 103
Percy, II. T 242, 720
Pickrell, George McC 185, 720
Pigott, M. R 103
Schofleld, W. K 353
Smith, G. T 350
Smith, Howard 440
Stitt, E. R 103, 327, 720
StOUghtOn, James 1S5, 009
Navy, Changes of Medical Officers of the :
Turner, T. J
Uric. John F 242,
Van Reypen, William K
Von Wedekind, Luther L 103,
Waggener, J. R
Walton, T. C
Wells, Howard 242,
White, C. H
Wilson, George B 037,
Wilson, H. D
Woods, George W
Young, L. L 242.
Navy, The Medical Corps of the
Navy, The Surgeon-General of the
Neck, Tubercular Glands of the
Needle, A New Hypodermic Syringe
Needle-holder, A New
Needles, The Preservation of Hypodermic-
Syringe
Negligence, A Case exemplifying Gross
Neoplasm. A Case of Intracranial, w ith Localiz-
ing Eye Symptoms
Nephrectomy 157,
Nephrectomy for Nephrydrosis
Nephritis, The ^Etiology of
Nephrydrosis, Nephrectomy for
Nerve, Injury to the Ulnar
Nerve, Rupture of the External Popliteal, in
Jumping
Nerves, Superficial Ciliary, in Man
Nervous Derangements, Some Prevalent Errors
relating to " live-strain " as a Cause of. 648,
Neuralgia, Facial, and Ear Troubles
Neuralgia, Taenia as a Cause of Persistent Inter-
costal
Neurasthenia and its Mental Symptoms
Neurasthenia, Treatment of
Neurectomy, Intracranial, of the Second and
Third Divisions of the Fifth Nerve
Neuritis, Optic Neuritis as a Form of Peripheral.
Neuritis, Peripheral
Neuritis, The Mental Derangements obstrved in
Multiple
Neurology, Live Issues in
Neurology, Reports on
Neuroparesis, Epidemic
Neuroses of Development
Newton, R. S. Letter to the Editor
New York, Infectious Diseases in 102, 133,
184, 212, 241, 271. 300, 320, 352. 3S3,
New York, The Ambulance Service in
New York, The Ambulance Service of the Na-
tional Guard of the State of
New York, The Office of Coroner in
Nomenclature, An Addition to our
Nomenclature, Chairmen of Committees on Ana-
tomical and Biological
Nose, The Route of Respired Air through the .
Nursing in Germany, District
Obituaries :
Brow n, Buckminster. M. D.. of Boston
Clarke, Edward Wight, M. D., of Englewood,
N. J
Obstruction, Intestinal
Obstruction of the Superior Vena Cava, A Case
of
Occlusion, Intestinal
G2sophagus. A Contribution to the Surgery of
the 141,
G5sophagus, A Tooth-plate lodged in the Lower,
More than a Year
Ointments
Oophoritis, Suppurative
Ophthalmia, The Question of .Sympathetic
Ophthalmitis, Operations upon Eyes blinded by
Sympathetic ....
Ophthalmology and Otology. The Annals of . . . .
Ophthalmology for the General Practitioner, Es-
sentials in
Ophthalmology, Reports on 218, 24 1.
Ophthalmoplegia, Parageusia with
Ophthalmoplegia, The Pathology of
Ophthalmoplegia1, The Pathology of the
Ophthalmometer of Javal and Schiotz
Ophthalmoscoptoineter with Micrometer
Orbit, A Case of Malignant Fibroid of the
Orbit, Echinococcus of the
Orchitis, Acute, following Influenza
Orthopaedics, On the Scope of
Orton, The Death of Dr. Samuel II
Osteoma of the Cartilaginous Portion of the Ex-
ternal Auditory Canal
Osteoma of the Ovary
Osteomyelitis, Treatment of Acute
Osteosarcoma of the Jaw
Osteotomy, Cuneiform
Otology, Reports on
Ovaries, The Incomplete Removal of Diseased..
Ovary, Osteoma of the
Ovary, Superficial Papilloma of the
Overlock, S. 15. Influenza in Northern New
England
317
95
160
186
630
137
530
138
490
155,
430
418
271
340
405
700
665
070
218
Ml
Pachymeningitis 301
Paediatrics, Reports on 329
Page, E. D. Aneurysm of the Asccm.ing Anita. 510
Pagct's disease of the Glaus Penis 101
Pain, its Nature, Diagnostic Significance, and
Treatment 428
Painter. The Physician and the 190
Palate, Cleft 157
Panophthalmitis, The Pathological Anatomy of. 273
PAGE
Pap, Ophthalmological 203
Papilloma of the Conjunctiva 275
Papilloma of the Cornea 220
Papilloma of the Ovary. Superficial 312
Parageusia with Ophthalmoplegia 219
Paralysis, Facial, due to Rupture of the Ear-
drum , 138
Paralysis, Musculo-spiral, complicating Fract-
ure of the Humerus 708
Paralysis of the Externa] Tensors of the Vocal
Bands 209
Paralysis, Sensory and Vaso-motor Disturbances
in Facial 181
Paraplegia of Syphilitic Origin 138
Parkinson's Disease, Vision in 246
Parturition ? Does Organic Disease of the Heart
preclude the Use of Chloroform in 642
Patella?, Congenital Dislocation of Both 724
Patient. The Dignity of the 579
Paton, S. Superficial Papilloma of the Ovary . . 312
Pedicle, The, in Hysterectomy 19
Pemphigus, A Case of Traumatic 409
Pental, a New Anaesthetic 75
Perforation of Typhoid Ulcer, with Adhesive
and Protective Peritonitis 400
Perimeum, The Part the Shoulders play in pro-
ducing Laceration of the 20
Periostitis, Albuminous 411
Peritonitis, Adhesive and Protective 400
Peritonitis, On the Early Diagnosis and Treat-
ment of Septic 673
Perityphlitis 013
Perityphlitis, Fascal Fistula following 613
Peroneus Tertius Muscle, The Function of the.. Ill
Pes Valgus on Both Sides, etc 040
Pessary, Away with the Hollow 573
Peterson, F. An Ancient Spa 713
Peterson, F. Letter to the Editor 273
Peterson, F. Some Observations upon the
Riviera 379
Pfingst, A. O. A Case of Obstruction of the
Superior Vena Cava 659
Pharmaceutical Preparations. An Appreciative
Notice of American 445.
Pharynx and Naso-Pharynx, The Adenoid Tis-
sue of the 397
Pharynx, Excision of the, for Sarcoma 133
Phasemeter, A Magnetic .352
Phlebotomy 322
Phtheiriasis Ciliorum. ... 058
Phthisis, New Remedy for 102
Phthisis, The Use of Drugs in the Treatment of
Early 25.
Physicians, A Prescription for Young 439
Physician's Estimate of his Class m
Pilcher, L. S. Tuberculosis of the Urinary Blad-
der, and the Value of Suprapubic Cystotomy
in its Treatment 256
Pillars of the Fauces, Symmetrical Congenital
Defects in the Anterior 526.
Pilocarpine as a Remedy for Rabies 17
Pinguecula, The Anatomy of 276
Pin Sensation in the Throat, Five Cases of
the 645
Placental Localization by Abdominal Palpation. 675
Pleurisy with Effusion, Salicylate of Sodium in
the Treatment of 27
Pneumonectomy 527
Pneumonia in the New-born, Septic 132
Poisoning, A Case of Bromoform 331
Poisoning. A Case of Santonin 331
Poisoning, Cocaine 353
Poisoning, The Effect of Lead, upon the Peristal-
tic Action of the Intestines 382
Poliklinik. The German 307
Poliomyelitis Anterior, A Peculiar Case of
Chronic Ascending 711
Poliomyelitis, Rotary Lateral Curvature of the
Spine after Empyema and 386
Polyclinic, The New- York 579, 693
Polypi. A Contribution to the Histology of
Aural 666
Polypus, Osteoplastic Resection of the Upper
Jaw for Naso pharyngeal 580
Polyscope, The, and the Diaphanoscope 579
Pomeroy, O. D. Glaucoma of Different Varie-
ties 314
Pooley. T. R. Clinical Observations on the
Treatment of Trachoma by Expression 169
Poorc C 1 Statistics "f Op;iati:;ns upon T11
berculous Hip Joints 449
Poore, C. T. Tubercular Glands of the Neck.. . 705
Potassium, Eruptions from Iodide of 4J2
Potter, of New York Slate, The Case of 662
Pott's Disease, Compression Myelitis ill Connec-
tion with 722
Pott's Disease. On the Benign Course of Abscess
in, under Efficient Mechanical Treatment... 206
Pott's Disease. The Treatment of Large Ab-
scesseB in 725
Pott's Fracture at the Ankle 701
Pott's Fracture, \ ieious I nion following. . 123
Powers, C. A. Fracture of the Radius 396
Powers C. A. Resection of the Posierior
Branches of the First Three Cervical Nerves
f::r Spasmodic \\ ryne: k . ;
Practitioner, Essentials in Ophthalmology for
the General 259
Practitioner, The Conviction of an Unlicensed!. 323
Pregnancy, A Case of Twin Extra-uterine 090
Pregnancy, Some Mooted Points concerning the
Vomiting of 83
Pregnancy. The Influence of Purpura Ha-mor-
rhagica on Menstruation and 467
734
INDEX TO VOLUME LV.
IN. Y. Med. Jou
PAGE
Pregnancy. Thinness of the Uterine Walls simu-
lating Extrauterine 21
Pregnancy, Uncontrollable Vomiting of 034
Preparations, Messrs. Reed & Carnrick's 476
Prismatic Combinations, The Action and dees
of £80
Prismospheres and. Decentered Lenses, The Ac-
tion of 274
Prisms. The Proposed Methods lor numbering.. 274
Prize, The Alvarenga 102
Prize. The Alvarenga of the Paris Academy of
Medicine 181
Prize, The County Society 241
Prolapse of the Rectum.." 150
Prolapsus Uteri, Hysterectomy for 50
Prudden, T. M. The Element of Contagion in
Tuberculosis 421
Psoriasis, Pyrogallic Acid in 469
Ptosis, A New Operation for Congenital 246
Ptyalism by Colchicum, A Case of 15
Pulsations noticed in the Bar by the Endoscope,
The Symptomatic Value of the 6i>7
Punishment, Report on Capital 265
Purpura Hemorrhagica, The Influence of, on
Menstruation and Pregnancy 467
Pyelitis, Tubercular 157
Pyloroplasty for Stenosis after the Heineke-
Mikulicz Method 723
Pyoctanin, Herpes Cornea; in Influenza and its
Treatment by 216
Pyrogallic Acid in Psoriasis ui!)
Quinine Blindness. The Lesion in 218
Rabies, Pilocarpine as a Remedy for 17
Rabies, The Prevention of ." 716
Rabinoviteh. L. G. On the Reduction of Fever,
particularly in Typhoid 320
Racemosa, AcUea 41
Radius, Fracture of the 396, <87
Radius, Fracture of the Head of the.. 134
Ranney, A. L. Some Prevalent Errors relat-
ing to "Eye-strain" as a Cause of Nervous
Derangement 648. 676
Ran, L. S. The Saratoga Waters ; their Uses
and Abuses 518
Rectum, Gonorrhoea of the 379
Rectum, Obstructing Cancer of the 133
Rectum, Prolapse of the 156
Rectum, Prolapse of the, in Children 330
Rectum, Resection of the 135
Rectum, The Second Year's Work in Diseases
of the, at the New York Post-graduate Hos-
pital 847
Reeve, J. C. Report of a Death from Chloro-
form 635
Reeve, J. C, Jr. Some Surgery of the Liver
and Gall-bladder 589
Reflex. The Consensual Pupillary Light 219
Reflexes, The Diagnostic Significance of Altera-
tions of the 53
Refraction. Analyses of Two Hundred Cases of
Errors of 490
Register for 1892. The Navy 319
Resection in Traumatisms of the Extremities. . . 303
Resection of the Liver ... 132
Resection of the Optic Nerve, The Indications
for Simple 246
Resection of the Posterior Branches of the Fir.-t
Three Cervical Nerves for Spasmodic Wry-
neck 253
Resection of the Rectum 135
Resection, Osteoplastic, of the Upper Jaw for
Naso-pharyngeal Polypus 580
Resorcin 534
Retort, The Doctor's 393
Retractor, A Ne v Aural 665
Rhode Island State Board of Health. Monthly
Bulletin of the Secretary of the 241
Rice, C. C. The Troublesome Symptoms
caused bv Enlargements of the Epiglottis. .. 393
Richardson, The Death of Dr. T. G., of New-
Orleans 720
Rickets in Australia 332
Rickets, The Treatment of 132
Ridlon. J. Obituary of Buckminster Brown, M.
D , of Boston 272
Riley, The Death of Mr. Henry A 690
Riviera, Some Observations upon the 379
Robinson. A. L. A Case of Twin Extra-uterine
Pregnancv. Abortion per vias nat urates at
the Fourteenth Week 690
Rcbinson, B. Some Nasal, Throat, and Aural
Symptoms and Disorders met with in Influ-
enza 425
Robinson, B. The Relation of Disturbances of
the Mucous Membrane of the Upper Air
Passages to Constitutional Conditions. . 340, 359
Rockwell, A. D. A Case of Hereditary Nervous
Gout 575
Rockwell. A. D. Letter to the Editor 358
Rosenthal. The Death of Dr. H., of Berlin. . . . 353
Rupture of the Extreme Popliteal Nerve in
Jumping 156
Sachs, B., and Armstrong, S. T. Morvan's Dis-
ease 482
Sachs. B. What can we expect from the Surgi-
cal Treatment of Epilepsy ? 197
Salicylic Acid. The Melting-point of a Mixture
of Acetanilide and 210
Sanitary Convention, The Sixth Annual State,
of Pennsylvania 352
Sii itary Feat quietly accomplished, A Worthy. 692
PAGE
Sarcoma, Excision of the Right Tonsil, the
Pharynx, and the Tongue for 133
Sarcomaof the Femur 641
Sarcoma of the Uveal Tract 275
Say re. L. A. Results in Cases of Hip-joint Dis-
ease treated by the Portable Traction Splint
without Immobilization ... 477
Scarification of the Conjunctiva, Fatal Haemor-
rhage in an Infant after 15
Scarlet Fever, Eucalyptus in the Treatment of.. S32
Scarlet Fever, Relapse in 47
Scarpa, In Honor of Antonio 102
Scissors for the Removal of Sutures 501
Scleroderma, A Case of 337
Sclerosis, Disseminated 274
Scleroses of the Spinal Cord, The Nature and
Cause of the 29
Screaming, Spasmodic 160
Seabrook. H.H. Ophthalmologic^ Pap 263
Shaffer, N. M. On the Benign Course of Ab-
scess in Pott's Disease under Efficient Me-
chanical Treatment 206
Shand. J. A Case of Ptyalism by Colchicum... 15
Sherman. B. F. See Jacobi. A.
Shirley, I. A. Fatal llamorrhage in an Infant
after Scarification of the Conjunctiva 15
Shock, Surgical 212
Sinuses of the Face, The Functions of the 667
Skin Disease, A Rare Form of 470
Skin-grafting bv the Thiersch Method for Cica-
tricial Deformity of the Eyelids 181
Skin-grafting, Thiersch's Method of 722
Skinner, W. W. The Relative Humidity of the
Adirondack Region 631
Skull. Compound Fracture of the 40
Small-pox, Ichthvol in 201
Smell, The Loss of 634
Snare, A New Universal Double-acting 668
Societe de biologic 468
Societies. Meetings of :
Academy of Medicine, New York 77. 384
Academy of Medicine, New Tori. Section in
General Medicine 524
Academy of Medicine, New York. Section in
General Surgery 49. 135. 302
Academy of Medicine, New York. Section in
Obstetrics and Gynaecology 78
Academy of Medicine, New York. Section in
Orthopaedic Surgery. . 188, 215. !97, 386, 609, 724
Academy of Medicine, New York. Section in
Paediatrics 51
Academy of Medicine, New York. Section in
Public Health, Hygiene. Legal Medicine,
and Medical and Vital Statistics 548
Association, American Laryngological IliO,
22K, 314
Association, American Medical 662, 693, "21
Association, Harlem Medical 103
Association, Southern Surgical and Gynaeco-
logical 19
Society, New York Neurological 49, 159, 301,
414, 688, 639
Societv, New York Surgical 133, 150, 157* 580,
583. 612. 040. 694, 722, 723
Society of the Alumni of Bellevue Hospital. . . 441
Societv of the State of New York, The Medi-
cal.". ia5, 212
Societies, Meetings of State Medical, or the
Month of April 383
Societies, Meetings of State Medical, for the
Month of June 520
Societies. Meetings of State Medical, for the
Month of May 413
Society for the Promotion of .Maternal Lacta-
tion 352
Societv for the Relief of Widows and Orphans
of Medical Men. The New York 579
Society of Chicago, The Medico legal 001
Society of Leipsic, The Obstetrical. 18
Society of Medical Jurisprudence 1.10, 297
Society of Rhode Island, The Natural History. . 035
Society of the County of Queens, The Medical . . 092
Societv of the County of New York, The Medi-
cal 608
Societv of the State of New York. The Medical.
130. 151. 579
Society of the State of North Carolina, the
Medical 327
Society, The American Chemical 719
Society. The American Pediatric 168
Society. The Brooklyn Dermatological and
Genito-urinary. . .." 333
Societv, The Brooklyn Pathological 037
Society, The Brooklyn Surgicaf. . . 272. 327. 408, 637
Society, The Harvard Medical, of New York 2T2
Society, The Iowa State Medical 446
Society. The Lenox Medical and Surgical. . 156, 521
Society, The Massachusetts Medical 608
Society, The Metropolitan Medical 18
Society. The Michigan State Medical 523
Society, The Microscopical, of W ish i gton 511
Society, The New Y'ork Dermatological 608
Societv, The New Y'ork Ophthalmol: gical 7.1
Sen i' t'v. The New York Otological 384
Society, The New Y'ork Pathological 102
Society, The New York Post-graduate Clinical.. 352
Society, The New Y'ork Surgical 102. 156
Society, The Northwestern Medical, of Philadel-
phia 579
Society. The West End M dical 210
Sodium. Salicylate of, in the Treatment of Pleu-
risy with Effusion 27
Soup. Homoeopathic ('44
Spa, An Ancient 713
PA'
Spasm of the Accommodation, Notes OH,
Spinal Cord. Gunshot Wounds ol the
Splint, A Hip 21
Squint, General Considerations on
Squint, The Treatment of, by Advancement of
the Recti Muscles 21
Stapes in Animals, Avulsion of the 66l
Starch in a Fungus 2?1
Starr, E. A New Instrument for quickly deter-
mining Refractive Errors of the Eye 40l
Stenosis in Tubercular Laryngitis. Intubation
for the Relief of 23i
Stenosis, Pyloroplasty for, after the Heineke-
Mikulicz Method." 72f»
Sterilizer, Soxhlct's Modified Milk ftj
Sternum, Multiple Fracture of the ; 10
Stiinson, L. A. Pott's Fracture at the Ankle. . . 701
Stimulant, Ether as a 383
Stomach, A Ball of Hair in the Human lof
Stomach, Malignant Disease of the, in which
Gastroenterostomy was considered 27a
Stomach, Some of the" Dangers of washing out
the 533;
Strabismus, Methods of advancing the Internal
Rectus for Divergent 214
Strabismus, On the Operative Treatment of Di-
vergent 292
Strangulation, Intestinal, by a Fibrous Band... 7241
Stricture, An Instrument for the Measurement
of the Resistance in a 553
Stvrone in Chronic Suppuration of the Middle
Ear 666
Sublimate, Subconjunctival Injections of Corro-
sive, in Ocular Therapeutics 245
Sugar in the Urine of Diabetics, Note on the Dis-
appearance of. just before Death 4S61
Suit \n I Djnot 4 ward in ~i Miilpraeuj: Sog
Snlphonal, New Observations in the LTse of 406
"Sundowners" 607
Supervenositv, The Knee-jerk in the Condition
of 325
Suppuration of the Middle Ear. Stvrone in
Chronic. 996
Surgery, A British View of American 332
Surgerv, A Plea for Progressive 19
Surgery, Cases of Gall-bladder 120, 134
Surgery, Enrpphen in Minor 638
Snrgery in .japan. The Vernacular Medicine and. 194
Surgerv of the Gisophagus, A Contribution to
the 141, 158
Surgery, Parisian 364
Surgery, Reports on General 526
Surgery, Some of the Indications for Interfer-
ence in Orthopaedic .. plO
Surgery, The Present Status of Cerebral 21
Suture" of the Cornea and Sclerotic. The Indica-
tions for 2-JS
Syphilis and Heredity 47 1
Syphilis, Heat in the Treatment of. 470
Syphilis of the Bones, Tardy Hereditary 85
Syphilis, The Modern Treatment of 470
Syphilis, The Spread of, by Cigars 327
Syphilis, The Treatment of Infantile, by the
Subcutaneous Injection of Mercurial Salts. . 331
Syphilitic Infection. Sources of 715
Syringes, A New Attachment for Aspirators or. 248
Syringomyelia, A Case of 647
Syringomyelia, The Diagnosis of Anaesthetic
Leprosy and 137
Tabes, Treatment of 638
Taenia as a Cause of Persistent Intercostal Neu-
ralgia and Herpes Zoster 269
Talipes Equino-varus 157
Talipes Yaro equinus. Open Incbion for 186
Tannin in Tea 494
Taylor, G. H. Massage at Rapid or Vibratory
' Rates 371
Taylor, R. W. Genital chancres in Women 1
Tea-drinking. Dyspnoea after. 411
Tea, Tannin in 494
Teeth. Artificial, from a Hygienic Point of View. 448
Testicle. Gangrene of the 159
Tetanus cured with the Tetanus Antitoxine 74
Thacher. J. S. The Diagnosis of Pancreatic
Disease 365
Therapeutics, Points in Uterine 586
Therapeutics. Shall Success in, be imperiled by
Ethical Considerations ? 76
Thesis. The Decadence of the (iraduation 300
Thiersch's Method of Skin-grafting 722
Thilanine 210
Thilanine. The Treatment of Eczema by 409
Thomsen's Disease 159
Thorax in Cases of Rotary Lateial Curvature, A
New Method of making Plaster Cists of the. 38S
Throat. Five Cases of the Pin Sensation in the.. 645
Thymacetin 547
Thyreoidectomy 197
Thvreotomv in a Child Eighteen Months of Age,
A Case of 329
Tongue, An Instrument for the Removal of Hy-
pertrophic Tissue from the Base of the 162
Tongue, Cancer of the 134
Tongue, Excision of the. for Sarcoma.. . 133
Tonsil, Excision of the, for Sarcomi 133
Toe. A Form of Painful 444
Torticollis, Resection of Posterior Branches of
Upper Three Cervical Nerves for Spas-
modic 49
Toxalbumin of Diphtheria. The Histological Le-
sions produced by the 447
Trachoma, Clinical Observation.- on the Treat-
ment of, by Expression 169
INDEX TO VOLV ME LV.
735
PAGE
Trachoma, Lymphatism and 247
Trachoma, The Micro-organism of Sttl
Transplantation of the Cornea 271
Tremor anions Epileptics, Attacks of 13S
Trephining for Traumatic Epilepsy 50
Trichiasis, Hairs on the Intermargir.al Edge of
the Eyelids as the Usual Cause of 276
Trichiasis, Results of operating in Cases of
Xerosis co-existing with 210
Trouve, G. Letter to the Editor 579
Tubal Disease, The Conservative Treatment of. . 092
Tubercular (Hands of the Neck 705
Tubercular Patients, The Choice of Climatic
Resorts for 4.33
Tuberculin, The Action of, on the Inoculated
Tuberculosis of the Rabbit's Eye 221
Tuberculin, Tin' Action of, upon' the Experi-
mental Eye Tuberculosis of the Rabbit 27
Tuberculosis. Acute General Miliary, without
Fever 25
Tuberculosis, Experimental Eye, of the Rabbit,
The Action of Tuberculin upon the 27
Tuberculosis, New Outlooks in the Prophvlaxis
and Treatment of 561
Tuberculosis of the Urinary Bladder, and the
Value of Suprapubic Cystotomy in its Treat-
ment 256
Tuberculosis of the Uveal Tract, The Origin of. 245
Tuberculosis in Budapest 212
Tuberculosis, Origin and Restriction of 204
Tuberculosis, The Element of Contagion in 421
Tuberculosis, The Treatment of Laryngeal, with
Lactic Acid locally 44
Tuberculous Affections, Results of the Applica-
tions of Lannelongue's Sclerogenic Treat-
ment in 616
Tumor, Alleged Cerebral 49
Tumor of the Brain, A Case of 41
Tumor of the Thyreoid Gland 157
Tumors, A Contribution to the Studv of Cerebral 710
Tumors of the Ear, Malignant .' 668
Tumors of the Uterus after the Menopause, The
Growth of Fibroid 19
Tuttle, J. P. Gonorrhea of the Rectum 379
Tuttle, J. P. Recovery after taking a Large
Quantity of Veratru'm Viride 691
Typhoid Fever. Chloroform in the Treatment of. 439
Typhoid Fever, Intestinal Perforation in 24
Typhoid Fever, The Elimination of Toxic Prod-
ucts in 26
Typhus in New York 211
Ulcer, Gastric 225
Ulcer of the Stomach, Excision of a Large 584
PAGE
Ulcer, Perforation of Tvphoid 400
Ulcer, Typhlitic 715
Ulcers, Aristol for Venereal 471
Ulcers of the Cornea, Tincture of Iodine in In-
fectious 246
University of Buffalo, The 212
University of Pennsylvania, The 719
Uraemia, The Secretion of Rile in 425
Urea, Quantitative Tests for 70, j 0 1
Urethritis, A New Method of treating 486
Urethrotomy, External, as a Preliminary to an
Operation for Inguinal Hernia 613
Uric Acid in Health and Disease. Observations
on the Excretion of 017. 039
Urinary Apparatus, Diseases of the 5. 31,. 61, 92,
122, 147, 170
Uterine Appendages, Removal of the 304
Uterus, Dilatation and Drainage of the. for Dis-
ease of the Endometrium 214
Uterus in Chronic Endometritis. Drainage of the. 77
Uterus, The Growth of Fibroid Tumors of the,
after the Menopause 19
Uterus, The Surgical Treatment of Anterior Dis-
placements of the 20
Uveitis, Iritic 246
Vaccination, Celebration of the Centennial of
the Discovery of 694
Valk, F. Report of a Case of Tonic Spasm of
Accommodation 408
Van Allen, H. W. A Case of Congestion of the
Lungs 322
Van Cott, J. M Letter to the Editor 76
Vanderberg, The Death of Dr. Charles R., of
Columbus, Ohio 272
Van Wyck, the late Dr. William H 84
Vaughan, B. E. A New Method of treating
Acute Urethritis 486
Vena Cava, A Case of Obstruction of the Superior 059
Venereal Diseases, Reports on 409
Veratrum Viride, Recovery after taking a Large
Quantity of 691
Verein deutscher Aerzte von Brooklyn. The 184
Vertebra?, Tubercular Disease of the, in its Early
Stages 189
Vertigo 97
Vertigo, A Case of So-called Laryngeal 128
Vesicles at the Equator of the Lens, The Forma-
tion of 220
Virchow, Professor, in Defense of his Name 271
Virginia, The University of 608
Vision in Parkinson's Disease 246
Vitreous Humor, The Introduction of an Artifi-
cial, into the Scleral Cavity 248 1
PAGE
Vivls c tion in Germany 592
Vomiting. \ Casr of Induced Abortion for Re-
lief of Nausea and 21
Vomiting of Pregnancy, Some Moi ted Points
concerning the 86
Vomiting of Pregnancy. Uncontrollable 634
Von Ruck. K. The Choice of Climatic Resorts
for Tubercular Patients 433
Vought, W. A Case of Syringomyelia 647
Waters, The Saratoga ; their Uses and Abuses . 518
Weed, C. R. The Treatment of Laryngeal Tu-
berculosis with Lactic Acid locallv 44
Weekly. The Doctors' 75
Weir, R. F., and Page, E. D. Aneurysm of
the Ascending Aorta treated In Macewen's
Needling Method 510
W'erdcr. X. i). Some Moot Points in Ectopic
Gestation 90
Wessinger, J. A. Letter to the Editor 353
Wey. W. C. See Jacobi, A.
Whitman, R. The Radical Cure of Confirmed
Flat-foot 227
Wilcox, R. W. Anaemia : its Treatment with a
New Preparation of Iron.. 512
Williams, L. L. Compound Fracture of the
Skull and Wound of the Arm Center 40
Willis, G. Letter to the Editor 413
Willis. The Circle of 439
Women, Genital Chancres in 1
Woodward,.!. H. Skin-grafting by the Thiersch
Method for Cicatricial Deformity of the Eve-
lids 181
Wound of the Arm Center 40
Wound. Spontaneous Cure of a Sev ere Abdomi-
nal 714
Wounds of the Spinal Cord. Gunshot 351
Wounds, The Objections to the Insertion of
Drainage Tubes into 719
Wounds with Dynamite 692
Writers, A Stumbling-block to Medical 47
Wryneck, Resection of the Posterior Branches
of the First Three Cervical Nerves for Spas-
modic 253
Wyeth, J. A. Ether Narcosis as induced by the
* Ormsby Inhaler 629
Xerosis co-existing with Trichiasis, Results of
operating in Cases of 219
Zalewski, The Death of Dr. Stanislas, of Bor-
deaux, France 131
Zoology for Medical Students, Comparative
Anatomy and 155
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